Three key components of successful BFRB treatment

Hello all! For those of you who haven’t seem my Instagram feed (@lotustherapyatx) I wanted to share a talk I gave recently about three key components of treatment for body-focused repetitive behaviors (BFRBs):

I’m here today because I led workshop for the American Group Psychotherapy Association (AGPA), and I figured that with so much on my mind about working therapeutically with hair-pullers and skin-pickers, I’d like to share a bit with you all.

I had a wonderful group at the conference, just a wonderful group of therapists so interested in this topic and they reminded me that there’s not much information out there about how to work with these populations, especially from a psychodynamic perspective. I incorporate cognitive and relational techniques, but the work is grounded within the therapeutic relationship, which is where I think the magic happens.

For today, I’m just going to go over one of the slides I used in my presentation that I think might be helpful to everyone, in terms of both if you are someone being treated for hair-pulling or skin-picking or you are a therapist working with this population. Of course these are very complex disorders and a complex treatment process, but I’ll try to break it down to the three key components of successful BFRB treatment.

The first key is attention to sensory needs. In counseling, people are going to have to do something with their hands if they are to learn to not always relate to their emotions by picking or pulling. So therapists should understand that it is important to be able to fiddle with something while you get in touch with your emotions.

Along with that, the second key component is that it is the therapist’s job to really help the client translate body language into words. So I notice, in my sessions, that often we will be talking about a topic of emotional stress, perhaps an argument with one’s partner, or maybe a phone call with a mom, and that’s when I’ll start to notice a person’s hand starts to go to their hair to search for something to pull or to their face to find something to pick.

So it is really important for therapists to help the client translate that motion into words. So I will often tell a client something like, “I noticed that your hand went to your hair just as you started talking about your mother, I wonder what feelings might have come up in that moment?” That way we begin to break down the impulsive and compulsive elements of these behaviors and begin to add some mindfulness and understanding to them. We see that there usually is a reason why the hands go to the hair or skin.

As I talked about in my workshop, I often use fiddle toys to help with this translation. In the case study I discussed, I mentioned a client who squeezed my toy caterpillar really hard in a group session, and another group member was able to ask her what she was so angry about and help her translate that angry motion into words.

The third key component is one that isn’t as well-understood as I think it should be, and that is, we need to work through the perfectionism defense of people who struggle with picking or pulling. Perfectionism is a theme that runs through all of the literature on this population, and yet, we haven’t really answered, what does that mean, and how can we work with it now that we know this fact?

What I have discovered is that this perfectionism is usually a coping strategy, when as a child someone finds that it works better in their families if they have less needs and less anger. That’s where perfectionism comes in. It’s a very tricky one, because it is a defense that is very popular. If you are pleasing and you keep your anger to yourself and you always do what people ask of you, you may well never be noticed, you might glide through, people think everything is OK but really, the picking or pulling is the one signal that something is not OK.

So I think some researchers have made that mistake, in that some early treatment results looked really good after behavioral treatment but were followed by many relapses. This may be because people who pick and pull are likely to try to please their therapist, and go along with the treatment protocols, while the deeper needs and feelings being expressed through the behaviors get lost behind that perfectionism and aren't addressed. And the main feeling being tucked away behind that perfect exterior is anger.

So, if we think about it that way, one of our key goals is to help people express their anger in words, and to get some of that frustrated energy out of their hands. So I would be interested to know what that brings up for people, I know that’s a stimulating idea, that anger is really a lot of what is in restless hands.

Nancy Keuthen and some other researchers did study this topic in 2016 and found that people who pick and pull do tend to internalize their angry feelings in particular more than others, and that the more intense the picking and pulling and its consequences, usually, the internalization and repression of anger is also more intense.

One thing we know about anger and keeping it in is that that aggressive energy needs to go somewhere! One way to think about picking and pulling is as a way to release some of that energy bit by bit and the more we can help people put their anger into words, the less they will need to rely on that behavior to get it out of their bodies.

For me, as a recovering skin-picker, I found a way to get the anger and frustrated energy out of my body through an amateur boxing career. That’s a bit on the extreme side, but really, anger is a physical emotion and it needs to come out of the body.

So just to wrap it up, the three key components of successful BFRB treatment are attention to sensory needs, helping each clients to put body language into words, and going beneath the perfectionism defense to bring the expression of anger into the room.

For those therapists out there, it can be very helpful to bring angry energy out toward yourself, because you have the opportunity to model making space for angry energy without being intimidated by it ourselves.

I’m ready to go home and release all of the stress and pressure of planning for this workshop, and it was nice to have the last hurrah with you all before I head home. Until next time!

Self-Compassion for Skin Pickers and Hair Pullers

Hello all! For those of you who haven’t seem my Instagram feed (@lotustherapyatx) I wanted to share a talk I gave recently about why building self-compassion is a necessary part of treatment for body-focused repetitive behaviors (BFRBs):

Self-compassion is really important to counter shame. And, as those of you who pick your skin or pull out your hair know, there is a lot of shame that goes along with those behaviors. The shame can be crippling and it can form sort of a cycle, where you pick or pull and it feels good while you are doing it but at the end of it all you feel really ashamed. And then that shame itself can be a feeling that will draw you into pulling more hair or picking your skin again.

So we are really trying to interrupt that cycle and I tend to really work on that from the very first session when someone comes to see me. So, when we talk about self-compassion, I like to use a definition and some understanding about it brought to us by Dr. Kristen Neff, an author and professor at UT. She talks about how self-compassion has three different components: mindfulness, self-kindness, and common humanity.

First, mindfulness. We have to be aware of the feelings that are coming up that are driving us to be really self-critical, and to have an opportunity to counter those voices. Mindfulness also helps us to tolerate painful emotions. So, if any time I get mad, I pick my skin, if I bring some mindfulness in, as I am picking my skin I can think, “Oh, I wonder why I am picking my skin, and what feelings I am trying to avoid.” If I realize I am frustrated, I can maybe stop picking my skin and go talk to someone about how frustrated I am. So, once we are mindful of the feelings behind our behaviors, we have a better chance of maybe finding some other way to meet that need.

Second, self-kindness to counter self-judgment. And I like to tell people right off, you might think that your behavior of picking or pulling is your enemy or this thing you have to get rid of or this thing you hate, and that is understandable because it does cause problems in your life. But, on the other hand, we might think about it as a thing that has helped you cope. When we think about it as a coping mechanism, it’s a lot easier to feel self-kindness , to think “Oh, OK, I had a hard day, that’s why I was picking, and let me be nice to myself instead of just beat myself up for picking.

One thing I encourage people to think about is if you have a spot that you keep picking at or a bald spot after an episode of pulling, you might want to even think about naming that spot, what caused that, what led to that? So it could be, that spot is from that exam, when I worked really hard and I had to focus in, and that’s a trigger for me to pull my hair, so that’s an exam spot.

Or, that picking spot, that’s the pandemic spot, where any time I get really anxious, or frustrated from being cooped up indoors, or worried about getting sick, or grieving someone who I love who is sick, that can sort of be a name you give to that spot, to bring in self-kindness. Like, “I’m doing this because I am hurting, not because I am gross or weird.”

The third element is common humanity. This involves recognizing that none of us is perfect. So, of course, those of us who do pick or pull know that perfectionism is probably part of our personality. We like everything to be perfect and don’t want to show that we have any flaws, but once we can admit that we have some flaws we will often find out that others do also.

That’s where we begin to realize that we are just like everyone else. Everyone struggles, everyone has ways of coping, and it really helps to know other people who use picking or pulling as their primary way to cope. In this way, group therapy can be particularly helpful, or a support group, or just someone who you can look at and see, “Oh, I see, they are not weird or gross because they pick their skin or pull out their hair, they are just trying to cope with the same kind of stressors as I am. All of that together can lead us out of a cycle of shame and into a cycle of self-compassion. Like, “OK, I picked today, and I understand why, and today it might have been the best way to meet my needs but tomorrow I might find a different way.”

I just wanted to close by sharing with you a story from a recent client maintenance-treatment interview. And and I have been working together for several years. She picked her pseudonym and gave me permission to share some parts of her story.

Ever since pulling her first hair at the age of 10, Andi had labeled the part of herself that pulls and chews and eats her hair as not only bad but monstrous, and her hair itself as disgusting. She needed to shed that identity in order to allow self-compassion to build. She reflected on that shift: “From our initial contact, I felt very comfortable and cared for by Stacy. But it took a while to realize that there was no compassion for myself. It took even longer to build that compassion, to where now I can talk to myself, like, it’s going to be OK. And I can brush my hair with love now, I really started loving my hair, and recognizing that it is really beautiful, and I can take care of it and be nicer to myself.”

So I wanted to leave you all with that beautiful reflection by Andi, to remind you that you may start with not even knowing why in the world you would be nice to yourself or how you could ever think about doing that but with the help of someone, a good therapist, a good friend, someone who can really help reflect with you on the ways you’ve used picking or pulling to cope, you might be able to have a better relationship with ourself and some self-compassion.