The people who have come through my office have consistently been bright, intelligent people. Their minds are effective, often in fact overly so. This has meant that they can master handouts, articulate behavioral chains, identify healthier alternative behaviors and thoughts, and still see little to no changes. To me this occurs because all of these tasks can stay circumscribed to the intellectual realm. Clients can go through the motions of superficially recognizing their triggers, reciting more adaptive thoughts, or pausing before acting. However, the energy to actually choose something (e.g. grab a fiddle toy, go for a walk) that goes against inertia and immediate gratification continues to be absent.
To me, what is missing from usual cognitive-behavioral approaches is an appreciation that people are always divided. It is a not a matter of simply pointing out what the healthier or more logical thing to do is or BFRB folks would have done it a long time ago.
Here is some of my experience:
- I can give tracking sheets but clients quickly stop filling them out because they are too confronting
- I can elucidate problematic ways of thinking and clients can see them but still choose "indulgence"
- I can teach about boundaries but clients just cannot get themselves to frustrate or disappoint others
- Clients can see progress and then be filled with impulses to undo
- Clients are hyperaware of others' needs and expectations but struggle to know what they really need or want
- Clients are unready to detach from the idea that they can magically stop picking/pulling/biting tomorrow or next week
- Clients cannot relax into being because they are so caught up with doing
- Clients can get frustrated but not vulnerable
Christina Pearson, founder of the TLC Foundation, has framed BFRBs as a long term relationship. So, like any long term relationship, it's complicated. Part of us wants to give up our BFRBs and part of us doesn't. This means that we can't expect to simply tell people how the "healthy" way to be and expect them to simply walk through that door. There are anxieties and there are attachments we need to speak to and honor first.
What also has become increasingly evident over time is that folks with BFRBs are tired (exhausted). They are always "on," figuring out the "right" thing to say or do in every situation. This means that (1) they are expert at assessing external scenarios but poorly motivated by internal agreement, and (2) even after absorbing therapy lessons about antecedents, mental sets, or consequences, in a moment of pulling, picking, or biting, they just don't want to think critically or correctly. There isn't enough ease or gratification in their lives in general so they are protective of and hungry for this chance to turn off and not think.
I once had a client tell me, "It's like I can't sustain the health" when her skin picking was lower. She felt impulses to attack her face. This is an important testament to how hard it is endure success. Enduring success means having to bear belief which, when you have been skin picking, hair pulling, or nail biting all your life, can feel instinctually stupid and dangerous. Staying skeptical and disbelieving has grown to feel smart and safe. I think usual, cognitive-behavioral approaches overlook the attachment clients can have to their failures and their failure mindset. Deep parts of clients have emotional reasons for resisting the belief that they are both worthy and capable.
While stopping pulling/picking/biting may technically be in clients' best interest, no one likes to have something taken from them and that's how it often feels for clients. Therapists have to appreciate that messaging from society internalized day in and day out is that BFRBers are wrong as they are and need to get right. This means it's hard for clients to look at BFRB cessation with enthusiasm or pride. Getting "treated" only means finally being able to fall in line with a way of being that other people have always been. The decision to pull or not pull doesn't and has never felt like it belonged to them. For them, the expectation was always clear and they've only been disappointing. Therefore, relinquishing their BFRBs is a reform they have been burdened with and thus can harbor resentments about too.
To me, BFRB treatment is not just about managing thoughts and behaviors, it's about becoming a whole person. And I don't think change really comes from overt knowledge, it comes from love. Individuals with BFRBs are learning to have a relationship with themselves as whole beings instead of relating to parts of themselves (hair, skin, nails) which they treat more like objects. And once they can be fully embodied, then they can relate to others and allow others to relate to them in a full and meaningful way.