When I first started treating Body-Focused Repetitive Behaviors (BFRBs) in 2005, I learned that the “success” rate for treating BFRBs was 10%. This shocked me. I felt like I had to either prove that this was wrong, or do something to change it. I took a deep dive into the research on treatment for BFRBs, attended and then presented at national BFRB conferences, and worked with as many clients with BFRBs as I could.
Eighteen years later, I can confidently say that in my clinical experience with hundreds of children, teens, and adults with BFRBs (including my own patients, clients I’ve coached, and clients of therapists I’ve supervised), recovery is very commonly reached when the BFRB sufferer is motivated to change and has adequate support and accountability.
I first want to explain what I mean by “recovery” from a BFRB because this is commonly misunderstood. Recovery from a BFRB does not mean completely stopping the behavior. It’s nearly impossible to never pick or pull again, so expecting that outcome is like setting up for failure.
The most common cycle that occurs with BFRB sufferers starts with finding a helpful strategy that allows you to stop the behavior for a small amount of time. For some this could be just a few minutes, for others it’s a few days or weeks. Then a stressor pops up, or you just slip because you’ve been doing this behavior for over 10 years so of course the second you get distracted your muscle memory kicks in and you’re picking again.
As soon as you realize you’re picking, thoughts pop into your head like, “I’m such a loser. I can’t even stop for 5 minutes, I’ll never be able to stop forever.” So then you feel angry, disappointed in yourself, embarrassed, and hopeless, which just leads you right back into a longer pulling episode. Then you’re trapped in what feels like a trance that you so easily slip into but struggle daily to get out of. The nearly constant internal battle between the side of you saying, “I hate that I pull my hair out and the bald spots are making my life smaller and smaller so I have to stop!” and the other side that says, “It’s impossible. I’ll never be able to totally stop so what’s the point?”
The point is that you’ve been thinking of recovery all wrong. Being in recovery from a BFRB means that you are living your life fully without your BFRB causing a major disruption. It means being able to manage the urges and even stop yourself when you catch yourself picking most of the time, but it also means occasionally having slips of going back into hours of pulling. The key to long-term recovery is catching your slips as soon as possible, being kind to yourself about the slip, and then resuming one of your strategies that has been specifically tailored to your needs.
So, someone in recovery will deal with a slip in a much different way than what was described above. Here’s a real example from one of my coaching clients who is in recovery from her BFRB, with names and identifying information changed.
Mary is a young adult who has picked her skin excessively since she was 13. She has a lot of scars on her face and body, and she often misses activities due to open wounds. She completed a 10-week online program that I led with 6 other women with BFRBs. Mary has been in recovery since about the 4th week of the course, which was almost 2 years ago.
She identified when, where, how and why she tends to pick, and uses strategies that have been specifically chosen for her. Instead of picking for several hours a day, she now picks for less than 10 minutes, and she allows any damage to her skin to heal rather than continuing to pick off the scabs. This has allowed her to feel comfortable doing more with friends and family, and she generally feels much happier.
A few weeks ago, Mary had what she calls a “bad week” that involved a lot more picking than normal. When she recognized that she had slipped, she told herself, “you’ve had a hard week and you picked more. That really sucks, AND you’ve gotten through worse before. You’ve got this.” That self-compassion propelled her to then ask herself what tools had been successful in the past when she struggled like this. She printed out a calendar and bought herself some new fun stickers, and set two small, achievable goals – meditating 5 minutes before bed and keeping a tangle on her coffee table right next to the remote. At the end of the month she’d earned enough stickers to buy herself a book she’d been wanting. Even though she didn’t do her goals every day, and she still picked some, she still gave herself the reward because she was moving in the right direction.
Mary attributes her long-term success to the support and accountability she gets from a group of alumni of the BFRB course who I meet with once a month to check in and set new goals. This is a quote I received in an email from her referring to the alumni group, “It is the one place I feel most understood about my bfrb, and I don’t feel like I’m alone with it even though each one of us have unique relationships/circumstances with our own bfrb. I’ve had some pretty bad weeks, but I’m able to get back on track the week after. Being able to start again each time, without as much shame as I used to carry, has really helped with my mental health as well.”
I know that most of you have tried the strategies mentioned and many others without success. Most people I see say that these “tricks and tips” that work for others don’t work for them. There are several reasons why a general list of strategies doesn’t “work” for most people with BFRBs.
The first reason is that the strategies usually aren’t specifically tailored to that individual person, so they may work some or not at all. If they work a little bit, or even if they work a lot but not for very long, people tend to give up. I don’t blame them. I would give up too in that situation. You tried something and it didn’t work.
The problem with that logic is that BFRBs are much harder to stop than most other behaviors, and they don’t occur at the same times, in the same ways, or for the same reasons for every person who does them. There are some common situations in which they often occur, like pulling while driving to work, or picking while watching TV or getting ready for bed. However, in order to truly make a long-term difference in managing the behavior, we have to understand when, where, how, and why that particular person is doing the behavior, and then use a specific strategy for each instance.
These tailored strategies also have to be paired with a mindset shift towards acceptance that you will never completely stop doing the behavior, but that you can manage it well enough to have a full, happy life. The other major factors leading to long-term recovery are support and accountability, which are much stronger in a group setting than in 1:1 counseling or with a friend or family member. In next week’s post, I will explore why groups are so powerful, and.how to find the right group for you.
Laura is teaching a webinar for therapists on Friday, August 4th. Click here for more information or to sign up for free.
She and Lauren Hendrix will also be starting an online program for adults and mature teens with BFRBs on August 22nd. Click here for more information.