Jennifer Agee:
Hello. Hello, and welcome to Sh*t You Wish You Learned in Grad School. I'm your host, Jennifer Agee, licensed clinical professional counselor. With me today is Laura Chackes. She is a licensed psychologist and the owner of the Center of Mindfulness and CBT. I invited her on the program today to talk about body-focused repetitive behaviors. So welcome to the show today. Thank you for being on.
Dr. Laura Chackes:
Thank you. I appreciate you having me on.
Jennifer Agee:
Absolutely. So, tell me, what is something that you wish most therapists do or understood about body-focused repetitive behaviors? What are they, and what are some of the basics we need to know and understand?
Dr. Laura Chackes:
Yeah. Definitely. I mean, I think the number one thing is that they are treatable. I think we, I learned very little in graduate school about—well, the term wasn't even there—BFRBs when I was in grad school almost 20 years ago. It was just trichotillomania, but even then, very little was taught on that. But I, yeah, I think to know that they are treatable and that it's a very rewarding population to work with. It's really been like the highlight of my career to see the progress that these individuals make in therapy and the gratitude that they– They just are always so grateful for my help, and I don't see that as much with other populations. But to go into the basics of what they are, so, yeah, we call them BFRBs for short, body-focused repetitive behaviors. And that encompasses trichotillomania or hair-pulling disorder than, dermatillomania, or now it's called excoriation disorder. So that just made it into the DSM. Well, I guess it's been 10 years. In 2013, it was added to the DSM. So that's the skin-picking disorder. And those are the only 2 that are in the DSM, but we also see other things like lip biting, cheek biting, It could be, nail-biting. We don't see that all that often in therapy because most people who bite their nails, it doesn't cause any, you know, significant distress. But, any behavior that is done repeatedly and causes some kind of damage to the skin or hair or body in some way is a body-focused repetitive behavior. And then I really think another really important thing is to understand that these people don't want to be doing the behavior most of the time. So, they do get a generally some kind of sensory or there's some level of satisfaction to it. Think of it like a thumb-sucking, that actually can be a BFRB if it's done later into life and becomes a problem. So, there's this, you know, it's reinforcing it. It feels good to do it. But then again, they don't wanna be causing this damage to their, you know, skin or hair or wherever else they have caused damage. So, it's this battle inside where they desperately wanna stop, but they feel like they can't stop.
Jennifer Agee:
Okay. I was always taught in—you know, I've been a therapist since '99, so I know things have certainly changed—but I was always taught, specifically, trichotillomania is usually some form of a symptom of OCD, that it's a self-soothing behavior, but I also know that I could be wrong and that we could know more information now. So, tell me a little bit about where it comes from and, you know, that realm. I'd love to learn more.
Dr. Laura Chackes:
Yeah. Well, they do have it classified currently as an OCD-related disorder. There's definitely some overlap, like many people with trichotillomania and the other BFRBs do have OCD, but many of them don't, and it's really not exactly the same, so it doesn't quite fit in any category. I guess it best fits there. But, there's a lot of people with these, and it is what you said, that, like, satisfying, it is like a self-soothing behavior. So, for many people, it starts from, like, some kind of perfectionism, anxiety, and it can be like an OCD kind of thing where they feel like their skin isn't perfectly smooth, so they need to get rid of the bumps or something, so they end up scratching or picking off a scab. But other times, it is more of just, like any kind of self-soothing behavior, almost like overeating or drug and alcohol use where it just becomes a behavior to use to cope with either emotions or thoughts or, just kinda coping with life stressors. So, we see it in really all different types of people. It's not, I mean, we see it some with trauma, but it's not always with trauma. We see it some with ADHD. Sometimes a lot of people who have that kind of just impulsiveness will have more trouble with the picking or pulling because it's hard to stop or they just kind of feel like they're impulsively doing it. But, yeah, there's really no one cause. And so, that kinda leads into what's been the most effective treatment is understanding for each individual person what is causing it for them. So, why are they doing the behavior?
Jennifer Agee:
Okay. And what methods do you use to get to that information?
Dr. Laura Chackes:
So, what I use is I start with mindfulness. I didn't always start this way, I used to always do CBT, the cognitive behavioral therapy. That's where I was originally trained, but in the past decade or so, I've been incorporating a lot more mindfulness. And I feel like that is a good starting point. It helps with awareness, first of all, because many people are doing it mindlessly. So, they're just in the car and just pulling out hair, don't even realize they're doing it, or while they're watching TV, that's another common time. So, the mindfulness and starting with just a daily meditation as well as kinda doing some mindfulness of your daily activities can help them build awareness of when they're doing the behavior. But then as we know, it can also help with the emotional regulation piece and just, yeah, just kind of all the benefits of mindfulness can certainly be helpful. So then, from there I go into tracking. So, you know, just having either an app or a paper that they keep track for a week of every time—oh, not every time; that's almost impossible, but as many times as they can throughout the week—and really identifying what thoughts are they having right before, during the behavior? What emotions? Where are they? What are they doing? What time of day is it? All those kind of factors. And as well as the sensory. There often is a big sensory component, so noticing any, did they see something in the mirror that triggered them? Or did they, you know, they're just fiddling with their hair and they feel a thicker hair? It can start with even noticing gray hairs, and then pulling, and saying, oh, that kinda feels good, and keep pulling. And that reminds me of, you know, there's a little bit of, we all do this a little bit. You know, I've certainly had gray hairs and pulled them out, and like, oh, I wanna pulling because I wanna get them all, but I don't have a BFRB because I'm not spending hours a day doing that, and I don't have bald spots. And I, you know, so it's not significantly impacting my life. Same with, like, popping pimples. We all do that from time to time, but someone with the BFRB will be causing significant damage or just so much distress in their life because they can't stop doing it, and the damage into their skin, as well as they feel a lot of shame about the behaviors because they feel like something's wrong with them for doing it and not being able to stop. So, back to the treatment, yeah, we do tracking, and then we get into from the tracking specifically geared intervention. So, looking at, like, the sensory triggers and then coming up with sensory strategies. So, for instance, like, if they, whenever they feel a spot that isn't smooth, that that triggers them, they might, well, one thing that works for a lot of people or helps is putting, like, a band-aid over 1 or 2 fingers that you tend to use to scan. And then if they start to feel, they feel the band-aid, and that kinda prevents them from feeling the rough spot, or it might be wearing gloves or... So, it can be some kind of block or satisfying that sensory need in another way. Maybe it's rubbing a smooth stone or maybe it's putting lotion on, and that feels good. So, there's a lot of trial and error involved. But it's all often also kind of multi-layered. So, it might be the sensory part, but then also the emotions. And so, noticing, well, how can we handle those emotions in a better way? And a lot of it is there, you know, through the tracking, we find out what the emotions are, and then through therapy, just, you know, doing the CBT or just kind of processing the emotions can be helpful through that, and then giving them strategies they can do on their own. And so, that's a big part of the treatment. And then another big part is self-compassion because, as I mentioned, a lot of shame comes along with these disorders. So, teaching people that, really to accept themselves, that, you know, they are a good person. They have lots of good things about them. And then to give themselves forgiveness when they do do the behavior. So, the goal is eventually to be able to notice when they're doing it, stop themselves most of the time or just be able to use an alternative behavior, and then, you know, when they do slip up, let's say, they go for a while without doing the behavior and then they do it, to be able to say, like, it's okay. You know, I slipped, and that happens, and just what strategy can I use next?
Jennifer Agee:
Mhmm [AFFRIMING]. One of the things that strikes me when you're talking is we're not trying to remove self-soothing behaviors. You're trying to help them figure out ways to get the needs of their system met in a way that isn't harmful to the system.
Dr. Laura Chackes:
Exactly.
Jennifer Agee:
It sounds like it's the excess of those things. Like you said, everybody's, you know, popped a pimple before. But if we then hyperfocus on texture of skin and things like that, that is going to end up creating damage. Whereas if I occasionally do something, or I rub the stone, that's not gonna harm my skin or harm anyone else. No one's gonna notice in my appearance that I've been doing these things.
Dr. Laura Chackes:
Exactly. Yes. Yeah. So, I can't remember who said this, but at one of the conferences I went to on BFRBs, I remember this helped me a lot learning that the behavior is not the problem, but it's the messenger. So, it's kind of giving you a message. There's something we need to address. Is that– Then we look. Is that sensory? Is that a thought you're having? Is it an emotion? Or is it the environment you're in, or, you know, so kinda looking at all those things And so, by reframing it as that, it can help then address kind of what's underlying it or what's in the moment causing it to come out.
Jennifer Agee:
Okay. You mentioned there's an app that you sometimes have clients use for tracking. What is that? What's that app look like?
Dr. Laura Chackes:
There's 2 of them. So, for hair pulling, it's called trick stop. It's T-R-I-C-H and then the word stop. And then the other one is for skin picking. I believe it's pull free. They're both made by the same company or whatever. They're very similar. And so, yeah, it's basically tracking, and then it kinda can give you the data. It's really cool.
Jennifer Agee:
Do you find that your clients are very compliant with the tracking? ‘Cause I've had very mixed, a mixed bag when I have clients track behaviors.
Dr. Laura Chackes:
Yeah. Well, so the other big thing I'd say for treatment, and this kinda speaks to that, is for a long time, I was just doing individual therapy for BFRBs. Now I do group therapy. And, actually, I only take new patients for group. We have other therapists in our practice that'll do individual, but with the group format, and I do this, like, week by week. So week 1 is mindfulness. Week 2 is tracking. With the group accountability and having that structure, I've gotten much better compliance. And I also do explain with the tracking is to think of this, like, little research. You know, you're just getting some data. So, because in the past, what I would get is people say, oh, I just notice I'm doing it all the time, and just beating themselves up more instead of saying every– Instead, we say every time you write something down, you catch yourself, that's great. You're being mindful, and we're getting some good data here. So, I, yeah. And then I also tell people, you only have to do it for 1 week. If it's helpful, some people do find it actually helpful in reducing the behavior, you can continue, but let's just try getting some data for 1 week, and then we'll use that data. So, when they kinda know the structure and then they have a group of people doing it with them, I've gotten much better success.
Jennifer Agee:
Which makes perfect sense to me because we know that when there's shame involved, often behaviors of any type stay higher because we don't vent those out. We don't say them out loud. We don't have support for them. And so, when we just keep running the same things around and around in our head, they can become almost obsessive thoughts. So, yeah, I could see why the group component is so helpful to hear that you're not the only one that struggles with it. And then to also be able to celebrate things that some parts of you might feel like you shouldn't celebrate that because that's just what everyone else does naturally. To be able to be celebrated in those times that you are having victory would probably feel really good too.
Dr. Laura Chackes:
Exactly. Yes. All of what you just said is so important. I think that so much of the healing comes from that support from the group members and feeling like they're not alone. I'm that's why I originally started the groups was because I would hear client after clients say, like, “I’m such a freak,” or “there's just something wrong with me. I know no one else does this. I know you must think I'm crazy.” And I say, no. Like, I've heard four people tell me that today. And so, I thought I wish I could just get these people all in one room. And so, yeah. About 10 or so years ago, I started doing in-person groups. And then I switched to online, and I've added more and more structure through the years, and it's really just gotten even more and more successful of just, yeah, that support, and the reduction of shame, and then, just like you said, cheering on and celebrating. We also do use a lot of rewards. I mostly work with adults now, and I strongly encourage them to reward themselves for the use of the strategy. So, in the past, they would always, you know, reward themselves if they go a day without picking. And we say, no. No. We're not focusing on that. Let's say your goal is you're gonna do your meditation, you're gonna track at least three times today, and you do those 2 things, you get your little daily Starbucks or whatever reward you wanna get. And many, many people with BFRBs do not wanna reward themselves. This is a constant struggle. But in the group, we'll say, okay. Like, next week, I want you to tell us about what you got, and people encourage each other to actually reward those little wins.
Jennifer Agee:
What got you interested and in to working with this specific group?
Dr. Laura Chackes:
Well, so I did my post-doc at St. Louis Behavioral Medicine Institute and in the specialty of OCD and anxiety disorders. And this was back, you know, 17 or so years ago. And so, at the time, they didn't have a trichotillomania expert. And my my boss there, Alec Pollard, who he's known in the OCD community. He said, you know, Laura, do you wanna treat trichotillomania? And I was like, sure. And I was new in my career. I'll give it a try. And so, I just learned everything could, and then I started going to the national conferences. And I immediately just felt drawn to the idea of helping this underserved population. I think that's when I realized there's really, like, barely any therapist doing this. And still, almost 20 years later, there's still barely any. So, I have the center, as you mentioned at the beginning. I train every new employee or intern or, you know, on my BFRB approach. Some just still don't take to it. They'd rather not do it. That's fine. They still get the training, but many of them have. So, you know, we are training more people. And I've trained people throughout the, really throughout the world. Now I do have an online course for therapists. So, yeah. That's kind of become my passion is like spreading awareness to therapists as well as to just everyone in the community because what the other common thing besides not being enough therapists is that nobody knows what these disorders are, or not enough people know. So, people in school, you know, if a teacher sees them pulling, the teacher might say, just stop pulling your hair. What are you doing? You know, but if they knew this is trichotillomania, maybe they would say it in a kinder way or they talk to the counselor about how to handle it or something rather than just kind of shaming the kid or just telling them to stop. That's what parents tend to do. And, actually, the worst tend to be dermatologists who should have this training—and that's another area I'd love to get into is how to train more dermatologists—but people go in for acne, I mean they have acne and they're picking, and then the dermatologist says, like, well, you're the one doing the damage. It's all your fault. If you would just stop picking, it’d go away. And then, of course, they never go back. And then that can also be very dangerous because people can get life-threatening infections and be afraid to go to a doctor because the doctor will criticize and blame them. So, it is just, yeah. I mean, these disorders, actually, the research shows about 1 in 20 people will suffer from a BFRB at some point in their life. So, it's a huge percentage of our population, but most people just don't talk about it. And even the people that do the behaviors, they kind of hide them. They cover them up, you know, by wearing hair coverings, head coverings, or clothing. Sometimes in the summer, they won't wear sleeveless shirts because they have, you know, scars all up and down their arms.
Jennifer Agee:
Is this a population where there's a…Recidivism isn't the right word. I'm having a hard time thinking of the right word in the moment, but where you kinda cha cha slide with, like, progress and then you go back.
Dr. Laura Chackes:
Yes. Exactly. That is huge with this. So, I also have a Facebook group of lots of just people with BFRBs. And in there, I see that so much. And, that they try something new, and it works for a couple weeks, and then they mess up. And that's why I try to correct that language too, but they're, you know, yes. They slide back. There's a lot of that. And so, that's where the self-compassion piece, I think, is so important. And continued accountability. So, what I've been doing is in addition to the online groups, and I also do have online courses for adults that are—I only practice in Missouri as a psychologist—but I do have online courses taking the same content for adults throughout the world. And so, I've been doing alumni groups where we meet monthly to check-in after they complete the 10-week program. And I think those people that are in, I mean, I'm at least getting to see these people year after year continuing to improve. They slide back, but they come in and they say, yeah. I had a horrible week or I had a horrible month, but here I am back, and I'm gonna start with mindfulness again, or I'm gonna start tracking again, or wherever they wanna pick back up.
Jennifer Agee:
In the research, is there any link to specific vitamin deficiencies or, you know, anything like that? I always try and look at are there any natural biological components to really any of the things that we're treating. Is there anything that's known with this population?
Dr. Laura Chackes:
Well, one thing is there's a very, there's a lack of research. So, there's not any big, you know, funding sources for this because people don't see it as as big of a problem as other psychological problems. But they have found some. There's some links to alcoholism and addiction. And so, they have tried some similar medications. There is a lot of overlap with anxiety and OCD. So, sometimes, like, the SSRIs can be helped. But there is a supplement, NAC or N-acetyl cysteine—they called NAC for short—has been the most promising, and it is like a supplement that you can get on Amazon. They recommend, of course, to ask your physician to make sure it's safe for you, but that can show some reduction in the urge. So, it can reduce the urge to do the behavior. Because people will often feel like this strong urge and it's really hard to resist.
Jennifer Agee:
Fascinating. Man, I'm learning a lot today, and my wheels are turning. As we're wrapping up the podcast, is there any 1 or 2 takeaways that you really want to make sure that therapists that listening to this know and understand as they might have a client walk in their office and realize that their client does have a BFRB?
Dr. Laura Chackes:
Yeah. Well, I mean, I would say actually to start with asking every client, you know, on intake as just adding one more question to your intake is, do you repetitively pick your skin and/or pull your hair? They can just say no if they don't or if they do, you'll get to be able to treat that, even if you don't feel capable of treating it, you could refer out for that, or at least you're reducing the shame just by asking that question, that you're aware of it. So, I think that's a big thing. And then I think the other is just to not be afraid of treating this disorders, or I've seen a lot of disgust in the community of therapists. Like, people say, like, why do you wanna treat that? And I'll be like, well, what do you mean? Like, what… So, there's just this, yeah, lack of understanding, I think. So, I think just you're on the right track if you're listening to this and then to just, you know, just as you would be compassionate to your clients about everything else, just kinda bring that to this as well and just by putting it out there. Cause I've also had clients that I've seen for years before I started asking an intake, and I had seen them for years, and they'd say, oh, I see a flyer for this hair-pulling group. You know, I have that. And I never knew. They didn't tell me because I never asked, you know, and they didn't know it was a disorder.
Jennifer Agee:
Wow. Yeah. I think a lot of people might feel something's not quite right, but until you have the words for it or a name for it, it's hard to even know how to ask for help. Thank you so much for being on the podcast today, Laura. Tell the listeners how they can connect with you.
Dr. Laura Chackes:
So, you can join my Facebook group. It is for adults with BFRBs, as well as just therapists who wanna learn more. It's called Overcoming Skin Picking and Hair Pulling. And if you want more information, my website, I do have a website just for, like, my online coaching and BFRB training, and that's called mindfulstlonline.com.
Jennifer Agee:
Perfect. And I will put the link below. Thank you for listening today. If you'd like to connect more with me with coaching or retreats, counselingcommunity.com, I hope you get out there and live your best day in life. Have a great day.