Tackling Picking and Pulling from all Angles – the ComB Model for BFRBs

What are BFRBs?

Body-focused repetitive behaviors or BFRBs are more commonly called skin picking or hair pulling disorders. They involve “any repetitive grooming behavior that involves biting, pulling, pinching, or scratching one’s own hair, skin, lips, cheeks, or nails and that may cause physical harm to the body and has been met with multiple attempts to stop or decrease the behavior.” ”. (TLC Foundation)

One treatment option that has promising data and research supporting it is the ComB model.

What is the ComB model?

Comprehensive behavioral treatment or ComB model is a treatment protocol developed by (Mansueto 2019) that addresses the complexity of treating BFRBs. It begins with the use of a CBT assessment tool, a functional analysis. This looks at the ways in which internal and external environments are impacting the BFRB the client wants to change. It is a way for the clinician to develop a unique and specific treatment for the client. It is a way of setting up your environment so that you are more likely to be able to control the urge to catch or pull.

Let’s go with an example!

The SCAMP model is a framework that guides the clinician through different areas or domains to be evaluated. Each domain approaches treatment from a variety of creative angles and leaves the client with a variety of skills and techniques for specific triggers.

Sensory – We all have a nervous system that has different needs. Using this domain, we analyze the particular sensory needs that the client has and choose techniques based on them. For example: If a client’s nervous system craves a feeling of softness, the doctor can provide examples of gentle items the client can use, such as using a face mask or pimple patches that create softness on a pimple or bump. . Or use a worry stone or calming touch patch.

Cognitive – There are specific cognitive thought and belief systems that frequently arise in therapy. The self-help book lists some of them. This is one way to look at how the client’s self-talk and thoughts can unknowingly increase or manage picking/throwing effort. For example: “I’ll only catch/pull for a minute/just one” Rebuttal: How often do I stop after one minute or after just one? Answer: Never! It may be helpful to use sticky notes in the bathroom with some of these rebuttals.

Affective – Our moods and emotions impact how we see things and how we interact with them. This part of the model involves emotion regulation skills. For example: if a client pinches/pulls every time he gets stressed, the clinician will provide techniques and options to relieve stress instead of pinching/pulling.

Engine – Specific movements a client makes or the position in which they place their hand may trigger the urge to grab or pull. Thinking of things to make him less attractive or harder to pick out. For example: getting gel nails or a manicure may change the feel of the client’s nails and they may be less likely to get the same relief/feeling from picking and pulling.

Place – Specific places may cause a client to pick or pull more, such as the bathroom or while driving. For example: Dim the bathroom lights so you can’t see in the mirror as clearly or as closely and are less likely to cause a bump in your hair or skin.

I would recommend the following if you are interested in further training or resources. The TLC Foundation BFRB Training Program:
Clinical Training Institute – TLC Foundation for Bfrbs.” Clinical Training Institute – TLC Foundation for BFRB. Accessed August 21, 2023.

Book: Mansueto, Charles S., et al. Overcoming repetitive body-focused behaviors: A comprehensive behavioral treatment for hair pulling and skin picking. New Harbinger Publications, 2019.


This publication is brought to you in collaboration with the ADAA OCD and Related Disorders SIG. Learn more about GIS.

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