Sweet success! The process of moving from idea to book contract with Routledge!

Treating Body-Focused Repetitive Behaviors: An Integrative Psychodynamic Approach will be published in the Routledge Focus on Mental Health series in 2022-23.

It is true that if I had known that the book I imagined writing in 2011 would take me A DECADE to finish, I might never have started the project. It is also true that if I could have imagined that my writing could one day lead me to publish this book with Routledge I would have told my younger self that it would all be worth it!

I remember the first time I thought about writing the book. My husband convinced me to go to a bed and breakfast for a weekend to get started. I spent most of the time reading articles and books. I was so irritable, I couldn’t find anything in the literature that came even close to capturing the complexities of body-focused behaviors, but I also couldn’t get more than a sentence or two down on paper. How do you start from nothing? How do you write when you have no idea if your words will ever come together or see the light of day?

For me, it was just that the sense that I needed to say some things that weren’t being said kept bugging me, in the back of my mind. I decided I needed a writing coach, and through Write By Night I found a great fit with Cecily Sailer. Throughout the years she challenged me to stick with the project, take the steps toward the larger goal one by one. She also let me grumble at her about what a terrible taskmaster she was and how she could be a joy-killer whenever I would think I was done with a chapter only to be met by, “Well, you’re getting there, but…”

I spent 2013 and 2014 working on and publishing my first peer-reviewed article, A healing herd: Benefits of a psychodynamic group approach in treating body-focused repetitive behaviors, in the International Journal of Group Psychotherapy. I was thrilled that editor Dominick Grundy helped me to meet that goal. Through the process, I connected with my favorite author, Dr. Barbara Natterson-Horowitz, co-author of Zoobiquity and Wildhood. Her understanding of the social/emotional component of grooming among animals and humans inspired the name of the article.

In turn, that publication led me to connect with another of my mentors, Dr. Mohammad Jafferany. In his 2020 article, Non-Pharmacological Approach to the Treatment of Trichotillomania in Dermatologic Therapy, he cited my article as evidence for the psychodynamic approach.

We collaborated on my next article, Psychodynamic Treatment of Trichotillomania, along with Erica Aukerman, which was published online in Dermatologic Therapy, in 2021.

Four years ago, my BFF Gabi Snyder and I met for a writing retreat at the Writing Barn here in Austin TX. She is a children’s book author, notably of Listen, published this year. When we wrote together, I learned from her about the discipline it takes to see a project through. I learned that I needed to write for 3 or 4 hours at a time, not get up when I was frustrated, not just jot down the thoughts in my mind. I looked at what I had written over the 6 previous years and realized that I had virtually NOTHING as far as a real book was concerned. I cried and vented and freaked out and then I started from page 1 and wrote a full draft of the book, 140 pp. over the next 3 years.

Through my connection to the American Group Psychotherapy Association, where I have served as faculty for 5 of the past 8 years and the local branch, the Austin Group Psychotherapy Society, where I have served on the board and committees for many years, I met the third of my significant mentors, Dr. Molyn Leszcz. As the co-author of The Theory and Practice of Group Psychotherapy, he had very helpful recommendations for my draft manuscript, including his suggestion that I include some parts of my own history of recovering from skin-picking in the book and that I prominently feature the most up-to-date research.

Two years ago, no longer as my coach but now as friend and peer, Cecily nudged me out of shyness to start an Instagram account. Little did I know that I would enjoy the connections I could make with other professionals and groups linked to BFRB treatment as well as with those struggling with BFRBs.

In around May, Cecily told me it was time to finish the book, all the way to line-edit and proof—before I sent in any queries about publication. She talked me into taking a week off of work to spend writing, at a little airbnb in Port Aransas. I can hardly remember that week in June, it was hellish and satisfying, and after 20 hours of work I frolicked in the waves. I spent another 20 hours the following month and finished the draft, then sent it to Write By Night for the finishing touches.

Finally, on September 28, I submitted a query to Routledge, where Anna Moore took an immediate interest in my project and asked me to submit a full proposal along with my manuscript.

The hardest part of the proposal was asking my mentors to serve as peer-reviewers, and then waiting on pins and needles while they reviewed the material. Soon after Thanksgiving I heard back, the reviews had been positive toward publication!

After 2 more weeks of anxiety and excitement, I signed the contract!

I am thrilled that I will have the chance to add to the literature on treatment for BFRBs, opening up an attachment-based, depth-oriented treatment option to add to the largely cognitive/behavioral treatment landscape. Stay tuned for more info and publication date!

The Who, What, Where, When, Why and How of Body-Focused Repetitive Behaviors

This post is a compilation of information from a video series you can find on my YouTube channel, Stacy Nakell - Lotus Therapy ATX.

First, let’s talk about what body-focused repetitive behaviors really are. I’d like to share my definition:

Body-focused repetitive behaviors are repetitive over-grooming acts, on the self-harm continuum, that serve as coping mechanisms. They do damage to the dermis. They are very effective in the short term in regulating physiological and emotional states. They include skin picking, hair pulling, and cuticle/nail/cheek biting.

My clients have some insightful ways of defining their BFRBs. Em (not her real name), who began pulling, chewing, and eating her hair during a chaotic childhood, which included sexual abuse, says of her relationship with repetitive behaviors, “When I found hair pulling, I found a friend, a family, an acceptable soother. I never wanted to let it go.” Em’s description reflects the significance of hair pulling as a way to calm her central nervous system, illuminating the power of her love-hate relationship with the behavior. Many of you may relate to this, hating the behaviors but aware that they have also been helping you cope with the stressors of your life.

Let’s talk about who develops body-focused repetitive behaviors like hair pulling, skin picking and check, nail, lip and cuticle biting. People from all cultures are known to engage in these behaviors, and between .4% and 6% of the general population have clinical versions of these behaviors, meaning that they get in the way of their quality of life. So, many more people develop these behaviors to some extent, but they don’t become problematic. 70% of the people who come to treatment are women or girls, which doesn’t mean there aren’t boys or men suffering with these behaviors, they may just be more reluctant to come to treatment. Also, these behaviors can begin at any age, even as young as 2 years old. They usually develop in adolescence but can also happen later in life, if there is a trigger for the behaviors at that time. So, if you are a therapist working with these behaviors, you can expect that many people of different ages will be walking in your door.

When we think about who develops these behaviors, there are two different things to think about. We just talked about the demographics, and there are also certain personality characteristics common among this population. Even from an early age, those who go on to pick, pull or bite tend to experience some sensory processing issues, often really sensitive skin, not liking the tags on the back of clothing or the lining on socks, or sensitivity to loud noises, or even a negative reaction to the textures of certain foods. So that’s an important thing to know, that there seems to be an underlying sensory processing piece that makes it a little harder to find the equilibrium in their central nervous system. Another thing that people who pick, pull or bite tend to have in common is that they tend to be perfectionists, really good boys or girls, trying to please, and often times may have a sibling whose immediate needs are higher, or who are more vocal about their needs. These are usually the kids who try to cause the least trouble in the family.

Let’s get to the when and where of picking, pulling and biting. In adolescence, when the behaviors typically arise, there is a lot going on, with hormones coursing through the body. If we want to think more about triggers for ongoing behaviors, it tends to happen for different people at different times. For some people, it might happen when they are relaxing in front of the TV or with a book, maybe in the living room, and that can be when it feels like it is a way to unwind, and the release the behaviors bring might become a part of the winding down ritual. For others it may happen more when they are stressed, like in a class taking a test or sitting in front of the computer and struggling to figure out a problem. It can happen for some people when they are in the bathroom, looking for imperfections, and people can get lost in an automatic trance like state, in the bathroom or in the car, that mindless picking pulling or biting can happen. For others it may be when they enter into a social situation and may start to feel some social anxiety, making those hands really restless.

So when and where can really be any time, anywhere, but those are some of the most common places and times people describe as part of triggering picking, pulling or biting.

On to the why: why do people end up picking, pulling or biting in ways that harm their bodies? Of course, like everything the question and answer are complicated, but basically, people engage in these behaviors because they work, they help people cope when other coping mechanisms aren’t available. From sucking thumbs as children to eating disorders to any of the ways people fill some emotional holes, it is so complex how we use a variety of behaviors to cope.

So, how exactly do these behaviors that seem so painful and do sometimes cause pain also soothe and calm us, how does that work?

I think of the answer in a few ways. One is just chemical, pulling out hair, picking skin releases endorphins. A good thing to remember is that taking a deep breath can also release endorphins, changing the body’s state. We can feel calmer and engage our parasympathetic nervous system by taking a deep breath.

Another piece is that playing with hair and feeling for bumps on the skin can lead us into a trancelike state, a bit of escape, so that’s another function BFRBs can have.

The third, I think of in a sensual way. We soothe ourselves by engaging in our senses, and with pulling, picking and biting it is all about how many of our senses get soothed or get stimulated or get some kind of input.

I have a new little grand baby (4 weeks old) and I was able to feed her with a bottle yesterday. I was thinking about how many of her senses were being stimulated and soothed and fed during that experience. I think that connection of skin on skin, even if it’s our own hair, our own hands, our own skin, there is something soothing in a primal way about that.

All of that is to say that these behaviors are soothing, they do workout helping us cope with some of the stressors of our lives, and that’s part of why they are so hard to let go of. They deserve some of our respect for how they have helped us get through.