Therapist and Author, Dr. Marla Deibler Speaks with Bethesda Therapy's Founder Melissa Murphy
Bethesda Therapy Founder Melissa Murphy spoke with author and therapist Dr. Marla Deibler about her fantastic guide, The BFRB Recovery Workbook: Effective Recovery from Hair Pulling, Skin Picking, Nail Biting, and Other Body-Focused Repetitive Behaviors, which several Bethesda Therapy clinicians use to help clients change their habits while practicing self-compassion. We hope that sharing their (lightly-edited) conversation helps anyone struggling with a BFRB.
I really stumbled into this specialty. My first training placement during my doctoral program was at the Behavior Therapy Center in Silver Spring, Maryland. At the time, they were developing the ComB Model for treating BFRBs.
This was back in 1999. We were doing a lot of in-house research and treatment using that model, and I became fascinated by the work. At that time, the literature around BFRBs was very limited and often pathologizing. What I was reading didn’t align with what I was experiencing while working with clients.
The population was also underserved. People were eager to find therapists who knew anything about BFRBs because so few resources existed. That made it feel very rewarding as a clinician.
So, here I am 25 years later. My coauthor was actually at that training site with me back then, and we’ve shared this journey—through research, clinical work, and writing. The book is really the culmination of everything we’ve learned in treating BFRBs.
It was very different. The standard of care at the time was Habit Reversal Training (HRT), which was effective but not well-documented for BFRBs specifically. There were a few seminal papers by Asrin and Nunn, but beyond that, most of the literature consisted of case studies.
Much of what was written about BFRBs was rooted in psychodynamic theory, focusing on trauma or self-harm. That didn’t align with what I was seeing in practice. It wasn’t my orientation as a clinician, and it just didn’t seem accurate.
What I observed was that BFRBs were often self-grooming behaviors gone awry—automatic, habitual behaviors that served a function but had become problematic.
It absolutely is. People often assume these behaviors are rooted in deep psychological wounds or intentional harm, but for most people, that’s simply not the case.
BFRBs are sometimes automatic, often unconscious behaviors they can also be conscious, goal-directed behaviors. Unfortunately, the stigma surrounding them is enormous. Many clients carry deep shame, believing they are causing harm to themselves and can’t stop. That shame makes these conditions particularly isolating.
I’d tell them two things.
First, as I just said, you’re not alone. BFRBs are more common than most people realize.
Second, I’d encourage them to approach treatment with curiosity rather than resistance. Clients often come in saying, “I just want this to stop,” which is completely understandable given how distressing BFRBs can be.
But part of the work is accepting where they are right now. They may not want the behavior, but they have it, and that’s okay. Approaching it with curiosity—rather than judgment or resistance—creates space for progress.
It can. Many people come to therapy with the expectation that their problem can and should be completely eliminated. But for many conditions—BFRBs included—the goal is management, not perfection.
I often compare it to chronic medical conditions like asthma. We might not be able to eliminate the condition entirely, but we can help clients live full, meaningful lives while managing it effectively.
Fidgets: Tangled toys, spinner rings, and calm strips are great tactile options.
Barriers:Buff head coverings work well for hair-pulling, as do gloves or bandages for skin-picking.
Everyday objects: Hair ties, textured fabrics like burlap, and even things like fake grapes can serve as effective fidgets.
One of my clients once went to Home Depot, felt an urge, and asked for carpet samples. The employee gave him a variety of textures—shag, berber—and he used them as fidgets. It was a great example of thinking creatively!
The most important thing is communication. Ask your loved one, “How can I be helpful?” rather than assuming.
Some people want reminders, gentle cues, or help accessing tools like fidgets. Others prefer to handle it on their own and don’t want their behavior monitored. Power struggles—like asking, “Did you pick today?”—can create stress and make things worse.
Every situation is different, so the key is to collaborate and respect the person’s preferences.
In addition to The BFRB Recovery Workbook, I write a blog called From Surviving to Thriving on Psychology Today. I’ve written about topics like cultural perceptions of BFRBs and treating younger children.
We also offer a 10-hour continuing education course for clinicians, which will soon be available on-demand.
doing to support this underserved population.
