Sunday, February 7, 2016
Trichotillomania and Other BFRBs Are Not Self-Harming Behaviors
Therapists working with Trich (as well as those with Trich themselves) must understand that Trichotillomania is not self-harm but rather a self-soothing behavior. That is not to say that one does not experience harm as a result of doing it, but one can say the same of addicts. yes the addiction causes harm, but it is done to feel good and is not known as a "self harming" behavior. This is a crucial psychological point when understanding and working with Trich and BFRBs, whether your own or your patients.
I have many clients whose previous therapist addressed their hair pulling as though it was analogous to "cutting." This is highly ineffective and without understanding the difference, it's not possible to get better or to help someone else get better.
When I say Trich is not self harm often people reply, "But Claudia, how can you say that, hair pulling does cause harm." I understand that the *results* of hair pulling and skin picking are harmful to people. Both picked-at skin and missing hair can deeply affect one's self-esteem and well-being. However this is the same kind of harm caused by any addiction, i.e., drinking, shoplifting, bulimia, excessive spending, narcotics use. People with BFRBs pull, pick or bite with the goal of self-soothing; the goal is not to harm but to feel good in the moment. Similarly an alcoholic who drinks to excess isn't drinking with the goal of causing themselves liver damage but because they want to feel better.
Self-harming behavior on the other hand is a behavior in which one's will is involved and the goal is to hurt one's self (even if one has learned to "enjoy" the pain). Sometimes this is because the person has felt or currently does feel so much emotional pain that they have decided it's better to at least be in control of the pain they feel. For others who may feel "numbed out", they explain that they want to feel something, even pain, rather than nothing. People who self-injure may even describe causing themselves pain as a way to self soothe because feeling pain is soothing to them. But this is very different from addictive behaviors done to feel pleasure or to numb out.
The type of personality involved in each of these behaviors is also quite different. People who self injure are likely to have been victims of abuse. According to the U.S. National Center on PTSD as many as 93% of those who engage in self harming behaviors harve been severely abused.* You don't see this with people who have BFRBs. It isn't that no one who has a BFRB has been abused, but there is no correlation between the behavior and having been abused. In other words, the occurrence of abuse in those with Trich and skin picking disorder is the same as that of the general population
The way one works with someone who self-harms is very different than the way one works with BFRBs. For one thing, there just isn't intent when it comes to Hair pulling and skin picking. They are often begun unconsciously and, as with alcohol and the first drink, after the first "pull" or "pick" there is an uncontrollable urge to keep going as with other addiction.* I consider working with BFRBs somewhat similar to working with people who overeat addictively. It probably will continue to happen for a while while you're working with them and it won't put their lives at risk. It's a process of gradual recovery, learning to let go of shame and learning to love one's self (and not to base self-love on one's appearance). (Note I didn't say self-esteem but self-love. Even if one doesn't like the way one's appearance is affected by any of these behaviors, one must still love and accept the self).
With self-harm one generally has to treat PTSD and one may even make a contract with a cutter not to cut. One may also explore the feelings that preceded the desire to cut. Such an approach does not work with BFRBs. Although there are general feelings that people must deal with who suffer from BFRBs, a contract to abstain is not possible with BFRBs. Recovery is almost always gradual for one thing. And almost no one will be able to identify what they were feeling before they started pulling were picking. Using these approaches can cause people with BFRBs to feel they are failing. This ingrains a sense of hopeless about ever being able to recover. And believing that one can recover is absolutely crucial to any kind of recovery.
I believe one reason skin picking and hair pulling were initially understood and self harming behaviors is because those of us who suffered from them did not know how to explain to a doctor or a therapist that these things felt "good" to us. I pulled my hair out for over 20 years (and I've been mostly pull-free for 20) and it never occurred to me to explain to anyone that the behavior felt good. there was so much shame involved in the behavior to begin with talking about it was excruciating. When it comes to things like bulimia, everybody understands that eating food feels good. And people also understand the desire to get rid of the calories. Hair pulling and skin picking perhaps only feel good to those with these disorders. But feel good, they do.
I believe the feeling ultimately replaces an internal sense of security, wholeness and selfhood. Hence many with BFRBs have codependent behaviors and perfectionistic traits. almost everyone I have worked with has begun to pull or pick less and less as we address these core behaviors and work together on instilling in a person the internal sense of self-soothing they are missing.
I am located in Los Angeles but work with people in many other countries on these issues via Skype. Feel free to contact me at ClaudiaMilesMFT@gmail.com .
**In terms of impulse control and inability to abstain, BFRBs are highly addictive. The behavior has not been called "addiction" in any scientific study but has been categorized under impulse control disorder.