Substitutes, Fiddle Toys, and Blockers

Employing outside aids - sensory substitutes, fidget toys, behavioral blockers - are not by rule good or bad. I am, however, thoughtful about when I recommend them. The key to me is whether they are being employed honestly and earnestly. Slapping them on yourself in an automatic attempt to stop your picking, pulling, or biting is different from putting them on after you have gone through the hard work of choice.

Our first reactions to our BFRBs commonly involve unanimous censure of, “You need to stop,” which differs from the personally and eventually attained, “I want to stop.” Beanies, vaseline, stress balls, and gloves should not be employed at times when you try to impose a No when you are honestly feeling a Yes (to picking, pulling, or biting). They have to be tools that merely support your decision for a different outcome in a BFRB moment. The root of change needs to be YOU because you will always be more powerful than any piece of fabric, cloth, lubricant, etc. (and thus can simply ditch any of these). They can and will not stop you unless you want them to! Furthermore, expecting these random things to do the work for you instead of because of you will maintain a belief that hope, power, and salvation lie outside of you when they do not.

BFRBs offer a source of comfort, so we turn to them as simply as a child would to their blankie or pacifier. For adults, choosing to go from comfort to absence requires commitment and possibly help. These outside tools come in and ease the burdens of follow through once you have surrendered to the reality of your BFRB, made your choice, and now can simply use some support. (Mindful awareness, internal reflection, emotional vulnerability, weighing of outcomes is hard work!)

I don’t believe anyone should have to “fight” themselves, and it is no longer “restriction” when you are giving yourself what you have resolved you want. Remember that these tools shouldn’t be exploited to “block” you, but embraced to aid you. Invoke them once you have arrived at a feeling in a BFRB episode that you truly want to desist and you don’t want to do it alone (because you don't have to!). Remember to leave time for the urge to pass, and that you can also involve PEOPLE and not just things.

Best of luck, devotion, and skill!

Insulated, but Isolated: Part I

One of my primary interests is in “self-containment.” I’ve never attempted to discretely define this before as I understand it in a more felt than articulated way. My interpretation of it has to do with how you feel held. Our skin is one of the first that comes to mind as one of our first - and perhaps most foundational - containers to our existence. It holds us together and sets the limits of our physical boundedness. We then evolve to understand and appreciate not just the physical container of our house, but also the containing functions of our social units (e.g. family, church). The laws and norms of our institutions, generation, and culture provide us with a reassuring feeling of structure, or containment.

Containers are designed to keep the desired in and the undesired out. They, by design, INSULATE, which, by nature, can ISOLATE. This is the potential problem. There is a high amount of emphasis in this society on self-sufficiency and independence. There is also a high belief in this society about logic (“neat and contained”) > feelings (“messy and uncontained”). Both of these can put significant (even if unconscious) pressure on us to self-contain.

What does that even mean or look like?

Imagine that you are wanting a raise at work. You’ve been at this company for just over a year and you have a new car that you need to make payments on. You think you’ve been doing a good job but are also aware that a year is not a short time, but also not a long time. Is this enough time to warrant a raise? You dropped a hint to your boss last week but she seemed to ignore it. Say something again? Making payments on your car is a real stressor for you, but is this a good enough reason? You know that your co-workers also have their own stressors too. You even know that some of them have been there longer than you and are also doing good work and you’re pretty sure they haven’t gotten a raise. What makes you so special? Why should they make exceptions for you? Especially when they talked about budget in the last meeting and it doesn’t seem like there are extra funds to go around. Guilt sets in. Doubt sets in. And you realize sometime in this train of thought your hand moved up to your head and five hairs are now lying on the desk before you.

This vignette captures the common way we can get stuck in our heads. The problem is when this becomes our default and regular mode of being. We stop looking beyond ourselves for answers or comfort, and become invested in this process of figuring it out ourselves. We have stopped engaging others in our thinking, enlisting our friends or teachers in compassion, seeking out places to discharge energy, or trusting in others' ability to validate and accept us. We have interrupted feeling and diverted all our energy instead into thinking. Our preoccupation with our minds also keeps us out of our bodies (which is different than enacting on our bodies). We fail to develop trust in ourselves to be able to bear the uncertainty of what will happen. We switch to neurotic analyses to predict outcomes like the one above under the false (but desperate) belief that we can know (and thus control) everything… if only we think about it thoroughly enough. However, there will never be a degree to which our thinking can substitute for simply approaching our boss with our needs and concerns. There is no way our private analyses can make up for the bond that can be created between people having a lived conversation. And there is no way internal predictions can produce anything more reliable-feeling than actual conclusions. When we self-contain, we never end up as satisfied or as soothed as we do when experiences are shared with others and lived out beyond our own heads.

.. Stay tuned for Part II! ...

For individuals seeking insurance reimbursement

I'm including this post on behalf of current clients and potential ones who are seeking insurance reimbursement for their body-focused, repetitive behavior (BFRB) treatment.

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If you have a PPO: You have the freedom to choose any healthcare provider you want (which includes me!) and receive benefits. You are guaranteed some financial assistance; however, your out-of-network reimbursement (e.g. 40%) will not be as generous as your in-network reimbursement (e.g. 80%). (These numbers are for illustration, you will have to speak with your insurance company to learn the details of your particular plan.) If you are feeling ambitious and would like to pursue the higher reimbursement rate, the following is for you...

If you have another type of plan, like an EPO or HMO: You must stay within the contracted network of providers (which does not include me) to receive benefits. You will be paying out of pocket to see me... unless you get an exception. The following will guide you on how to get your insurance company to help pay for your BFRB treatment...

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The magic term here is a "network gap exception." Insurance companies won't advertise it because of the cost to them, but these provisions were designed for cases like BFRBs. This article (<-- click there!) provides a more detailed explanation:

"A network gap exception is a tool health insurance companies use to compensate for gaps in their network of contracted health care providers. When your health insurer grants you a network gap exception, also known as a clinical gap exception, it’s allowing you to get health care from an out-of-network provider while paying the lower in-network cost-sharing fees."

In short, if an insurance company does not have an in-network provider for your condition nearby, by law they must cover you to see an out-of-network specialist. In an attempt to not have to subsidize, they will provide you with a list of names of providers who treat "anxiety" or "depression" or "OCD" or maybe have seen a patient or two with hair pulling issues, but THIS IS NOT AN APPROPRIATE REFERRAL. You need a BFRB SPECIALIST and I still have not encountered a single insurance company who has one on their panel. Your insurance company may also refer to a "single case agreement," but THIS IS ALSO NOT WHAT YOU WANT. You need them to bridge the gap in their network as your right and their obligation.

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I recommend you read over this (<-- click there!) article as well, and consult me for further advice and the necessary diagnostic and procedure codes for your inquiry. Keep good documentation of your conversations (including reference #'s), and remember to set your network gap exception to the maximum allowable time frame. BFRB work is long-term work! Dealing with insurance companies will test your will and patience, but if you stay committed you can prevail!

Why We Pull, Pick, and Bite

Basic principles of operant conditioning tell us that behaviors are usually maintained because they deliver pleasure (positive reinforcement), or because they relieve some source of displeasure, like anxiety and tension (negative reinforcement). The answer to the "Why?" in terms of body-focused, repetitive behaviors, such as hair pulling, skin picking, and nail biting, may be more an "AND" situation: These behaviors are both positively AND negatively reinforced. While they may provide subtle stimulation, they are also an important source of distraction or dissociation... which brings me to my next "AND"...

Body-focused, repetitive, behaviors, better known as "BFRBs," are behaviors AND much more than just behaviors. They are physical means of emotional coping. BFRBs allow us to reduce our attention (cognitive narrowing) to a simpler and thus more tolerable level of experience - basic, objective, and rote sensations of the body. In this process, we get to distance ourselves from all of the harsh judgments we hold about ourselves, and fear that others may hold about us. This explains why BFRBs often arise while we are doing or thinking about a task we tie to our performance; for example, writing a paper. It is also our mere awareness of ourselves in these behaviors that keep them going. We judge ourselves for succumbing to pulling, picking, and biting and not ___(fill in the blank with whatever else we are "supposed" to be doing)___, and that makes returning to reality even harder. We wrap ourselves up in our sensations to create an autistic bubble where we are insulated from uncomfortable, emotional feelings.

Stay tuned for more on the autistic bubble and treatment implications...