In a study of trichotillomania, it was revealed that only 19.1% of respondents had received psychotherapy, and 30.7% a behavioral intervention (e.g. self-monitoring, habit reversal), for their hair pulling symptoms (Flessner et al., 2006). These findings illustrate that majority of individuals are not seeking help, and that majority of providers are not informed to recognize or ask about pulling. Only 3.1% of those reporting treatment felt that their provider was an expert on trichotillomania, which clearly pertains to another finding: 74.5% rated their hair pulling as minimally improved to very much worse following treatment! This issue is illustrative of a broad problem: Sufferers need (1) to recognize when their BFRBs are problematic, (2) to be informed that help exists, and (3) to be able to enlist help from a competent provider.
These three issues each have their own complications. In the first issue, recognition is complicated by the fact that some amount of picking/pulling/biting is normal. This makes it easy to overlook the behavior with rationalizations or minimization about it as a form of grooming, development, etc., any of which can be true! The point is that it may be benign… or it may be something that warrants clinical attention. BFRBs can seriously impair daily functioning and bring on lasting physical damage, social avoidance, and feelings of shame, anxiety, and depression. No matter if it’s a child, teen, or adult, if someone is regularly picking, pulling, or biting, there’s good evidence something’s underneath that they feel they have to resolve auto-sensuously. And I don’t want people to have to suffer alone.
The second issue is more systemic. There is no single, reliable, or comprehensive place to find a therapist. And there is little education guiding people into knowing what they are looking for. Mental health remains one of those elusive and ambiguous fields that leaves individuals feeling around in the dark. Sufferers are limited in their awareness of providers, and providers are similarly limited in their awareness of each other. The TLC site is one of the most unified for BFRB sufferers, but still can only offer listings of those who opt to be listed. Referrals still rely primarily on word of mouth so ask around, and ask others to ask too. When you arrange a meeting with a therapist, know that it may take multiple, in-person sessions to get a sense of the fit. Therapy is built on the relationship, so listen to your subjective feelings of comfort with and trust in the therapist, and allow that to be a priority. People have all different personalities and work in all different ways, so “good” and “bad” will be more about personal taste.
Last but not least, the third issue involves enlisting help from a competent provider. In general, the underlying mechanisms for BFRBs and the extent of their impact are vaguely understood. Given the lack of attention and literature, it is especially hard to find a therapist who is familiar with, let alone specializes in BFRBs. More commonly, you’ll find a therapist who has heard of trichotillomania, for example, or has happened to encounter a client or two with it. A competent provider is one who can manage the hair pulling, skin picking, and nail biting through recognition of it as part of an entire impulsive, compulsive, anxious, depressed, desperate, and lonely picture. The focus needs to be on the person, not just the behavior. Commonly, other impulsive behaviors, such as binge eating, are co-occurring but not assessed, so take the time to invest in a therapist who can think globally, compassionately, and smartly on these issues.