Psychotherapy for Skin Picking, Hair Pulling and Other BFRBs

Most people have been pulling, picking or biting for a long time before they tell anyone. Often since childhood or adolescence. Some have never said it aloud before, including to a previous therapist.

Body-focused repetitive behaviours, often shortened to BFRBs, include hair pulling, skin picking, nail biting and other repetitive behaviours involving the body. Clinical terms such as trichotillomania, excoriation disorder or dermatillomania can be helpful for some people. Others do not identify with a diagnosis and simply know that something has become difficult to control.

By the time someone contacts me, the behaviour is rarely the only thing troubling them. Often, they are also carrying what they have decided it means about them.

What this can be like

The hand sometimes, or often, arrives before the thought does. You come back to yourself ten minutes later, or much longer, and there is damage you cannot fully account for.

There may be a search: fingertips moving across the skin or scalp, looking for something raised, coarse or out of place. Then the pick or pull itself, and a sense of relief that is real, even if it is quickly followed by regret.

Afterwards there are calculations and compensation: sleeves, a different hair parting, a hat indoors. Whether you can swim, be seen under bright light or let someone touch you there. Whether to cancel plans and how long healing might take.

Then there is often the promise to stop. It is made with genuine conviction and broken almost automatically. The breaking of it can become further evidence against you: that you lack control, that you should be able to manage this, or that there is something wrong with you.

Many people have also received advice — “Sit on your hands, wear gloves, keep busy, use fidgets.” While the intention is well-meaning, sometimes advice can leave you feeling even less understood.

Understanding what the behaviour does

Hair pulling and skin picking usually do something, although the function is not the same for everyone.

They may soothe, regulate, occupy the hands, release tension or create a sense of completion. They can happen during stress, boredom, tiredness, concentration or emotional overwhelm. At times they are highly focused; at others, the person barely notices they have begun.

For some people, the behaviour first appeared during a period when it helped them manage something they could not yet name. For others, sensory experience, anxiety, neurodivergence or particular environments are significant.

Understanding the behaviour as doing a job changes the question. Instead of asking only, “Why can’t I stop?”, we can begin to ask what your system is trying to manage and why this particular response became available.

That does not mean ignoring the distress or physical harm it may cause. It means approaching change without turning the behaviour into proof of a personal failure.

Shame and the cycle around it

The behaviour itself is often only one part of what keeps the cycle going.

Self-criticism increases distress, and distress can increase the urge to pull or pick. What happens next then appears to confirm the criticism. Over time, shame can become as painful and restrictive as the behaviour itself.

It may shape how close you let people come, what you wear, how you use mirrors and lighting, or whether you seek medical or emotional support. It can make an ordinary lapse feel like a verdict on your character. The shame may also be not related to appearance but to the experience of needing to hide the behaviour in itself.

Part of therapy is making it possible to look at what is happening without recreating that judgement in the room.

How we might work

My approach is relational and somatic. This means paying attention both to the meaning and history around the behaviour and to what happens in the body before, during and after an urge.

We might explore when the pulling or picking began, what was happening around that time and what the behaviour has come to manage. We may also look at beliefs that have gathered around it.

Alongside this, we pay attention to the more immediate details such as what your hands do before you consciously notice, where you are sitting, and the tension in your body overall. What you were feeling earlier in the day before you found urges increasing also becomes important. At the same time, any difficult feelings found earlier in the day may not be the same as those that trigger your hand to scan, so we work to separate

This is not about watching yourself constantly but about developing enough awareness that a little more choice can gradually become possible.

Insight and practical attention can support one another:

Understanding why you pick does not automatically change what your hands do.

Equally, controlling the hands without attending to distress, shame or emotional need can leave the underlying cycle untouched.

Tracking without keeping score

There can be tracking in this work, but it is not a tally of “good” days and “bad” days.

We may become curious about what happens beforehand:

• Where were you?

• What were your hands doing?

• What kind of tiredness or tension was present?

• Had something felt unfinished?

• What did the urge feel like in your body?

• What did it seem to be promising?

Over time, patterns often become clearer. Certain rooms, hours, tasks, emotional states or kinds of sensory experience may appear repeatedly.

I am careful about how we approach this. If you already monitor yourself harshly, a tracking sheet can become another instrument of self-surveillance. We use it to support noticing rather than judgement, and change it if it begins to feel punitive.

What change can look like

Wanting fewer episodes, less damage or longer periods without pulling or picking is entirely understandable. These can be meaningful aims, but they are not the only ways to recognise movement.

Change may also look like noticing your hand earlier. Finding a pause between the urge and the action. Stopping partway through. Understanding what preceded an episode. Being able to care for your skin or hair afterwards without attacking yourself.

It may mean telling someone rather than hiding, or discovering that a difficult week does not have to become evidence that all progress has disappeared.

These changes can emerge before frequency shifts. They matter because they begin to loosen the authority the behaviour has over how you feel about yourself.

A note about my own experience

I know something of this territory from personal experience as well as from my work as a therapist.

I mention this because it may change how much you feel you have to explain. I will not assume that your experience is the same as mine, and I will not bring my own experience into our sessions unless it would genuinely support your work.

You remain at the centre of the therapy.