What Do We All Have in Common?

What do we all have in common, someone asked on Instagram recently. I was immediately intrigued by the question because it would require me to gather my otherwise scattered clinical impressions and look at dermatillomania and trichotillomania from a more integrative perspective. An intriguing, difficult task. At the same time, I felt some reluctance to do it because I don’t enjoy generalizing. The pleasure of being a therapist is the exact opposite: approaching every person with “naïve” eyes, not comparing them, or putting them in some predefined boxes and instead allowing their life story to unfold in its own language and on their own terms. Consider this the caveat for this blog post. I’m collecting my clinical experiences to point out some themes that my clients often bring up. These may not be relevant to you, or they may be relevant, albeit in a very specific way. Your lived experience is the ultimate judge. Always.

Think of this as part one. In this blog I will outline the big, comprehensive topic and I will gather some “smaller”, at least on the surface, less relevant tidbits that I find intriguing.

Shame

This may seem like a very general place to start, and you’d be right to ask: sure, Vladimir, who doesn’t feel shame?

But shame and BFRBs have a special bond. This is no ordinary shame we’re talking about. In some ways, shame is a building block of the problem itself.

As a therapist, I don’t work only with clients who struggle with BFRBs. I also help people with other problems such as borderline personality disorder, depression, schizophrenia, panic attacks, etc.

It’s very rare that I see other clients struggle with so much shame like my clients who have BFRBs. Because BFRBs are not talked about very much, because there are very few public personalities who speak openly about their struggles, because psychotherapists and psychiatrists aren’t very knowledgeable on the subject, many people come to me thinking that there is something particularly wrong with them, that their issue is somehow “gross”, “disgusting”, “unacceptable”, etc. At the same time, how can having a “gross” or a “disgusting” problem not change how you see yourself, on a very deep level?

Shame is something I often address in therapy right from the start because it’s such a corrosive force. Shame leads people to hide their behaviors and find ways of picking and pulling that make it less noticeable. When your problem exists only in the private sphere and you don’t share it with anyone, there’s very little accountability or even insight: it’s very easy to overlook the full extent of the problem when it becomes invisible.

Shame protects your BFRB.

Emotional regulation issues

Perhaps the most common topic of conversation with my clients is how easily they get overwhelmed and what a “great” resource BFRBs are for those intense situations, what a refuge a picking trance can be and how soothing pulling is.

Although I have yet to see two clients who told me identical family stories, a common theme that I see is that those clients who develop BFRBs grow up in families where they weren’t taught how to process their emotions very well or at all. Issues such as avoidance, suppression, dissociation or acting out can stem from their inability to understand their feelings. After all, what else do you do with a scary experience but run away from it, if you have no functional tools to make sense of it?

Another issue related to this is that many of my BFRB clients struggle to recognize what they’re feeling – or that they are feeling anything at all – until their feelings become too intense to cope.

Conflict avoidance

Conflict avoidance is another important recurring theme and it’s often connected to the previous one: if you struggle to self-regulate in emotionally charged situations, conflict can seem unbearable. Another reason why many of my BFRB clients dread conflict is because they anticipate that conflict may lead to the end of a relationship or that they may disappoint someone they care about.

The buildup of tension in anticipation of conflict often triggers picking or pulling episodes and can even lead to long trance-like states.

External sources of validation

It’s difficult to say if this is just a matter of Zeitgeist because so many of my clients spend their time ruminating on how they’ll be perceived and judged by often irrelevant others, but it’s important to mention it here as fear of being judged or rejected is often a trigger for BFRBs and their consequence: what if people notice my bold spot? What if they see my red face? The more they ruminate on this, the more anxiety builds up and triggers picking or pulling, creating more damage that will only exacerbate fears of being judged. Guess what that leads to? More picking or pulling and on and on we go!

It’s worth mentioning that societal beauty standards play a huge role in the suffering of many of my clients and this applies to female clients especially. Even though there are beauty standards for men – especially for gay men! – society still singles out women’s bodies and projects unattainable ideals onto them. If you’re prone to seeking validation from your peers, you are more likely to internalize these standards.

Negative self-talk and lack of self-compassion

While people who are anxious or depressed don’t necessarily lack self-compassion, my clients struggling with BFRB lack self-compassion to the point where I find it so striking, I almost feel like each of them should go through a self-compassion course. (Nota bene: that’s why we have a free, short one in the club.) This is a nearly universal theme in my practice.

This indifference towards one’s own suffering to an extent explains the choice of a symptom. While skin picking and hair pulling are not self-harm, they do involve hurting one’s body – inflicting pain and not working to experience less suffering.

This poses a bit of a conundrum when it comes to treatment. Even though many people come to therapy because they’re aware that their BFRB is a problem that they need to deal with, lack of self-compassion can represent a significant challenge. A BFRB is a problem because it causes suffering (obviously) and if you lack self-compassion, you lack the willingness to reduce your own suffering. In that case, what drives the treatment?

Ambivalence: “just” a habit or a deeper problem?

Especially when people begin their journey, there seems to be a great amount of ambivalence. There’s a strong temptation to write off their BFRB as merely a bad habit, but at the same time, when one can’t deal with a habit alone, it becomes clear that what seems like a mere habit may be something more after all...

Insisting that BFRBs are just habits is almost like trying to say „nothing to see here people!“ – a refusal to look under the surface.

Gender

While some recent data indicates that there aren’t significant gender disaprities in the prevalence of BFRBs, the overwhelming majority of my clients are female. I don’t know the exact statistics, but I believe that the majority of the BFRB Club members are female too.

I don’t know if this is any way relevant, but it appears that women are more likely to recognize BFRBs as problems and certainly more courages to seek treatment.