Perfectionism & BFRBs

One of the themes that I see time and time again working with people who pull their hair or pick their skin is perfectionism. Sometimes, people will come to therapy already aware of the connection, but often times they wouldn’t even identify their patterns of thought and behavior as being perfectionistic. Our exploration of perfectionism may come from innocuous (but repeated often enough) statements like I just want to do a good job; I want to be a good father/wife/co-worker, etc. In one instance – and I’m sorry if I’m repeating myself, but I tend to quote it often, a very blunt, direct: “All I want is for my skin to be completely perfect, is that too much to ask?”

Is perfection too much to ask for? I don’t, let me think.

Perfectionism is a double-edged blade that can drive people to achieve remarkable things while also inflicting tons of unnecessary stress and suffering and often depriving a person from feeling accomplished once they achieve true feats of greatness. Perfectionism is the psychological equivalent of “the world is not enough”.

Perfectionists often set exceptionally high standards for themselves and strive to meet or exceed them in at least one aspect of their lives. One can have a sloppy house but be a perfectionist at work. Even though all-or-nothing thinking is a common feature of perfectionism, perfectionism itself, like nothing else in this world, isn’t all-or-nothing. The pursuit of perfection can make a person with a tireless work ethic, superb attention to detail, a strong desire to excel at some things. Some of my favorite pianists like Michelangeli were perfectionists, and while this helped them perform incredibly well, it also made them averse to performing and chronically unhappy with their performances. Because my brain isn’t a perfectionist, but a ordinary sloppy Joe, here’s an unrelated and uncalled for tidbit. Brahms, the famous composer, was known in his day as very much of a perfectionist. It took him about 15 years to produce a score for his 1st Symphony!

The flip side of perfectionism is the overwhelming pressure it places on individuals to constantly perform at an unattainable level and to outperform themselves, leading to self-doubt, anxiety, and a fear of failure. A perfectionist can change the world and still feel like a complete and utter failure because they didn’t change the world 100% according to their vision, but only 99%. That 1% difference is all a perfectionist can see, or at least emotionally react to in the moment.

While it can fuel ambition and propel individuals towards greatness, it can also become an insidious trap that hinders progress and well-being. When the only acceptable outcome is perfection, trying out highly imperfect strategies for change is terribly difficult, leaving perfectionists trapped in a kind of a limbo: unhappy where they are but terrified of failing to change it… perfectly.

Perfectionist thinking

Without getting too technical, let’s consider a few traits of perfectionist thinking and how they may rear their ugly heads in body-focused repetitive behaviors. I will provide a few examples for each of these. Even if you don’t consider yourself a perfectionist, use this as an opportunity to reflect on your standards and different ways of thinking. If you’re different than a perfectionist, then – different in one way? If you’re curious enough about your psyche, opportunities to get to know it are everywhere.

Impossible Standards

Perfectionists set excessively high standards for themselves and others. And when I say excessively high I really mean impossible. They believe that anything short of perfection is a failure, leading to a constant pursuit of flawlessness and a constant sense of being a failure at it. In a sense, perfectionists confuse the map and the territory. To know how to act and what decisions is the right one for us, we need to have a sense of direction and for that we need an “image” in our heads. The error that perfectionists make is to confuse this image with reality. An image only an image. An image can be perfect, reality never is.

Here are some examples of impossible standards that I often see in my practice:

I have to have perfect skin to be happy.

My hair can’t have any grays, or I’ll look ugly.

I will stop picking when my skin is completely smooth.

Beautiful skin is skin without pores.

Black and white thinking

Perfectionists tend to view situations in black and white terms and find themselves conceptualizing their choices in a very strict all-or-nothing manner, seeing success or failure as the only possible outcomes. When you succeed, it’s a complete success. When you fail, it’s a complete failure. Gray is not a color that a perfectionist is well acquainted with! Perfectionists struggle with embracing the idea of incremental progress or accepting that mistakes are a natural part of the learning process.

When a perfectionist comes to therapy for BFRBs, this mindset poses a particular problem. Change is almost always incremental and very sloppy, it’s not a matter of either pulling your hair or not pulling your hair at all. Going from to the other is a journey with many twists and turns, one that most often involves reduction rather than changing overnight.

Fear of failure

Perfectionists have an intense fear of making mistakes or falling short of their own expectations and, in all fairness, this is because their lived experience tells them that this is likely. Think about it: if you set an impossible standard, what else can you do but fail? They often equate their self-worth with their achievements (self-esteem) and are deeply concerned about the judgment and criticism of others. A perfectionist must be beyond reproach.

Here are some examples of this I heard in the past two weeks alone:

I want to stop picking my skin by August because I’m going to a wedding. My skin has to look flawless. I don’t want people thinking I’m a messy, gross bride. (A client of mine on her motivation to start therapy for skin picking.)

I didn’t practice my competing responses at all. I was scared they wouldn’t work or that I’ll forget about them and then feel like shit. (A client doing habit reversal training, on why she didn’t implementing replacement habits for the third week in a row.)

It’s so hard to speak up at work because I’ll be seen as a belligerent person. I want my co-workers to see me as hard working and graceful. If I complain about my workload, they’ll think I’m lazy! (A client who has two young children and works 12h shifts because she’s overloaded with work. Her hair pulling is at its worst now and she identified burnout as a major trigger. Yet, it’s more important that she’s perceived positively than to stop pulling!)

Excessive attention to detail

A perfectionist is a person with a well-trained eye, catching on even the smallest details, often getting caught up in minor imperfections or insignificant errors. The mind of a perfectionist will amplify every flaw and every mistake and make it the biggest and the most important one. This attention to detail can be beneficial in certain contexts but can also lead to a lack of productivity and an inability to prioritize tasks effectively. Surprise, surprise but this leads to even more suffering and feeling like a failure.

Clients who have trichotillomania or dermatillomania will fine-tune their eyes or fingertips to notice even the slightest imperfection. When my clients tell me that they only pick or pull at what’s imperfect or what “shouldn’t be there”, I ask if it ever happens that they look or scan but find nothing and the perfectionist’s answer is a clear – no.

Lost self-esteem

Perfectionists are highly self-critical and have a harsh inner dialogue that eventually erodes their self-worth. A perfectionist is focused on getting validation through achieving what isn’t possible, so expecting anything but low self-esteem isn’t brain science.

Consider these few examples:

I didn’t pick for three days this week and then yesterday I ruined all of that by picking while watching TV. Christ, I’m such a fucking loser!

I’m really weak. I knew I was going to fail and, yes, things were going well for a few days and then I did fail and I pulled a few hairs.

Procrastination

Perfectionists often struggle with procrastination. They may delay starting or completing tasks because they’re terrified of failure. Procrastination is a curious phenomenon and its connections to body-focused repetitive behaviors deserve a more thorough exploration (here’s a topic for a future blog). Suffice it to say here that procrastination is not just putting things off. It’s actively not doing something, it involves pushing away thoughts that you should be doing something, it involves putting in the effort to avoid the anxiety resulting from those thoughts, and to invest the remainder of your energy into doing something else. Sounds exhausting? It’s because it is.

Skin picking and hair pulling can turn out to be quite useful strategies – and I don’t mean this ironically – to alleviate some tension that inevitably lingers while procrastinating. You can easily see how important this is if you know that perfectionists live with a lot of tension anyway, due to impossible standards they set for themselves. Although ultimately unhealthy, body-focused repetitive behaviors are effective ways to self-soothe!

In terms of treatment, it’s obvious: a person who procrastinates will start therapy but pay and not show up for sessions or may even postpone the beginning of the treatment. There’s a paradox there – a perfectionist must somehow be OK with their own current imperfection to actually start therapy! It’s an insight that doesn’t settle in quite so easily.

Decision-making paralysis

Perfectionists can find it challenging to make decisions. If deciding means that there’s even a remote possibility to make the wrong choice (and that possibility is always there by definition) then even the smallest decision can feel like a thousand yearlong torture in hell. A client of mine once described how choosing bread in the supermarket makes her pull her hair right there on the spot. Something that may appear banal to someone else is a core theme for her: what if she chooses the wrong type of bread?! Perfectionists may spend excessive time analyzing options and seeking reassurance, causing indecisiveness and inefficiency.

Avoidant behaviors and perfectionism

I hope it’s clear by now that perfectionists have plenty of reasons to avoid parts of their external world, but more than anything else – their own internal experiences. A perfectionist lives with so much anxiety and tension that constantly linger in the background that it would make it hard to function if they didn’t employ some kind of an avoidant behavior.

Avoidant behaviors can manifest in various ways for perfectionists. They may procrastinate on tasks or projects, continually delaying their initiation or completion due to the fear that they won't be able to achieve the desired level of perfection. By avoiding starting or finishing something, they can temporarily avoid the possibility of facing imperfections or criticism. Perfectionists may also avoid taking on new challenges or opportunities that carry a risk of failure. A promotion? No thanks. An honor to some, but a source of psychological horror to others. Organize a family trip? Nope, what if someone doesn’t enjoy it? They might shy away from trying new things or taking on roles or responsibilities where they feel they may not be able to meet their own lofty expectations.

Furthermore, perfectionists may avoid seeking help or support from others because they fear that it would be an admission of their own shortcomings or a sign of weakness. They may hesitate to ask for assistance or delegate tasks, believing that they should be able to handle everything on their own.

Experiential avoidance, which refers to the tendency to avoid or suppress unwanted thoughts, emotions, or sensations, can have various negative consequences on individuals' well-being and functioning.

It's important to note that while experiential avoidance may offer short-term relief from discomfort, it often perpetuates a cycle of avoidance and can exacerbate long-term distress. You get some calmness today, but you’re chipping away at your own self-esteem in the long run.

Body-focused repetitive behaviors like skin picking or hair pulling are often associated with avoidant behaviors described above and fit into the pattern perfectly (ha!) – they provide some relief but in the long run erode self-esteem.

Perfectionism and self-soothing

Self-soothing is a vital aspect of human development, stemming from the earliest stages of life. In developmental psychology, it is understood that infants rely on self-soothing behaviors to regulate their emotions and establish a sense of security. First, it is the parent who is meant to soothe the babie as babies develop, gain capacity to and learn how to self-soothe by sucking their thumbs, cuddling with a favorite blanket, or engaging in rhythmic movements. They begin to develop self-regulation skills. Many people who have BFRBs lack these skills or their picking or pulling may be the only ways they have to self-soothe.

These early experiences lay the foundation for the capacity to comfort oneself throughout life. The ability to self-soothe continues to be important in later stages of our development, as individuals navigate challenges and stressors. By recognizing and utilizing self-soothing techniques, individuals can tap into the innate human capacity for emotional regulation and create a sense of inner calm and stability.

Perfectionism and self-soothing are often intertwined as individuals who possess perfectionistic tendencies frequently seek ways to calm and comfort themselves amidst the relentless pursuit of flawlessness. The intense pressure and self-imposed expectations of perfection can lead to heightened levels of stress, anxiety, and self-criticism. In response to these negative emotions, perfectionists may instinctively turn to self-soothing techniques to find some relief. Body-focused repetitive behaviors provide such comfort, especially when they are a part of a person’s life for a very long time. Long-lasting habits are safe even if they have bad side-effects. What makes us feel safe is the ease of anticipation. Every time you pull or pick, you know how things will develop, what will happen and often in what order, and this applies both to self-soothing and to the bleeding and the scars and the bold spots. Predictability provides comfort even if what you predict isn’t particularly good.

Stabilizing strategies

Defense mechanisms such as experiential avoidance (and BFRBs as a manifestation of it) serve as psychological strategies that help us cope with challenging or distressing situations, allowing them to feel better temporarily. This is why it’s so difficult to “just stop” picking or pulling: it would mean giving up the only or one of the only ways that a person may have to protect themselves psychologically from experiences that feel overwhelming.

While defense mechanisms provide a sense of relief, they can also hinder personal growth and prevent individuals from making lasting changes. Picking/pulling creates a buffer between you and your uncomfortable internal experiences. That means that your ability to know yourself and develop self-awareness becomes hindered by the act of avoidance. Acceptance is a pre-requisite for change, and if you can’t see yourself clearly, you can’t accept yourself and, therefore, you can’t change intentionally.

Furthermore, defense mechanisms can become habitual and automatic responses when they’re present for a long time, making it additionally difficult to understand what they mean or even notice them while they operate. How many times do you just find yourself picking or pulling and you realize you’ve been doing it without any awareness?

Instead of addressing the root causes of distress (perfectionism in this case), individuals may rly on trichotillomania or dermatillomania as quick fixes, perpetuating a cycle of avoidance and denial. It perhaps sounds like a radical thing to say, but this is a way to preserve one’s perfectionistic identity. This can lead to the repetition of problematic patterns and the reinforcement of negative behaviors ad infinitum.

And to finally conclude

This was a long one, but hopefully you understand how perfectionism fuels BFRBs and how BFRBs further help perfectionism erode your self-worth.

I can only assume that I’m leaving you partially unsatisfied because here you are reading five pages of my rambling and you’re leaving without that one final, important piece of the puzzle: what on earth is it to be done? How do you change that? Stay tuned for next week’s blog for that one!