Methods for Addressing Body Focused Repetitive Behaviours

Although Body Focused Repetitive Behaviours (BFRPs) such as Trichotillomania (TTM) and Skin Excoriation (SE) can create significant stress, impairment, and interference in the life of your child, the good news is that there are several treatment components that can help. These treatments are designed to help your child to become aware and notice the triggers that lead to pulling or picking, and to engage in alternative behaviours. As a result, this will interrupt and weaken the cycle of trigger urge pull/pick relief shame, while also strengthening your child’s implementation of alternative behaviors. In addition, ideas to modify the environment to make pulling and picking harder are also outlined. Although you can work together with your child to learn and apply these treatments, we highly recommend finding a professional with expertise in working with youth using Cognitive-Behavioural Therapy to be your child’s guide as s/he learns these tools. For additional resources please click here.  

Tool #1: Become Your Own Expert

Body-Focused Repetitive Behaviours, or BFRBs, are a cluster of habitual behaviours that include hair pulling (called Trichotillomania), skin picking (called Skin Excoriation), nail biting, nose picking, and lip or cheek biting. In both Trichotillomania (TTM) and Skin Excoriation (SE), the individual experiences ongoing and repetitive urges and actions towards either pulling out of one’s hair or skin picking (dependent on the disorder), resulting in noticeable hair loss, or skin abrasions or lesions. This occurs despite extensive efforts to stop these behaviours. In both disorders there typically is significant impairment or disruption in routine life functioning for the youth that include, avoiding routine activities, missed school, problems concentrating, social isolation, and family conflict, among other examples. Finally, girls/women are affected more than boys/men in both disorders.

It’s important to understand that BFRBs are not simply habits your child could stop if s/he tried harder. Rather these are conditions than involve complex brain mechanisms, which create urges and actions of pulling/picking that require specialized help to learn to manage.

Tool #2: Habit Reversal Training (HRT)

HRT is a behavioural approach that combines awareness training, and use of an alternative and incompatible behaviour, to eliminate hair pulling and skin picking. By bringing into awareness all aspects that precede the pull/pick (triggers), including thoughts, sensations, urges, behaviours, and emotions, the youth is better able to recognize that the pull/pick is about to occur. Yet rather than allow it to occur, as soon as your child becomes aware, s/he learns to immediately engage in a competing response. A competing response (CR) is a behaviour that is incompatible with the pull or pick, such as clenching one’s fists or sitting on one’s hands, thus preventing the pull/pick from happening. When this combination of increased awareness and use of a CR is done every time the pull/pick would otherwise occur, the cycle weakens. A useful analogy is monitoring your child’s academic progress- If you check in with your child or his/her teacher every few days, you’ll quickly know if there is a problem before it becomes a massive situation. Supporting your child in using the tools as soon as s/he notices urges and early warning signs, the easier it will be to control or stop the urges, and to reduce and eventually eliminate the pulling/picking. However, it becomes much harder to use the tools effectively if s/he waits until there is a bald spot or skin lesions. To learn and engage in HRT, have your child follow these steps:

  1. Collect information about what happens both internally and externally prior to each pull/pick. Take a sheet of paper and record what you were thinking, feeling, doing, any sensations you experienced, and any other important details that occurred right before the pull/pick.
  2. On the reverse side of the paper write out all the details to a pull/pick incident. Record the sensations you felt as you pulled/picked, emotions you experienced, thoughts, actions (e.g., playing with the hair prior to pulling, rubbing a bump on your skin, etc.), and any other important information during the pull/pick incident.
  3. Based on the above information develop 1-3 warning signs that best predict a pull/pick is imminent. For example, a tingling sensation on the scalp and a lightness in the hand.
  4. Begin to pay attention to these warning signs. You can use a pad and paper to check off, or record on your phone, each time you catch a warning sign.
  5. Next, develop a competing response you would be willing to do rather than pull/pick. This is an intentional movement that makes it impossible for the pull/pick to occur. Ensure your alternative behaviour is easy to do, subtle, and socially acceptable. Common examples include clenching both hands into a fist, sitting on hands, holding a pen/pencil, or keeping hands in pockets.
  6. Choose a relaxing action that you can do while engaging in your CR, to shift your focus away from the urge and onto your CR. For example, slow deep breathing, use of a pleasant image like soft rainfall or a gentle ocean current, or a body-scan of your muscles. Pairing a relaxing action with your CR can also help to reduce the tension that usually accompanies urges.
  7. Start implementing your CR every time you notice a warning sign. Instead of pulling/picking, engage in the CR for two minutes, or until the urge to pull/pick passes.
  8. Once your awareness is improved, each time you detect your warning sign/s, engage in your CR. Do this each and every time you encounter and urge to pull/pick.

If you find your awareness has lapsed and you catch yourself in the middle of a pull/pick episode, stop immediately. Engage in your CR. 

Tool #3:
Stimulus Control

Youth may find HRT doesn’t always work because the urges to pull/pick can feel overpowering at times, and sometimes the mix of pleasure, relief, and soothing that comes from a pull/pick incident is hard to resist. Therefore, combining HRT with use of Stimulus Control is optimal. Stimulus Control functions to eliminate temptations and reduce access to pulling/picking, by modifying the environment. Stimulus control involves changing how you behave and interact in your home, work, and other environments to make pulling/picking harder. The following is a list of ideas, although it is not exhaustive.

  • Use Silly Putty, Rubik’s Cube, or other fiddle gadgets to keep hands busy
  • Draw, color, paint, clay, or do other crafts that keep hands busy
  • Play with a smooth stone
  • Use a pot scrubber, sand paper, dried glue, or emery board on the fingers to provide a rough/picking sensation rather than actual skin picking
  • Brush a fluffy pet
  • Chew gum, raw pasta, toothpick, sunflower seeds, or other items to keep hair out of mouth
  • Wear Band Aids on finger tips or gloves to prevent finger grip
  • Wear a hat to cover head or forehead
  • Use lotion on hands or Vaseline on eyebrows/lashes to make pulling slippery
  • Cover mirrors in paper to prevent looking at skin
  • Get rid of, or give away for safe keeping, any implements used to aid in the pulling and picking, such as tweezers, needles, cleaning solution, etc.
  • Sit in the middle of the couch when watching TV or reading, so elbows are not resting on the arm chair allowing hands to be closer to the head or face
  • Study, read, or watch TV with others to prevent being alone when pulling or picking may occur
  • Keep the bathroom door open to prevent long, private stays that can lead pulling or picking
  • Sleep with hands in gloves or under the pillow
  • Drive with both hands on the steering wheel
  • Wear a specific scent or a charm bracelet on your wrist to alert you to your hands moving closer to your face/head.
  • Using a variety of these ideas, create “kits” to place in rooms where pulling/picking most often occur. Include the car and your office.
  • Consider rewarding yourself for using your kit, such as buying a magazine or treating yourself to a nice coffee, for every 10 kit uses.

Once you have chosen a handful of ideas, begin to implement these. Some youth like to have a parent subtly prompt them to use their skills (e.g., a look or a gentle shoulder tap), while others prefer to do this independently. Talk with your youth about what might be best. You can also decide together whether it would benefit to get permission to use a kit in school if this is also a risky location.

An Important Message:

As a parent helping a child with a BFRB, you will quickly learn that while you can provide all of the above information to your child, s/he has to be the one to do the actual work. You know the saying, you can bring a horse to water but you can’t make it drink. However, this can be difficult to follow, and sometimes it’s heartbreaking to watch your child struggling. Therefore, we encourage you to remind your child that success is in the effort, not the outcome. This means you can cheer for your child when s/he practices using the tools, even if at first the pulling or picking persists. But of course, the more s/he practices, the more likely the tools will begin to work. It is also important to remember that the purpose of these tools is to help control the urges, not to eliminate them. Just because your child has an urge does not mean s/he is failing. In other words, its what you do with the urge that counts, not the urge itself.