It’s true we can’t force another person to be ready to change. But with Body-Focused Repetitive Behaviors (BFRBs), like hair pulling, skin picking, and nail biting, ambivalence about stopping isn’t resistance. It’s expected because the behavior is serving a function. It may be regulating arousal, soothing a difficult feeling, providing reliable sensory input in an overstimulating day, or meeting a need that nothing else has yet met.

When we ignore that function and pressure a child to stop, we often make it harder to understand the behavior and meet the child’s needs. Pushing a child to change a behavior that is, on some level, working for them tends to produce a paradoxical effect. The behavior moves underground. Children pull or pick in secret. They may lie about it. Resentment builds. Shame builds. And the parent-child relationship, one of the most protective factors a child has, bends under the weight of a behavior nobody discusses honestly.

This is genuinely difficult for parents, because the instinct to protect your child is exactly that, instinctive. The clinical challenge is to honor that parental instinct while meeting the child where they are and joining them with kindness and curiosity.

Willingness is a continuum, not a switch

Some children arrive with no interest in working on their BFRB. Some are curious but uncommitted. Some are willing to talk about it but not change it. Some will try a strategy if there’s a reward attached. And some are quietly ready, and simply need the right clinician and the right invitation. All of those starting points are workable.

When a child isn’t yet willing to address the behavior directly…

There’s still substantial, meaningful work to do.

Much of it focuses on helping the child to develop a clearer sense of self, discovering what interests them, what they’re good at, and what they care about. Children who can articulate their own values have something to anchor to, which matters later when they’re asked to tolerate the discomfort of doing things differently. Once those values are identified, the clinician and child can gently look at whether the BFRB gets in the way of any of them. Sometimes the answer surprises a child, and that’s often where willingness begins to shift.

Therapy also involves helping the child get curious about what’s hard in everyday life — not the BFRB itself, but everything around it. This can include friendships that don’t quite make sense, a teacher experienced as overwhelming, feelings that arrive too big and too fast, or sensory experiences that other people don’t seem to notice. These everyday struggles are often the context driving the BFRB.

A significant piece of therapy is building the skills that better meet the needs the BFRB is serving, such as cognitive flexibility, emotion regulation, distress tolerance, and interpersonal effectiveness. If a child’s BFRB is, among other things, a strategy for managing overwhelm, developing additional strategies for managing overwhelm doesn’t require targeting (for instance) the pulling directly. As the toolkit fills in, the function gets met elsewhere, and the behavior often softens.

Self-compassion matters too. A child who has been quietly hating their own hands, scalp, or skin for months or years is carrying a heavy load. Helping them turn toward themselves with kindness changes the internal climate in which the behavior lives.

And then there’s connection. Shame thrives in isolation, and shame is one of the most powerful forces keeping BFRBs stuck. Books and videos featuring others with BFRBs can be profoundly disarming. So can in-person communities at conferences, retreats, and support groups. Children opposed to working on their BFRB sometimes walk into a room of others who pull or pick and walk out willing to get curious with their therapist.

When there is some willingness, rewards and systems can help

Family systems become useful here. Bringing parents in to plan for praise and rewards around practice can boost motivation, but it has to be collaborative and child-centered. The child decides how they want their caregiver to help. What’s genuinely useful? What’s annoying? What would they want a caregiver to say if they noticed the BFRB occurring? What would they prefer a caregiver not say? Putting the child in the driver’s seat preserves autonomy, gives the caregiver a welcomed role, and prevents the secrecy-and-resentment cycle.

When there’s a willingness to talk but not yet to change, the ambivalence itself becomes the work. A child might generate two lists: reasons to work on the BFRB, and reasons to keep it. Both are honest. Sitting with the ambivalence, rather than arguing one side of it, is frequently what makes movement possible.

A word on parents and caregivers

Sometimes the person in the family who most needs support is the parent or caregiver. When a caregiver is significantly distressed, a caregiver-only session can be invaluable as a place to listen and to share information they may not have heard. This might include the fact that many children and adults live full, healthy lives with a BFRB; that the worst-case narratives found online at two in the morning or in their fearful imagination aren’t the typical course; that common myths, like “she’s doing this for attention,” “something must be deeply wrong,” or “a better parent would have prevented this” aren’t accurate; and that a less anxious caregiver is a more effective partner in their child’s care.

When the child is comfortable, caregivers can also be invited in at the end of a session to walk through what was worked on and how they might gently echo that approach at home.

Willingness is built, not waited for

Left unaddressed, BFRBs can have real physical, emotional, and social consequences. It’s understandable that caregivers want intervention now. But intervention doesn’t have to mean “making the child stop.” It can mean finding a clinician who understands BFRBs, meets a child where they are, treats the whole child, and partners with caregivers in a way that protects both the child’s autonomy and the caregiver-child relationship. That isn’t waiting. That is treatment — and often, it’s the treatment that eventually makes targeted BFRB work possible and effective.

Willingness is built. It grows out of feeling known, capable, less alone, and less ashamed. Children don’t often arrive at therapy wanting to change. What they can arrive at, with the right support, is wanting to understand themselves and to be who they want to be. That’s almost always enough to begin.

To find a therapist, visit the Psychology Today Therapy Directory.