Supporting Your Loved One with a BFRB

Handout from the Pulling Together Conference in May 2016

Amy Jacobsen, Ph.D. & Becky O’Halloran, LMFT

A common reaction when discovering that a loved one is pulling their hair or severely picking their skin may be a combination of fear, distress, frustration and hopelessness. Many parents describe feeling angry – at their child for not stopping the behavior and at themselves for not being able to fix it. There also may be shame – about how the loved one looks and how others are judging them. Here are 10 helpful strategies to support your loved ones (and yourselves!):

  1. Educate yourself about the condition and what evidence-based treatment entails
  1. Stop being the Hair/Skin Police!
    1. It is rarely helpful to tell individuals to stop pulling or to insist on daily updates – this can actually cause more stress – on both you and your loved one – and give unhelpful attention to the behavior that could exacerbate it
  1. Be loving, supportive, and without pressure or judgment
  1. Remember that these are not life-threatening conditions
    1. At times, medical intervention is still important, such as with skin infections or indications of hair ingestion
  1. Consider who is more motivated: you or your loved one? – Be aware that your loved one may not be at the same point of readiness as you, and don’t make it more your problem than theirs! Hand it over to your loved one, be there to support them accordingly, and love unconditionally.
  1. Remind yourself that you did not cause this condition in your loved one
  1. Join the TLC Foundation for BFRBs (
  1. Consider joining a group email or forum, such as the, a group email set up by TLC Foundation
  1. Consider setting up an incentive plan with emphasis on rewarding use of new strategies in place of pulling/picking, rather than the absence of pulling/picking
  1. Be patient with slips that will occur and take a problem-solving approach



The Hair Pulling “Habit” and You: How to Solve the Trichotillomania Puzzle,” Revised Edition by Sherrie Mansfield Vavrichek & Ruth Goldfinger Golomb

“A Parent Guide to Hair Pulling Disorder: Effective parenting strategies for children with Trichotillomania” (Formerly “Stay Out of My Hair”) by Suzanne Mouton-Odum & Ruth Goldfinger Golomb

The TLC Foundation for BFRBs, – an outstanding resource for articles, education, and treatment information


Treatment and Resources for Body-Focused Repetitive Behaviors

A Follow Up: Pulling Together Conference


Last month, I had the pleasure of serving as one of the speakers at the first Pulling Together Conference. This conference, which was sponsored by the Kansas City Center for Anxiety Treatment’s Community Education series, promoted education and resources for Body Focused Repetitive Behaviors (BFRBs). It was fantastic to see so many people – individuals affected by BFRBs, loved ones, and clinicians – coming together to learn, share and support the journey toward recovery and greater management of these conditions.


BFRBs include compulsive hair pulling (Trichotillomania), skin picking (Dermotillomania), and nail biting, among other repetitive behaviors (e.g., lip biting). These conditions cause significant distress and impairment in the person’s life and are linked to anxiety, depression, and shame.


Here is an outline of the major discussion points for a presentation I provided on treatment options, followed by resources to learn more:


Treatment Approaches for BFRBs

While there are still many unanswered questions, clinical research to date most highly recommends the following approaches:

  1. Cognitive Behavioral Therapy – First line approach
  2. Pharmacotherapy – Mixed results
  • There are still few randomized controlled trials evaluating these treatment, and even fewer studies involving children and adolescents.
  • The focus of treatment is on strengthening the person’s active management of symptoms.

Cognitive Behavioral Therapy (CBT) includes:

  • Self-Monitoring (to increase awareness and understanding of factors that contribute to the unwanted behavior)
  • Habit Reversal Training (core interventions)
    • Awareness Training
    • Stimulus Control (e.g., barriers and use of fidgets as “speed bumps” to prevent unwanted behavior)
    • Competing Response Training (learning to replace the unwanted behavior with an incompatible response, such as making tight fists with hands)
  • Relaxation Training
  • Cognitive Techniques (challenging unhelpful thinking patterns that contribute to the BFRB)
  • Enhanced with Acceptance and Commitment Therapy (ACT)/Dialectical Behavioral Therapy (DBT) techniques (to promote self-regulation, tolerance of distress/urges of BFRB, and management of slips)
  • Relapse Prevention/Lapse Management to promote maintenance of gains and adaptive management of slips



  • No FDA approved medications for BFRBs
  • A few medications have been found to reduce symptoms in some individuals
    • Often seem to work by lessening feelings or sensations that trigger the BFRB, rather than directly targeting the BFRB itself
    • Also believed to help address comorbid conditions that can interfere with treatment
  • SSRIs (selective serotonin reuptake inhibitors)
    • Mixed results for trichotillomania and skin picking
  • Several other medications are currently being studied and/or have initial promising results, such as:
    • Mood stabilizers
    • Glutamate modulators
    • NAC (N-acetylcysteine; amino acid supplement)
    • Inositol (B-vitamin)

How do we define “Successful Response”?

  • Reduction in episodes of BFRB
  • Reduction in distress and interference
  • Increased knowledge and management of urges and “slips”
  • Franklin and Tolin (2010) also note:
    • Even if the pulling/picking does not decrease, individuals can still benefit from an initial trial of CBT by gaining an understanding of the condition, not feeling so alone or blaming self for being “weak,” and enhancing their awareness of strategies that can be implemented when they decide to proceed.

Treatment Resources:

For a wealth of information, visit the TLC Foundation for Body-Focused Repetitive Behaviors:

CBT Resources

Mansueto, C., Goldfinger Golomb, R., McCombs Thomas, A., & Townsley Stemberger, R. (1999). A Comprehensive Model for Behavioral Treatment of Trichotillomania. Cognitive and Behavioral Practice, 6, 23-43. Available Online:

The Hair Pulling Habit and You: How to Solve the Trichotillomania Puzzle by Ruth Goldfinger Golomb & Sherrie Mansfield Vavrichek

A companion workbook for Trichotillomania: An ACT-Enhanced Behavior Therapy Approach by Douglas Woods and Michael Twohig


Grant, J. (2016). “Medications for Body-Focused Repetitive Behaviors.” Retrieved from