Republishing this interview with licensed psychotherapist Tammy Fletcher, LMFT.
Dr. Fletcher, what does “BFRB” stand for? And what is a Body-Focused Repetitive Behavior?
TF: BFRB stands for Body-Focused Repetitive Behavior. BFRB is an umbrella term referring to chronic self-grooming behaviors which cause physical damage, such as to the skin or hair. There is generally a lack of impulse control, meaning the person may experience strong urges, and the behaviors are compulsive. The behaviors vary, but the two most widely known right now are trichotillomania, or chronic hair pulling, and dermatillomania, chronic skin picking. But behaviors like thumb sucking, nail biting, cheek biting, even chronic nose picking can be considered BFRBs if certain criteria are met.
When you say “generally,” do you mean each person with a BFRB is not the same?
TF: Definitely. There are some myths about BFRBs that we have to dispel in order to do the best we can to treat it. For example, not all people with a BFRB picks or pulls in response to anxiety. Some do rely on a BFRB to help them cope when they feel overwhelmed, especially in the beginning of the behavior’s development. But on the other hand, some people pull their hair when they are bored, or even when they are happy. Quite often, BFRBs are considered to go hand in hand with Obsessive Compulsive Disorder, Anxiety Disorder, Body Dysmorphic Disorder, and others. While I think they are likely more on the OCD spectrum, each person with a BFRB has to be treated as an individual, as they are not all alike.
Is self-harm one of the possible co-diagnoses?
TF: I am glad you asked, as this is a common misconception. BFRBs are not the same as self-harm behaviors like cutting. A person with a BFRB is not trying to inflict pain. More likely, they are trying to correct some perceived imperfection of the hair or skin. “That bump has to be squeezed, so that my skin will be smooth.” or “That hair is not like the others. I need to pull it out.” Yes, the result is often physical damage, but that is not the intent.
When someone comes to see you for treatment, how do you officially diagnose a BFRB?
TF: The person will usually tell me straightaway on the phone that they have a BFRB, like dermatillomania. Quite often they have just become aware that there is a name for this behavior, and possibly treatment. Still, I do a careful screening with each client. I developed a supplemental intake sheet that I send them, to fill out and bring to the first appointment. It not only gives me the information I need to make a correct diagnosis, but it gets the person thinking about their own history. In addition to the general intake questions that most therapists ask, I want to know exactly what the behaviors are, when they started, if anyone else in the family shows signs of a Body-Focused Repetitive Behavior, and what the person has tried to do to stop on their own. Broadly, the pattern I see that can lead to a diagnosis is the behavior usually starts in childhood or adolescence, it has gone on for a while, it may appear in other family members, the person is driven to the behavior by urges or compulsions, they may lose track of time or even dissociate, or zone out, during the behavior, there is some degree of physical damage, and they have usually tried to stop on their own and not been successful. I can’t stress enough that each person is unique, but those are some common signs.
How do you develop a treatment plan?
TF: My treatment plans are greatly informed by the TLC Foundation for Body-Focused Repetitive Behaviors’ Professional Training Institute (PTI) principles. Their curriculum is based in Cognitive Behavioral principles, and that is my background as well. That said, during a fairly extensive intake process, I begin formulating a tentative treatment program from the first meeting. I take into account what is invariably the person’s lengthy history with the behavior, and, for example, if they have found that fidgets don’t work, we hold off on fidgets for now. Most clients have already tried to stop the behavior on their own and failed. Some have come from other therapists or medical doctors, and they may feel they failed there, too. I want a treatment plan with small victories, so they start to know what that feels like (smiles).
What else do you need to know to move into the treatment phase?
TF: Clients are often amazed at how much detail I want about the behavior. “Where is your arm when you pull? Is it bent like this? Is it always the right hand that does the pulling? Will you pull with other people around?” etc etc. (laughs) The more we know about this behavior, the better we can work together to change it. Details help us figure out how to circumvent the behavior and buy some time, even a second or two, to allow the person to engage other tools they will learn, like awareness of any distorted thoughts, deep breathing, and mindfulness. It’s a multi-layered process and it takes some time to get all the parts working together. When it does, the person’s whole world shifts…it’s incredible. They feel empowered. They have felt this behavior have control over them for so long, and now they begin to experience being in the driver’s seat for a change.
You sound like you love your work 🙂 How long before you see these positive changes?
TF: I do love the work, no question there. My clients are my heroes. As for duration of treatment, I wish I could say “Do this, and within 4 weeks you will see a 50% reduction in picking behaviors…” but it doesn’t work that way. Most people come to me when they have been engaging in a Body-Focused Repetitive Behavior for a very long time. We move forward, see progress, hit a plateau, then regroup, then adjust, and move forward more. It can be frustratingly slow at times. I am an optimist, though, and I hopefully have an enormous number of tools in my toolbox (including the entire BFRB community, worldwide) to share. Ultimately, it is the client who does the work. I ask a lot of them and I know it’s not easy – journaling, putting fidget baskets everywhere, but I’m there to cheer them on every step of the way. Therapy for BFRBs does work, when you work it.
Any final words for people who think they may have a BFRB?
TF: You are not alone. Millions of people have some type of Body-Focused Repetitive Behavior. There is help out there. We have a resources page here, and there are some amazing organizations, like the TLC Foundation and the Canadian BFRB Network. Start there and follow their links, read their articles, and if you need to, reach out to someone trained in treatment of BFRBs and start your recovery journey.