Do you have dangerous habits such as frequent hair pulling and fingernail biting?

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According to my friend's recollection, one of her former colleagues often bit her fingernails. To what extent did she bit her fingernails? It is said that her fingernails were almost bitten off. I don't know what statistics are currently available in China on body-focused repetitive behavior (BFRB). In the United States, 5% of the total U.S. population suffers from BFRB, which is a very high proportion. BFRB usually includes compulsive behaviors such as hair pulling, skin picking, and nail biting, but please note that, unlike general obsessive-compulsive behaviors, BFRB usually feels relaxed, happy, and satisfied in such behaviors.
Studies have shown that the behavior of BFRB patients is related to the dysfunction of the corticobasal ganglia circuit. Since the corticostriatal circuit and the basal ganglia are responsible for regulating impulsive motor behavior, damage to any part of these circuits may lead to their overactivity and abnormal repetitive behavior. This dysfunction causes the brain's dopamine reward system to become dysregulated, thereby releasing pleasure and satisfaction (on the other hand, it also increases the patient's tolerance for pain). From this, it is not difficult to see that whether it is trichotillomania or skin picking, the reasons behind it are mostly positively correlated with psychological anxiety and depression.
Christina Pearson began pulling out her hair at age 14, which resulted in patches of baldness on her head. She was taken to a psychiatrist in 1970, but the disorder had no name at the time and certainly no treatment.

A doctor wrote a psychiatric certificate and Pearson withdrew from high school. At that moment, she felt relieved. Going to high school meant that someone might pull off her hat and find that she was almost bald - a possibility she found "too terrible, nothing could be worse."

Over the next few months, Pearson says she hid in her home like a monster, pulling her hair out. She was terrified and looking for relief, and eventually she decided to leave. “I was hitchhiking through Mexico at 14, like peyote in the desert, and I was really living a very marginal life,” she says. At 15, she began picking at her skin, often with open sores all over her body. By 20, she was drinking and taking drugs.

At 30, Pearson “finally got sober.” She and a friend started a small telecommunications company in Santa Cruz, California. In 1989, she got a call from her mother, who had listened to a radio report about a study published in the New England Journal of Medicine. “Your old behavior has a name,” her mother told her. (She didn’t know that Pearson still pulled out her hair.) The news that the behavior had been named trichotillomania “blew my mind,” Pearson says.

After decades of shame and loneliness, she began to feel hopeful: There were other people with the same disorder. She started a support group. A Seattle news network invited Pearson on its show, where she spoke about her life and provided the number for a trichotillomania hotline she planned to run.

She received more than 600 messages after returning home from the radio station.

“People were crying out for help,” said Pearson, who spent a week calling everyone back. “It was the best therapy I’ve ever had because their stories mirrored my life.”

One night, she had what she calls a peak experience or a psychotic hallucination in her bed. She decided to give up her business and devote her life to raising awareness about trichotillomania. "I was scared shitless," she says. "I was just an addict, I had a small business, I had graduated from junior high school, I was recovering from alcohol, and I was going to change the world and study weird pathological behaviors? I was terrified."

But she added: “Before anything as inspiring as this, let me say this: We are always called, but we rarely choose to respond.”

Walk into any classroom or coffee shop and there’s likely to be at least one person in the room who has a body-focused repetitive behaviour (BFRB), such as trichotillomania or skin picking.

People with BFRBs engage in repetitive self-grooming behaviors, such as picking, pulling, or biting, that can be physically and mentally harmful and, in severe cases, life-threatening, but people are unable to stop.

A rare minority of people with trichotillomania eat the hair they pull out. Over time, the hair can block the intestines and require surgery to remove. People with skin picking are prone to infection, requiring intravenous antibiotics and skin grafts.

More commonly, people with BFRBs suffer both emotionally and socially. BFRBs often occur in late childhood or early adolescence, making these children vulnerable to bullying. Similar to the experiences of many people, one man in his late twenties described middle school life as "absolute hell" because his classmates thought he was "the weird kid with no eyelashes." Another woman, now in her 30s, recalled seeing classmates playing catch with a wig that had been taken from her head. In addition, BFRBs are often the source of parent-child conflict and can exacerbate children's feelings of shame and loneliness. At the same time, adults with BFRBs may fear intimacy, lose job interviews, and waste time on behaviors such as pulling out their hair and picking their skin.

People with BFRBs often keep their condition secret, hiding their symptoms with makeup, wigs, and layers of clothing.

So many people are surprised to learn how common these disorders are. Some experts estimate that 2% to 5% of the population suffers from trichotillomania, and about 5% suffer from skin picking, also known as compulsive skin picking or excoriation disorder. However, due to the lack of large-scale global studies, the exact prevalence of BFRBs is unknown.

Although trichotillomania appeared in medical literature a century ago, it was not officially included in the DSM until 1987—17 years after Pearson first saw a psychiatrist and six years after I started pulling my hair out in first grade.

My mother took me to a dermatologist, but he didn’t have any advice. It turns out there are many other children like me, including toddlers and even infants, whose symptoms disappear without any treatment. By the end of the school year, my hair pulling had stopped. For most people, BFRBs are chronic, lasting for years, even decades.

In 2013, the DSM added skin picking to the list. “We were ecstatic to finally have a diagnosis for this disorder,” said Nancy Keuthen, director of the Massachusetts General Hospital Trichotillomania Clinical Research Center. She said a diagnosis allows patients to confirm that the experience is not unique to them and encourages them to seek treatment. Without a name, patients tend to think, “I don’t know anyone else who has this, I must be a freak.”

Both trichotillomania and skin picking are now included in the chapter on obsessive-compulsive disorder and related disorders. On the surface, OCD and BFRBs share similar features: both involve strong compulsions to engage in repetitive behaviors. But unlike the compulsions of OCD, BFRBs are soothing and even pleasurable. And they are not the result of the obsessions or behaviors that are unique to OCD.

The distinction is important because the two disorders have different types of behavioral treatments. For example, in the United States, medication is the first-line treatment for OCD, but for BFRBs, there are currently no medications approved by the Food and Drug Administration.

Indeed, BFRBs are significantly understudied compared with better-known psychiatric disorders, such as obsessive-compulsive disorder. “Historically, there has been almost no research funding for these disorders,” Koiten says. Funding is often reserved for disorders that are seen as severely interfering with quality of life or work.

However, Koiten believes that BFRBs are just as disruptive to life and work, but they are often misunderstood as "bad habits for lazy people." This obscures the important difference between ordinary self-grooming behaviors (who doesn't occasionally pick at a scab or pull out a hair?) and clinical cases (such behaviors are persistent, cause serious distress or damage, and the patient has no control over the behavior at all).

Pearson founded the Trichotillomania Learning Center (later renamed the TLC Foundation for Body Focused Repetitive Behaviors) in 1991. Her goal was to help people—especially children—avoid the fear and secrecy she had lived with for so long.

She wanted to provide people with useful, authoritative information. But there was one problem: such information didn't exist.

The disease is also associated with a great deal of stigma. At least some medical literature dating back to the 1950s and 1960s often attributes the disease to the patient's parents, especially the mother.

During that period, researchers at the National Institute of Mental Health studied 11 children with trichotillomania and concluded that the children’s behavior stemmed from an intense conflict “between the child and the primary love object, the mother.” The children pulled their hair “under the influence of a great deal of libido,” they wrote, and used the behavior to replace their emotionally absent mothers.

As for the fathers, they wrote: "[They] are passive-aggressive individuals, and most passive-aggressive individuals are also chronically controlled by their spouses."

Perhaps that’s why when Pearson was taken to see a doctor, the psychiatrist asked her mother, “What did you do to your daughter?” The question made her mother burst into tears. “It was terrible and shameful,” Pearson said.

Even after trichotillomania was added to the DSM, the judgment and accusations persisted. Pearson began renting booths at professional conferences. In the early days, psychologists would deliberately "pass by" her booth and tease her by pulling their own hair. Pearson said a dermatologist warned her that people who pick their skin and hair "often have mental illness."

She recalls a young man who was told by a mental health professional that pulling out his hair was like masturbating in public and that he had to stop. In another conversation, a Swedish doctor insisted that Swedes don’t suffer from trichotillomania. Pearson speculates that the stigma stems in part from the fact that the behavior is often attributed to animals (like cats, dogs, and mice), and people don’t want to acknowledge the connection between humans and the animal world.

Another reason for the misunderstanding is that trichotillomania is considered an extremely rare disorder. The first prevalence survey on trichotillomania was published in 1991, when the DSM criteria for trichotillomania were stricter than they are today. In addition to the strong urge to pull out the hair and the resulting hair loss, the criteria also included anxiety before pulling out the hair and a "satisfaction or relief" while pulling out the hair.

Ultimately, the researchers found that 0.6 percent of U.S. college students met the DSM criteria for trichotillomania at some point in their lives, and they noted that 1.5 percent of males and 3.5 percent of females experienced noticeable hair loss as a result of hair pulling.

In 1990, Pearson attended the first-ever professional conference on trichotillomania, organized by a psychologist named Charles Mansueto. There she met some interested clinicians, including Carol Novak, a Minnesota psychiatrist who had written a short booklet on the disorder.

“We didn’t have the internet back then, and nobody knew the word trichotillomania,” says Novak, who later became a founding member of the TLC Foundation’s scientific advisory board. At the time, Novak, Mansueto, and Richard O’Sullivan, a psychiatrist now based in Madison, Connecticut, attended a retreat for people with trichotillomania that Pearson organized. Novak remembers that participants expressed frustration and anger at the mental health field, “because they were being mistreated by professionals.” Soon after, more professionals agreed to join the board and to conduct research in the field. The cause of BFRBs remains unclear, although individual responses to different medications may offer clues to their biological basis. For example, Prozac, which targets the neurotransmitter serotonin, is ineffective for most people with BFRBs (although some experts say it may be effective for some).

Two small randomized controlled trials tested the effectiveness of N-acetylcysteine ​​(NAC), an amino acid that can be purchased in health food stores, for the treatment of trichotillomania. They found that about half of the participants significantly reduced their hair pulling and skin picking (although those given a placebo also improved: 16% reduced their hair pulling and 19% reduced their skin picking). NAC affects glutamate, a neurotransmitter involved in reward pathways. A small neuroimaging study also showed impairment in reward pathways in people with trichotillomania, but larger studies are needed to confirm these findings.

One such study currently underway is the BFRB Precision Medicine Initiative, funded by TLC. Conducted at the UCLA Semel Institute for Neuroscience & Human Behavior, the University of Chicago Medicine, and Massachusetts General Hospital, affiliated with Harvard Medical School, the study aims to test up to 300 participants using a variety of methods, including interviews, imaging, and blood tests.

Koiten is the lead researcher at Massachusetts General Hospital. She noted that so far, researchers have tended to study BFRBs in some localized detail. For example, a research team might conduct a small brain imaging study. While this approach can find an interesting abnormality, it is not particularly helpful without a broader network of data to illuminate the abnormality's causes and effects. Also, larger sample sizes are needed to ensure that the findings apply to a wider population.

Liz Atkin, a British artist who picks her skin, stood at the front of the room, placing tissues on a table. She was wearing a red cardigan over a T-shirt with orange, yellow and green spots. “We’re going to be messy!” she told the four girls sitting in the front row. Even though it was only 8:30 in the morning, she seemed enthusiastic.

It was a Saturday in April, and I was attending the 25th annual TLC Conference on Body-focused Repetitive Behaviors. The conference was held in San Francisco. The conference is one of the ways TLC hopes to help people directly. I was there with nearly 500 other people, including people with BFRBs, their families, clinicians, and researchers. The class was an art class for children 11 and under.

"We're going to paint now," Atkin said after a dozen or so kids had taken their seats and introduced themselves. She held up a stick of charcoal, explaining that it was a piece of wood that had been burned. "I have compulsive skin picking, and charcoal really helps me."

She distributed charcoal and paper to the children and asked them to draw a dot.

“Paul Klee said ‘a line is a dot that walks around,’ ” Atkin said as she held up her drawing paper and drew a black dot on it. She then demonstrated various wiping and smearing techniques before pulling out crayons and letting the children color.

“I think I drew my cat,” said the girl sitting next to me, who was wearing a Toronto Maple Leafs jersey. Her drawing did indeed resemble a tabby cat with black and orange spots.

Atkin asked if the group wanted to listen to some music, and someone suggested Prince.

Listening to the music, Atkin asked again: "Is painting good? Why do we like painting?"

The children gave different answers: drawing can calm the mind; one can express oneself through drawing; there is no right or wrong in drawing.

“Why do we make all this stuff? Why is drawing useful? The materials we use are tactile.” She then explained to me that for many people, BFRBs are touch-based disorders. Art engages the body and mind, allowing people to focus on things other than BFRBs.

I was sitting in a row with a boy and a girl. I overheard the boy ask, "What disease do you have? I have skin picking disorder." The girl answered calmly, "I have trichotillomania."

Then they quieted down and continued drawing on the paper.

It took some time for the scientific community to confirm what BFRB sufferers have long known: For many, the disorder has a strong sensory component.

Two studies published in 2017 and 2018 revealed for the first time that people with BFRBs are more likely to overreact to external sensory stimuli than the average person. In other words, they are more sensitive to hearing and touch. This phenomenon, sometimes called "sensory integration disorder" or "sensory processing disorder," was first proposed by occupational therapist Jean Ayres in the 1970s. Since then, sensory oversensitivity has often been studied together with autism and, more recently, has been more closely associated with obsessive-compulsive disorder.

One study found that people with trichotillomania were twice as likely to have severe or extreme auditory and tactile hypersensitivity reactions. One participant described her struggle with clothing: "My tactile discomfort is reflected in how I feel about my clothes. Whenever I leave the house, they feel tight and uncomfortable. As a result, I only leave the house when it is absolutely necessary, such as to go to school or work."

Later that day, it occurred to me that I had my own experience with sensory overreaction. As a child, I found almost all clothing itchy: tights, cardigans, sweaters, sleeves that tapered (like all children's clothing in the late 1870s). I vaguely remember my mother once leaving me alone in a store because she was so impatient with my fussiness about winter coats.

Others at the conference had similar experiences. One woman, who is still sensitive to high-pitched sounds, said: "Before, my brother would be playing normally and I would throw things at him. I would think it was too loud and throw books at him." Like many people with trichotillomania, she picks out specific types of hair when she pulls.

"I look for coarse hair, curly hair, and hair that doesn't feel right (too long or too short). For me, that's a tactile disorder," she said.

When researchers talk about BFRBs, they often refer to “subtypes” to account for the fact that people with BFRBs pick their skin and hair for many different reasons.

Someone might pull out their hair as a way to relax before bed at night. Someone might pick their skin out of boredom. Someone might pull out their eyelashes out of stress. For some people, all of these factors, and others not mentioned, may be triggers. As to why this is the case, no one knows for sure. However, in my conversations with patients, many of them mentioned the research of psychologist Fred Penzel.

In the early 21st century, Penzel proposed the stimulus modulation model of trichotillomania based on his studies of patients.

“Hair pulling may be an external attempt by genetically predisposed individuals to regulate an internal state of sensory imbalance,” he wrote.

This model suggests that although people with BFRBs are exposed to the same environmental stimuli as other people, their nervous systems cannot easily process them. “It is like a person standing in the middle of a seesaw or a tightrope, with one side overstimulated and the other understimulated, and he must constantly adjust his center of gravity (hair pulling behavior) to maintain balance,” he wrote.

“Picking your skin or pulling your hair can increase or decrease irritation,” says Karen Pickett, a therapist in Ohio. “I haven’t found anyone who doesn’t fit this [model] to some degree.” Why is this important? Because picking your skin and pulling your hair have real effects, which is why these behaviors are so hard to stop.

Many studies have found that people with BFRBs have difficulty regulating their emotions. A review published in 2013 found that people with BFRBs are more likely to suffer from mental illnesses such as depression and anxiety than the general population. In addition, many studies have reported that BFRBs can relieve negative emotions, including boredom, tension, anxiety, and depression.

Several people I interviewed told me that their BFRBs began when they experienced negative emotions consistently over a period of time. Aneela Idnani began plucking her eyebrows and eyelashes after moving to a new town during adolescence. There, she felt like an outsider and was bullied at school. For her, hair plucking was a coping mechanism.

A few years later, Idnani's father died of cancer. "I didn't know how to deal with it," she said. "(As a society) we don't talk about unhappy things, so we had to find ways to deal with them." She kept her illness a secret until she was an adult. Three years ago, she started seeing a psychologist, who helped her deal with some of her negative emotions.

Haley O'Sullivan began picking her skin when she was 20, a year after a traumatic sexual experience. "I started out by spending two hours in front of the mirror pulling out the hairs that grew under my arms or my bikini line, and picking at acne on my face and other parts of my body," she recalls. O'Sullivan has been organizing support groups in Boston for several years, and is now working on starting a support group in New Hampshire, where she lives. She is careful to point out that not everyone with a BFRB has experienced trauma. For her, however, picking her skin is "my body's way of saying, 'Hey, something's wrong with me.'" Picking her skin creates a rewarding feeling for her, at least in the short term: "Obviously, when you realize, 'Oh my god, look at the damage that's been done,' it's not a good feeling."

O’Sullivan has seen several therapists and has recovered from PTSD and depression. But she says she feels like progress in BFRB treatment has been slow. She did a lot of research on her own, but lacked the help of a professional clinician. There simply aren’t enough professional therapists, she says. Even if you find the right one, there may be a long line of patients ahead of you waiting for treatment, and insurance may only cover a few sessions. “It’s not going to get you fully healed,” she says.

There is a treatment gap for mental health problems in many countries, including high-income regions.

I spoke with Marta Isibor, a graduate student from Scotland who sought help for skin picking in her 20s. Isibor received traditional cognitive behavioral therapy, which helped her understand why she picked at her skin, but she did not receive treatment that focused on minimizing repetitive behaviors, such as habit reversal training or the Comprehensive Model of Behavioral Therapy (an intervention specifically for BFRBs).

Isbor says there is a lack of specialist clinics and BFRB researchers in the UK. In fact, as an adult undergraduate, after publishing a study on skin picking, she travelled around the country presenting posters at conferences held by the Royal Society of Medicine at Edinburgh University and the British Psychological Society. Most people in the room had never even heard of BFRBs, she says.

She had to explain the basics: the symptoms of BFRBs, where they are listed in the DSM, and the difference between common self-grooming behaviors and clinical diagnoses. She said people are often surprised to learn how common BFRBs are, and that many sufferers keep their conditions secret out of shame. She speculated that this might be especially true for people with skin picking, since picking is often associated with bleeding, scabs, germs, and infection.

“You come to a place like this (conference) and finally meet people who understand you,” O’Sullivan said. “But you still can’t escape the fact that once you leave here, people don’t understand your situation.”

Currently, among the treatments for BFRBs, a cognitive behavioral therapy called habit reversal training has the most experimental data support. This therapy first appeared in the 1970s and was used to treat tics. During the treatment, patients learn to identify situations in which hair pulling or skin picking is most likely to occur. With this understanding, patients can use a competing response to replace hair pulling or skin picking. For example, when there is an urge to pull hair, patients can make a fist or play with toys. In some studies, more than half of adult patients with trichotillomania have achieved short-term improvement. However, some studies have found that such improvements are difficult to maintain in the long term.

Psychologist Omar Rahman, who recently conducted a prospective study exploring the effects of habit reversal training on children with trichotillomania, says the therapy is designed to give the brain a chance to get used to the urge, meaning you can ignore it or replace it with another behavior.

Over the years, Rahman has come to believe that if you can’t learn to control the urge, there’s really no way to fix the problem, which may explain why habit reversal training doesn’t work for everyone and why treatment effects are difficult to sustain.

For this reason, researchers and clinicians are increasingly looking to other ways to augment habit reversal training to help people overcome urges. For example, mindfulness therapy can help a person observe and accept negative emotions, feelings, and urges without having to deal with them by pulling out their hair or picking at their skin.

In the early 1990s, after seeing many therapists and taking many medications without significant improvement, Pearson stumbled upon mindfulness therapy. "No one knew how to do this," she says. So she began paying attention to her thoughts, feelings, and muscle movements. "I had always been looking for greater awareness, but now I wanted to identify a roadmap to free myself from my behavioral prison," she says.

Children with BFRBs are sensitive and intelligent, she noted. “Am I trying to get rid of it? No. What I’m trying to do is, ‘Hey, how can I create the mental framework for an individual to thrive and make some contribution to the world?’”

Meanwhile, psychologist Charles Mansueto has been treating people with BFRBs and has developed the Comprehensive Model of Behavioral Therapy (ComB), which suggests that there are a variety of triggers that may lead people to pull their hair or pick at their skin, including thoughts, emotions, sensory experiences, specific physical actions (such as touching their hair), and the environment. Now, Mansueto and his colleagues are conducting a randomized controlled trial to test the model.

“We may seem like we’re not scared right now, but we weren’t always like this,” said Bridget Perez, who was leading a session called “The Parent/Child Journey: Building Relationships and Finding Acceptance” with her 19-year-old daughter, Gessie. They were both wearing T-shirts designed by Gessie that said “Trichotillomania” on the front. The room was packed.

Brigitte recalls one morning when Gessie was 14 and sitting at the breakfast table. “I was standing next to her and I started saying ‘Oh my God!’ because I saw this huge bald spot on the back of her head,” she says. Gessie had always had long curly hair, but in the years that followed she went from “a beautiful girl with long curly hair to a girl with a bald spot, and then she tried to cover it up and her hair was thinning and it was hanging from her scalp.”

"I was screaming and hysterical. I was devastated by my daughter's hair loss," Bridget said. Like many parents, her first reaction was to address the problem.

Unlike the previous generation of parents, Bridget knew the word trichotillomania and was able to use the internet to find information. Bridget said they attended their first TLC meeting a few years ago. She realized: "It's not about the hair, it's about being there for them. To support and love them no matter what they look like."

Geshe believes that meeting changed her life. Life with trichotillomania is difficult. Even today, she has no eyebrows and wears her hair short, but she considers herself in recovery “because trichotillomania no longer controls my life.” The hair-pulling behavior comes and goes, but she is not obsessed with stopping it.

"For me, cutting my hair, shaving my head, and realizing that I'm not defined by my appearance is..."

“It’s crucial,” her mother added.

Both agreed that trichotillomania made it stronger, both personally and on a mother-daughter relationship level.

Geshe said that after the meeting, she took to social media to share her story. People from all over the world reached out to her with questions and expressions of support.

“Honestly, I’m just so grateful for this journey,” she said. “These friends are so much more precious than having hair.”

Despite the obvious benefits of TLC meetings, be aware that attending a meeting is not an easy feat, especially for first-timers. One mother I spoke to said that her first meeting almost broke her down. “I broke down and cried,” she said. “You think you’re going to this meeting and it’s going to solve your trichotillomania problem, and then you realize you’re going to have to deal with it for the long term.”

And there’s no clear path forward for this long-term struggle. After all, if your child is sick, you take them to the doctor; but when your child is engaging in an abnormal self-grooming behavior that lacks an easy cure, you don’t know where the path lies. Parents are more likely to worry about how much money and emotion to invest in treatment than to accept the condition and support their child in other ways.

Adult patients can also experience these anxious feelings.

For example, many people with BFRBs say that completely stopping pulling their hair or skin is an unhelpful goal because it can amplify self-criticism and frustration. But one woman spoke positively about her experience in Trichotillomania Anonymous, a group similar to Alcoholics Anonymous. “We celebrate restraint,” she said. “Think of the AA program.” They use the same materials and spiritual tools. She joined the support group in January and said that in the three months since, “I’ve pulled my hair out so much less, it’s incredible.” She has a support person she can call when she has the urge. She also works on self-care, which is a big focus of TLC. “Maybe that’s why I’m making incremental progress, because I’m fighting all these things,” she speculated.

The last session of the meeting was titled "Let go of fear and stand up." This session was organized by Pearson, who left TLC in 2013 and founded the School of the Heart in 2014. There were about 20 kids sitting in horseshoe-shaped chairs. I sat next to the girl in a Maple Leafs sweatshirt. She was joined by a few kids 14 and under, and of course, a charcoal drawing class.

When Pearson came in, wearing a pink hair accessory and holding a floppy string puppet, she said, "I grew up like you did, and I started TLC." She greeted each child one by one.

Then she asked each child what they liked most about the meeting. The most common answers were making friends or liking everything. She said to a girl who seemed to have talked to her earlier, "You have a strong heart and a sensitive nervous system." The girl seemed to be holding back tears.

Next, Pearson took out a ribbon and handed one end to a child in front of the horseshoe chair, then asked her to hold the ribbon and pass the rest to someone else.

“Feel the ribbon in your hands, it’s connected to each of you.” I closed my eyes. The ribbon was smooth. I was thinking about the girl in the Maple Leafs jersey, who was only slightly older than I had been when I first started pulling my hair out. I unexpectedly found myself holding back tears.

Pearson led us out of our chairs and toward the door. As we left the conference room, she said, "This is your world." I walked forward, holding the ribbon, flanked by children who were barely as tall as my chest. I was surrounded by children wearing hats, bald heads, and skin-picking children. We walked through the hotel lobby, past people eating and reading. Outside the hotel, we saw a beautiful view of San Francisco Bay.

Pearson faced us, her back to the water. The sun was rising and planes were taking off from a nearby airport. She asked us to stand on the ground and twist our bodies. "Close your eyes," she said. "What do you smell?" We twisted again, and she asked, "What do you hear?" She told us to do this anytime, as a small step in mindfulness.

Back in the room, Pearson asked the children to write down what they admired about themselves on triangular felt flags. Everyone was free to move around and interact with each other.

Someone said: "Be compassionate."

“We have this amazing capacity for deep empathy,” Pearson said. “Why? Because we know what it feels like to be in pain, and we know what it feels like to be different. We can see that in other people.”

They began gluing sequins, fuzzy heart ornaments, and ribbons onto pennants.

Persistence, passion, compassion, courage.

"That's what courage is," Pearson said. "It doesn't mean you're not afraid, it means you're going to do something anyway."

By Sara Talpos

Translated by Amanda

Proofreading/Yord

Original article/mosaicscience.com/story/compulsive-hair-pulling-skin-picking-trichotillomania-bfrbs-ocd/

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