Therapy for Body Focused Repetitive Behaviors (like Trich. and skin picking) has changed a lot in the last several years.There is now a new therapy called COMB which helps the therapist and client pinpoint which strategies to manage pulling and picking are likely to help the most. It’s probably more effective than Habit Reversal Training, which used to be the best type of treatment. (Research is being done.) COMB was developed by Dr Charles Mansueto and colleagues.
Today I’m writing about how I might approach treatment with a child or teen. However, if you are interested in treatment for adults, please keep reading, as the same general principles apply.
I encourage parents to buy Ruth Golomb and Sherrie Vavricheck ‘s book, “The Hair Pulling Habit and You,” a COMB workbook for kids and adolescents.
First, I help the child make a list of all the places and situations (such as when in the bathroom, when sitting on the couch, when doing homework, etc.) in which he or she picks or pulls. Then we figure out a strategy to use in each of these situations.
I tell kids that some people have a greater need to “fiddle” than others. It’s important to recognize this and cope with it rather than fight with it. We can figure out good strategies to help cope with the need to “fiddle”. I explain that an easy way to remember the different strategies is to think of a “Fiddling Sheep.” Each letter stands for a type of strategy.
S stands for “sensory.” Many people like to “fiddle” with smooth stones, koosh balls, brushes, pipe cleaners, etc. I suggest additional “fiddles” such as knotted dental floss. The Trichotillomania Learning Center has a store on its website and sells many attractive “fiddles”. The kid will keep “fiddles” on hand, for example, when he is doing his homework, and use them to cope with the urge to pull. Some of the TLC “fiddles” are cleverly disguised as “regular” pens, erasers, etc, so that they can be used in class without attracting attention.
H stands for “hard”. Many kids are helped by strategies that make it harder to pull or pick. Putting Vaseline on eyelashes or wearing a hat can help, for example. Any kid can wear a hat in bed or at home, and some kids get permission to wear a hat in school. A kid who has to take his hat off before pulling is much less likely to pull.
E stands for “environment”. There are ways to change the child’s environment to lower the triggers for pulling. For example, dimming the lights in the bathroom means the child can’t see stray hairs.
E stands for “emotions”. Kids with BRFBs, like adults, tend to pick more when they are under stress. Learning better ways to cope is an important strategy for stopping picking. Many kids, and particularly adolescents, feel terrible after they pull, and it’s important to learn to cope with “lapses” and go on with the treatment program.
P stands for “perfectionism”. Kids with BFRBs sometimes think that anything less than a perfect grade or dance performance or game is a disaster. Some of them are perfectionists about their bodies, thinking that it’s terrible to have any unevenness in their hair or skin. This kind of thinking encourages pulling and picking. We work on challenging their perfectionist thoughts and replacing them with more realistic ones.
I help parents set up a chart and teach them how to reward their child, not for not picking, but for using the strategies. (Here I am teaching the parents not be perfectionists. It’s distressing to see your child suffer. Parents and kids both benefit by seeing the effort, not the result, as the thing to reward.) I also encourage adults to reward themselves for not pulling.
Kids and adults can be successfully treated for BFRBs, but they will almost certainly have lapses. I believe that therapy has succeeded when a kid can have a pulling episode, manage the resulting distress, and start using the strategies again. This is what helps in the long run.