A Brief Self-Help Guide for BFRBs

This is a blog from The BFRB Club. If you want to read more about each of these steps and learn practical ways of going through them, follow our series of webinars. In October 2022, Step 1 webinar was published and is available only to Club members. Club membership is either FREE or only $10 a month.

After this month’s webinar on habit reversal training in the BFRB Club, I was asked to write a blog expanding on the four steps that I outlined in the beginning. Each of these four steps covers a layer of psychological work that needs addressing on your path to healing. And even though I feel obliged to say that psychotherapy does it faster and more efficiently, all of these can be adapted to be for self-help and with patience and discipline, you can go through all of these steps alone. Even better, with others in a similar situation. In early 2023, I will organize a group who wants an affordable way to work through these steps with a little more accountability, but more on that when the time comes.

In this blog, I want to go through each of the steps and explain how to approach them and why they’re important. To give you a warning, a lot will be crammed in here! My goal is to give you an overview of the process and the process being complicated and long, there is a lot of material that I will try to condense in a relatively small space. Perhaps it’s best if you think about this blog as a reference, rather than something to read at once.

The steps are the following:

•       Step 1: Get to know your BFRB and introduce replacement habits

•       Step 2: Develop discipline, patience, and self-compassion

•       Step 3: Emotional work: develop tolerance, awareness and understanding

•       Step 4: Unearth the psychology beneath your BFRB

Step 1: Get to know your BFRB and introduce replacement habits

To get to know your BFRB isn’t exactly an easy thing to do. To begin with, it requires acceptance. You need to be able to look at your pulling or picking without disgust, shame or self-loathing. If you can’t look without judging, you can’t see clearly.

What do I mean by “get to know”. First and foremost, it means get to know the mechanics of it: how it starts, how it ends. I’ll articulate this in several questions, just so that you understand what I mean by mechanics:

1.       How much of your picking is focused (conscious) and how much of it is automatic (mindless)?

2.       What are the exact hand movements?

3.       What initiates the process, seeing/feeling rough skin or hair, or do you first feel the urge?

4.       What is the urge to pick/pull like? How does it come about, is it gradual or is it sudden?

5.       What are the last thoughts and feelings that you have before you start feeling the urge?

6.       How do you know it’s time to stop?

But this only the beginning. There’s more.

Getting to know your BFRB means understanding what it does. In constructivism, because we talk about meaning, we also talk about function (it’s where meaning comes from), so we ask ourselves: what is the meaning of my BFRB, what purpose does it serve? In some CBT schools we might talk about “secondary benefit”, that which is gained by maintenance of a symptom. I prefer to talk about function and meaning because it sounds less devious and sinister and because it helps us see our problems as just "special cases" of what is fundamentally normal psychological activity. Frame it as you like, the same question applies: what is picking giving me?

Even if you’re prone to reductionist views and consider BFRBs “just habits”, you can’t escape this question, because for something to become a habit it requires repetition, and for you to repeat something sufficiently, it needs to serve some kind of a purpose.

It’s easy to intellectually respond “oh, it’s about self-soothing”, and it’s not even a wrong answer necessarily, but it’s a lazy answer. Insights are not very useful if they are only intellectual, they need to be embodied, they need to “click”.

Why is it important to figure this out? It’s a fair question. And the answer is straightforward: how can you replace your BFRB unless you find something that performs the same function? When I say “replace” here, I don’t mean replacement habits, and I will clarify the differences shortly.

Let’s say that these are the main aspects of what it means to get to know your BFRB. What follows is replacing the behavior. Pay attention to what I am saying here: replacing behavior, not the function. An example of replacing behavior is habit reversal training, and the webinar on that is already uploaded and ready for you to watch.

HRT is an efficient technique to replace picking or pulling behaviors. You learn to sit on your hands every time you want to pick, or to squeeze a stress ball whenever you feel like pulling. This is an empowering process; it gives you some control over your behavior and it certainly helps your body recuperate. What HRT doesn’t do is make up for the function of your BFRB. Let’s say, for the sake of this example, that the function is self-soothing. I have heard many people over the years say that competing responses that HRT introduces prevent them from picking/pulling when they use them, but they are a far cry from the pleasure, gratification or a sense of accomplishment that BFRB provides, even if just for a brief moment. A competing response is used consciously so by definition it can’t even give you that feeling of zoning out. The need to self-soothe isn’t met with competing responses, so they can replace the behavior but not the function. The function will be addressed in subsequent steps.

Step 2: Develop discipline, patience, and self-compassion

The second step concerns these three qualities: discipline, patience and self-compassion. In a sense, this step is a bridge that, on one hand, allows you to keep the progress you’ve made in Step 1 and continue to use the skills you’ve developed, and to prepare you for an emotionally taxing steps that follow. Let’s briefly consider each of the three qualities that I included here.

Discipline

Most of us don’t have the best associations with this word, me included. I find that there is a kind of stubbornness in me that I cannot be forced to do things no matter what the consequences. Discipline is, luckily, not what we imagine in popular culture. No soldieresque yelling or harshness. As a fan of simple definitions, I define discipline as making sure that your actions align with your values. If your value is to be healthy, then whenever your pulse races at the thought of having a cheeseburger, you kindly remind yourself of what your value is.

If your value is truly your value and if it doesn’t conflict with other values that you hold (which is possible), discipline isn’t as difficult to develop as you might think. It’s often sufficient to start your day or enter certain situations with a clearly defined intention.

Patience

Patience is a superpower that is both simple and difficult to attain. My definition of patience is acceptance of the fact that things unfold at their own pace and not the pace you determine for them. You can think of patience as being the opposite of impulsivity in the sense that you don’t jump on every emotional roller coaster that you experience. You can think of it as the opposite of anger. You don’t yell every time you don’t get what you want, you wait.

Patience is waiting while things unfold.

Patience as a skill is particularly important so that you don’t stop using Step 1 techniques because you feel confident in a specific period in your life or because you just spontaneously give up on them. Patience, when combined with discipline, allows you to continue to do what you need to do to get better even when it’s inconvenient.

When lapses and relapses happen – and they will happen! – patience allows you to suspend judgment and slowly disentangle the web of circumstances that led to them. What other way is there to prevent them in the future?

Self-compassion

The third skill that Step 2 requires is self-compassion. There is a tone of literature on the topic and due to high demand, I might just release a short free course to everyone in the BFRB club in the near future.

Compassion is the desire to alleviate suffering, a noble feeling worth cultivating, but one that, when directed towards others, needs to be balanced with good boundaries. Otherwise, you risk causing yourself unnecessary suffering and hindering the badly needed changes others need to make. Equanimity is a welcome supplement to help you not lose yourself in unskilled efforts to help someone.

This leads me to insert a caveat: there is some suffering in life that we can’t avoid. You have to get a vaccine, it might sting. You need to take an exam; you might be anxious. You begin therapy, it’s terrifying. Compassion turned inward (self-compassion) isn’t supposed to lead you to avoid the suffering you can’t avoid, especially if that leads to well being in the long run. The differentiation isn’t easy, especially if you’re having a hard time processing difficult emotions, as many who struggle with BFRBs do. Here’s a quick orientation on how to differentiate between the two.

Self-compassion is meant to orient you towards greater well-being and to prime your thinking in such a way that you spare yourself the unnecessary suffering, that which you create yourself by judging your own actions harshly.

Self-compassion allows you to learn from relapses without being hard on yourself, it allows you to remove a whole layer of triggers that stem from shame, perfectionism, etc.

Step 3: Emotional work: develop tolerance, awareness and understanding

Now that your symptoms have hopefully reduced and by cultivating the above-mentioned three skills, you have more insight and diligence in your use of replacement techniques, it’s time right time to start considering what drives most of your behaviors – your relationship to emotions.

We can identify several parallel processes here:

-          You begin by learning how to remain nonreactive to your emotions, but not how to zone out or dissociate; to feel them fully and not try to run away. You can do this through exposure, mindfulness, day-to-day awareness, different emotional tolerance exercises, etc.

-          The second part involves becoming more aware of your feelings in everyday life. Being a mindfulness teacher, my go to is to cultivate body awareness and to learn how to recognize different emotions in different parts of my body. There are dozens of different formal, structured meditation exercises for this, as well as hundreds of informal ones. The whole point of Step 3 is to learn how to process your emotions without having to resort to dysfunctional coping mechanisms such as picking or pulling, and in order to process anything you have to be aware of it. That much ought to be clear.

-           The third part of this step is the very point of it, the reason why you work through everything else I listed above: developing proper understanding of emotions so that you can work with them in a healthy way.

Understanding your emotions

As a constructivist, I hesitate to tell you what your emotions mean. Instead, in constructivist psychology, we prefer to focus on the function of emotions rather than a particular interpretation. After all, it is a staple of constructivist thinking to look at meaning as being a product of one’s personal experiences. By default, that makes recipes and life hacks useless. Everyone has to figure out what something means for them.

When we talk about understanding our emotions, we usually mean knowing the information that they convey. We can talk about information based on function. Function is where meaning comes from. To give you an example of constructivist thinking regarding emotions, let’s consider guilt, just to give you a taste of the kind of thinking is involved in processing emotions.

Guilt is information that tells something about the meaning of our actions. You don’t need a degree in psychology to figure out that guilt means that you did something wrong. But guilt is more precise than that. It’s not just a casual screw up, you did something that, at least for a second, made you the opposite of how you want to see yourself. If you want to see yourself as a good person, then you did something that made you see yourself as a bad person. This is, of course, a generic example as we all have very different constructs. Even when we use the same words, their content is different, colored by different lived experiences. Therefore, when you recognize that you’re feeling guilt, there are two things to consider: either your actions need to be different in the future so that you adhere to your identity better, or you need to question and potentially change your identity.

When we process emotions, we use them to learn and to grow. No matter how intense or unpleasant they may be, instead of running away from them, we can look at them, understand them, take their message seriously and grow.

Step 4: Unearthing the psychology beneath your BFRB

This step comes in the end but since it’s a long and meandering process, you can make the case that in some form or another, this is what you’re working on the whole time. As you learn about your own emotions, you are learning about parts of your psyche that need revision and change (guilt, threat, fear), you learn about parts of yourself that you need to build more (anxiety), parts that are already dysfunctional and need to be let go of (sadness).

I already emphasized that working with our psyche is always a very individualistic affair, that there are no solutions that work for everyone. If you believe there is a general answer that works for every person’s personal circumstance, email me, I have a bridge to sell you!

Hopefully, as you go through all the other steps, you get bits and pieces of the larger puzzle that is you. You learn how to see your BFRB as a solution to some other internal conflicts, an expression of your own complexity. I’m not exaggerating when I say that a kind of gratitude develops even, because picking or pulling may have helped temper the devastating effects of a trauma, they may have helped you graduate from college or work successfully on a highly demanding project.

There is very little to be said about this step that is true in general terms, because you’ll be finalizing the puzzle whose pieces you will be assembling along the way. This step, like all the others, will be a topic for a separate webinar and I will illustrate it with clinical cases, so that you can get a better sense of what I mean.

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This was a lot to take in, I know. But I did promise a lot and it’s not easy to pack a long journey of healing into a light text. This should probably be a book or hours of video material (which I will make and make it available for free to all the Club members, of course).

Start with Step 1 and spend as much time as you need on it. Don’t get overwhelmed. This is not a race.