Lindsey M. Muller, M.S., LCPC is a specialist on the treatment of Body-Focused Repetitive Behaviors, anxiety, and self-discovery. She is the author of numerous articles, which can be found here, as well as her book, Life is Trichy: Memoir of a Mental Health Therapist with a Mental Health Disorder. Read her original article, “Perfectionism and Trichotillomania, Like Oil and Water,” here and check out her website to learn more!
You are a specialist on Body-Focused Repetitive Behaviors (BFRBs), and you have published multiple articles that explain the link between BFRBs and perfectionism. Can you explain for us the relationship between Type-A personalities; feelings of stress, frustration, boredom, and dissatisfaction; and BFRBs?
“After many years of treating clients struggling with BFRBs, certain patterns or themes begin to emerge. Many of my past and current clients would describe themselves as perfectionists while also struggling with skin picking, hair pulling or nail biting. Perfectionism is not exactly a psychological term so in this sense we are talking about the individual with high expectations for self, who thrives on accomplishing, who has difficulty with free idle time, feels frustration, anger or blame when mistakes happen, and doesn’t easily or ever let go of past mistakes, failures, or negative criticism.
While I may be describing a large majority of people who would define themselves as such, not all of those people struggle with a BFRB. The relationship happens when we see these underlying perfectionist traits in a given person, who as a result feels an immense amount of tension, stress, pressure, dissatisfaction, and inability to relax (due to the go-getter mentality). Then these feelings are either not appropriately accepted and understood by that person or there is a lack of healthy coping skills in times of tension/stress/dissatisfaction. Picking, pulling, or nail biting is an easy yet unhealthy and counterproductive coping skill to drop into the given situation. This is the cyclical relationship!”
How do BFRBs simultaneously ease and intensify feelings of unhappiness and discontent?
“The function, or purpose, that a BFRB serves varies from person to person. BFRB research specific to trichotillomania and skin picking have identified two types; focused and automatic. This moves us away from the idea that these behaviors are just habits and give us a better understanding that there can be a compulsive quality, thoughts, experiences, and feelings to go along with the behavior. The automatic type is more habitual and motorized while the focused type is done in conscious awareness as a result of an experience or feeling. So, the feeling of picking or pulling or biting sometimes (more so in the case of focused pulling) has some sense of relief, pleasure, gratification or is a ‘mental check-out’ to ease unpleasant feelings or thoughts. On the other hand, these behaviors are unwanted so the more they occur, the more feelings of unhappiness, discontent, guilt, blame, or shame are intensified. It is a vicious cycle which is why a BFRB would be considered an easy yet unhealthy, counterproductive coping skill. The feelings one is trying to avoid or escape are still there and usually stronger than before and then the physical damage/repercussions of the behavior have to be dealt with too.”
Would you say that many individuals who suffer from BFRBs are also perfectionists?
“I do not have any statistic on this so I can only answer from my experience working in clinics, hospitals and private practices throughout the U.S. There is a recurring theme of perfectionistic traits in those who have or have had struggles with a BFRB. But not all perfectionists are pickers, pullers, or biters and vice versa.”
You’ve stated during the interview process that this is your passion. How and why did you decide to pursue the study and treatment of BFRBs as a career?
“How I ended up pursuing this specialization was a result of some exploration in undergraduate. Growing up, I was always fascinated with the human body and the mind body connection so I knew I wanted to be a doctor or have a career in something medical-related. Growing up, I also struggled and suffered with skin picking, nail biting, and hair pulling which led me to see various child therapists, psychiatrists, and even a hypnotherapist from early on in life. As I got older, I realized there was lack of research, lack of knowledge, and lack of sound treatment for this group of behaviors. Along with that, I had taken some courses for some other Major tracks (business, communications, biology) and none of them really felt right in my gut so I started to direct my attention to something I had life experience with and an area of study I knew could benefit from another mind, another researcher, another clinician and that is when I narrowed my educational path to psychology.
To more specifically answer your question, you and I both mentioned ‘passion.’ Passion is tied to emotion. For me, passion is that feeling that motivates me to get out of bed in the morning and say ‘Yes! It’s a new day and I cannot wait to see what this day brings, who I can listen to, who I meet and who I can help!’ I had to reflect on who I am and my life experiences to uncover what would bring me those exclamation marks in the morning. It was not much time or process to see that specializing in BFRBs, something I had struggled with for the majority of my life, would be that something that would bring me excitement, fulfillment, and gratification day after day.”
Your book, Life is Trichy, documents your own struggles with BFRBs. How have these behaviors impacted your life and career?
“I did not suffer for many many long years of my life for nothing. I wanted to find the purpose and reason behind going through what I did, and then turn an unfortunate experience into something positive. So, my past behaviors (and the associated emotions) led me to make the educational choices I did which led to my career. And this career is one piece of this life I have created for myself. My struggles with BFRBs were/are exponentially impactful-life altering.”
Buy Life is Trichy here!
How do you mediate symptoms in your own life?
“Great question. I no longer pull my hair, bite my nails or pick my skin. I have been pull free for approximately 10 years and urge free as well. Getting here required me to put in the time, work, and self-exploration to figure out a lifestyle that works for me and incorporates balance, healthy coping skills, dietary changes, and an uncluttered, low environmental stimuli living space and work space. And, as a ‘perfectionist,’ I had to learn self-love, compassion, and how to take better care of myself. All of these things help me when I feel stressed, anxious, overwhelmed, disappointed, frustrated, lonely, unhappy, sad, bored, etc….Previously, those feelings, at times, were inappropriately accepted and allowed, which led to many episodes of picking or pulling.”
Do you have any advice for our readers who might suffer from BFRBs and perfectionism on how best to treat these maladaptive behaviors and increase self-acceptance and quality of life?
“There is no one answer for this which is why individuals sometimes go to therapy and can spend months or years treating these behaviors and working on improved quality of life. I do think a good starting place is to explore what makes you special and unique. Learn to love yourself and practice compassion for yourself even with a scabby, bloody face, or a bald head, or red, painful fingertips. I find that self-love and self-acceptance disappear as a BFRB becomes more frequent and intense. Erase the rule or belief that you are only worthy of love with clear skin or full head of hair. Just this one aspect of ‘advice’, can take you so far or at least move you one large step closer to where you want to be.”
In your practice, you use both Cognitive Behavioral Therapy (CBT) and Rational Emotive Behavioral Therapy (REBT) in the treatment of clients. Can you explain the basis of Rational Emotive Behavioral Therapy and how it aids in the treatment of BFRBs and perfectionism in particular?
“According to REBT, it is largely our thinking about events that leads to emotional and behavioral upset. If we can work in session to consider other thoughts and change our interpretation or perception of a situation that is normally upsetting, we can then change our feelings which would reduce behavioral symptoms, in this case a BFRB.”
Why is it important to educate ourselves about Body-Focused Repetitive Behaviors?
“The more we educate, the more people can be aware and accepting. And the more this happens, the more open we will see people become in admitting they are struggling, admitting they need help, or seeking treatment. Further, with further education, we refine treatment, and diagnosis. We also help get the word to those individuals, or to the parents of those individuals, who are pulling, picking, or biting nails on a daily basis and feel so alone and isolated because this person knows 10 people diagnosed with anxiety, and 3 people with attention problems, but knows no one who has bad skin or no eyebrows. Education helps to ‘level the playing field’ so we all have the equal chance of knowing we are not alone in one aspect of the human experience.”
What are your goals in spreading awareness about these behaviors? What do you hope to see from the Psychological Community in regards to the study of Trichotillomania and other BFRBs?
“My goals are to erase the shame and stigma associated with these behaviors, to help the public understand that these are behaviors that are meaningful and provide important information about how a person is feeling, functioning, and living life. It is not a life sentence, change can happen. Also, our society is so focused on appearance especially due to social media. The results of these behaviors may look ‘odd, crazy, messed up, or gross’ in the eyes of the public (words I have heard from people giving their perspective), but I would love to see society continue to push for a movement away from appearance and looking at the quality of the person. This would help to relieve so much additional pressure those struggling with a BFRB feel often, along with people who are deemed ‘too skinny, too fat, too hairy, too freckle faced, too this, too that.’ Life without judgment of the physical and more about judgment/improvement of one’s morals, values, beliefs.”
Thank you Ms. Muller for giving this interview, and for this great advice!