If They Teach It, We Will Treat It
Why behavioral health training programs must include BFRBs.
Posted November 20, 2019
Of the 1 in 20 people who are living with body-focused repetitive behaviors (BFRBs) like hair-pulling disorder, skin picking disorder, and chronic nail-biting, nearly half do not receive treatment. While shame and misinformation have long interfered with help-seeking for BFRBs, there is another variable that prevents patients from obtaining the care that they need: relatively few mental health professionals receive graduate-level training in the treatment of trichotillomania, excoriation disorder, onychophagia and other disorders involving BFRBs.
Unless graduate programs step up their game in training their students to treat BFRBs, the many individuals who are living with these disorders will continue to have limited options when it comes to effective, evidence-based treatment.
In the United States and Canada, clinical training programs provide an abundance of didactics on Mood Disorders, Anxiety Disorders, Eating Disorders, and Disorders of Substance Abuse. Graduate students may or may not have opportunities to treat clients with Eating Disorders or addictions during their training, but, at minimum, most will accrue an ample fund of knowledge about these disorders in the context of their coursework. When it comes to body-focused repetitive behaviors, however, classroom coverage tends to be sparse. This means that, unless graduate students have access to specialized practica outside of their home universities during their training, upon graduation the majority of these newly-minted mental health professionals not only know relatively little about disorders like Trichotillomania and Excoriation Disorder, but also lack the skills necessary to treat them. This curricular omission on the part of graduate programs places the onus of learning to treat BFRBs on licensed professionals, who must complete—and subsidize financially—BFRB training as part of their continuing education.
To be fair, no student finishes graduate school equipped to treat every disorder in the DSM-V, and all clinicians must seek out continuing education in order to develop areas of clinical specialty. That said, the deficit in BFRB training could be remediated fairly easily if graduate programs began making instruction on BFRBs a standard component of cognitive-behavioral therapy (CBT) coursework and practica. As most BFRB experts will attest, gaining competence in treating BFRBs does not require the same type of labor-intensive training that one needs to learn other detailed and theoretically-complex treatment protocols. Once students have had at least some instruction on the fundamental principles of cognitive-behavioral therapy, the interventions used to treat BFRBs are relatively straightforward to learn. Effective BFRB treatment hinges primarily upon a thorough functional analysis of the pulling, picking, squeezing, biting, or chewing behaviors that are specific to each client’s personal repertoire.
Is it realistic for clinical training programs to begin incorporating BFRB training into already jam-packed syllabi? In my opinion, yes it is. Ideally, BFRBs would be covered routinely along with the other disorders that fall on the spectrum of obsessive-compulsive and related disorders. Furthermore, given that the BFRB population prevalence estimates range anywhere from 1-5%, the community clinics and university counseling centers in which graduate students typically receive their clinical training would have no dearth of clients. If BFRB treatment interventions became a standard component of CBT training in graduate programs, BFRB clients would no longer have to search for “specialists” to get help. Instead, they could simply find a licensed therapist.
Mansueto, C.S., Golomb, R.G., Thomas, A.M., & Stemberger, R.M.T. (1999). A Comprehensive Model for Behavioral Treatment of Trichotillomania. Advancement of Behavior Therapy
Cognitive and Behavioral Practice, 6, 23-43.