The Practice of Therapy

Gordon Brewer: Well, hello everyone and welcome again to the podcast. And I'm so glad for you to get to know Stacy Nakel. So welcome, Stacy. Glad you're here.
Stacy Kim Nakell: Thank you so much, Gordon.
Gordon Brewer: Yes, yes. And so Stacy is in Texas and we chatted a little bit. We've got North Carolina roots in common. So that's that was fun to find out. But Stacy, as I start with everyone, tell folks a little bit more about yourself and how you've landed where you've landed.
Stacy Kim Nakell: Sure. Well, I'm a licensed clinical social worker and I've been in practice for a little over 20 years.
And I came to my expertise in working with hair pulling and skin picking a little bit roundabout. I had a client when I was just starting practice, who asked me for help with her hair pulling. And I really hadn't heard of it beyond maybe a mention in a diagnosis class. So I had to look into it.
And I was just very intrigued by what I found in a couple of ways. I started to understand that it intersected with my own body focused behavior, which was skin picking. And skin picking has become more a part of the research and the clinical understanding. So I was sort of drawn to something that I didn't realize also had a close connection to my own process.
And actually working on writing my book was part of what really brought me into a better relationship with my own skin picking. And so it all kind of came full circle.
Gordon Brewer: Yeah. And it interesting how a lot of us get into our different niche, niches and different therapy things. Things based on our own experience and our own kind of struggles and that sort of thing.
Speaker 3: Yes, exactly. I think that idea of the wounded healer is very, very.
Gordon Brewer: Yes. Yes. Yes. That is, that is a good analogy. So yeah, so in your, in your practice, tell us a little bit about your practice and how you've got it structured and all of that sort of thing.
Stacy Kim Nakell: Sure. Well, I work with teens and adults. Most people do come to me for my expertise, but I do work with other other presenting issues.
And of course, hair pulling and skin picking, like so many behaviors are really found comorbid with a lot of other conditions. So no matter what someone comes to me for, we're always kind of going to the roots and trying to understand how did you come to pick up this particular behavior as a coping mechanism and what needs is it serving?
And then are there other ways that we can meet those needs? So Some of those needs are related to usually the, the comorbid depression or anxiety or post-traumatic stress disorder and things we have to navigate through the therapy. So I do with individuals and groups and group therapy is my love.
And so, wow. I focus in a lot. I'm on the faculty of the American Group Psychotherapy Association and just love group work with this population.
Gordon Brewer: Right, right. Yeah. So are you in solo practice or you have a group or how are you set up?
Stacy Kim Nakell: Yeah, I'm in solo practice, but I office with two other women and we really it's, it's a great balance of being my own boss, but also getting that connection and collegiality that I think a lot of people in solo practice really miss.
Gordon Brewer: Yeah. Yeah. Well, that's good. Yeah. I think that's always important to have people around that you can bounce things off of and, and, and that sort of thing. So, yeah, yeah, it's good. Yeah. So let's, let's dive into this whole thing with the hair pulling and skin picking and yeah. And just yeah, you know, I always think of it from a clinical standpoint.
And I might be wrong about this, but I, I kind of. equate it or link it to kind of an OCD kind of behavior?
Stacy Kim Nakell: Yeah, so it is in the most recent DSM, it is linked under the umbrella of OCD and related behaviors. And there is some advocacy for body focused behaviors to be their own category diagnostically, because they do have some things more in common with themselves.
Although there is some overlap with OCD particularly in sort of a clinical setting. quest for perfectionism that can sometimes be what people are looking for. Maybe getting their eyebrows even, or their lashes looking perfect. And so that's, that's one overlap, but unlike OCD, there's not as much of a sort of magical thinking component of, if I pull this hair, something good will happen or something bad will happen.
And there's really more of a kind of release and relief that motivates the behavior.
Gordon Brewer: Yeah. Yeah. So, yeah. And so in your approach, tell us a little bit about that. And, and also just, I know you've, you've written a book on, on this whole thing and what are you finding?
Stacy Kim Nakell: Yeah. So what happened was when I did that search, that was back in 2002 I did find the trichotillomania resource.
Or the Trichotillomania Learning Center, which is now TLC Foundation for BFRBs. And I will recommend them as a a really important resource for information and connection. They have conferences. They used to have retreats. They may well start that up again. I did find is they only advocated and endorsed one particular kind of treatment, which was cognitive behavioral therapy.
And because that wasn't my, my interest, I had always been interested in psychodynamic therapy, and really understood too, that part of part of the CBT perspective that they endorsed. It really asks that a therapist not look at the roots of a behavior. And I knew that for me, what interested me and what helped me get better was really exploring and excavating the roots of my behavior and understanding the ways that skin picking had developed as a way to cope with circumstances in my life.
So I was very frustrated that there was no exploration, even sort of encouraged in any way in any of these, you know, manualized either treatment protocols or the books I was finding. And so I guess I just realized I realized so in 2009 I was when I realized I'm going to need to write this book myself.
And it was not a natural fit. I don't have a PhD. I was really kind of just, you know, Taking a huge leap, which took me 10 years. So it was incredible that it did end up with a academic publisher wanting to publish my book. And it came out in three. Yeah.
Gordon Brewer: Yeah. Yeah. So, yeah. So take us through kind of your process with, with clients and, you know, your, your approach with things.
Stacy Kim Nakell: Sure. So the book is titled, it has a really long title. It's treatment for Body focused repetitive Behavior, an Integrative Psychodynamic Approach. And that integrative psychodynamic approach is really at the heart of everything I do. So the integrative piece we're integrating number one, the body.
'cause these are behaviors that take place on the body and skin. Mm-Hmm, . So we're integrating awareness of the body. into therapy, as well as all of those really important treatment protocols. Like there are cognitive elements, there are behavioral elements, especially in meeting sensory needs. But the psychodynamic part means that we ground it all in a therapeutic relationship.
So what I really have enjoyed as neurobiology has sort of gotten clearer about how we, how we function and how we bond and attach and how we learn to regulate is that it really backs up Regulation is co regulation. And so my sense that a frustration with sort of being given a worksheet to try to work on my relationship with my skin picking that wasn't going to work for me.
I needed actually another person in the room to help me learn to regulate by helping me metabolize my feelings. And some of these deep feelings that underlie picking and pulling a lot of times in adolescence, these feelings, these behaviors develop when there's some kind of a crisis, often a divorce.
And so a kid kind of gets lost in that and doesn't have a way to process their feelings. That's one way that feelings kind of get stored in the body and then have to come out bit by bit. And so we really do have to go back and kind of grieve and process some of those losses that may have stimulated this behavior.
Gordon Brewer: Right, right. What, what do you find that is helpful in helping clients and particularly kids access those feelings and then be able to put, you know, labels with them and words with them and that sort of thing?
Stacy Kim Nakell: Yeah, that's a great question. Well, I think in some ways I found the magic sauce because we all have bodies and we all, And start to notice what I'm feeling inside of my body.
And so I don't have to have words for any of those feelings. I could just know I have a lump in my throat. And oftentimes when I'm using my body in, in treatment too, if a kid or adolescent isn't maybe able to acknowledge or know what they're feeling, I might have that lump in my throat. And I might say, Oh, my gosh, it feels like there's something I'm not saying or needs to be said and help people kind of get in touch with, oh, wait, yeah, there is something in my throat.
What is that? And sometimes it takes us a long time to figure out what, what words need to be put. But in that way we all have those experiences. We know when our heart is beating fast and we know when it's When our stomach is turning and so we can get to some of the feelings that we may not get to if we were just doing talk therapy.
Gordon Brewer: Right. Right. Yeah. Yeah. I know in my own work, that's been really helpful, particularly working with people with anxiety, getting them to, to recognize, you know, question. Okay. You're feeling anxious right now. Where in your body are you feeling it? And what does that, and what does that feel like? And so just, yeah, being able to kind of focus it, kind of lean into the feeling seems to be helpful.
Stacy Kim Nakell: Yes. Yes. And then of course you're such an important part of that because as they lean into the feeling now they have someone to listen to it and to help them manage it. And so again, you're, you as a therapist are just such a key part.
Gordon Brewer: Right, right. Yeah. So tell us are there any sort of quote unquote success stories you could tell us about or people that stand out that you'd like to share?
Yeah.
Stacy Kim Nakell: Yes, because I did, I wrote up a case study. We're looking for, for a home for it, but I did get permission to share and, and a pseudonym for this client. So Sadie came to me, for really intense nail biting, picking and she was really, really unhappy with her hands. She was getting ready to become a doctor and just realizing how much her hands are going to be a part of, you know, what people see when they meet her.
She had so much shame. So the reason that I really, really like to talk about her story is that she was such a huge part of of the healing process. All of it came from sort of her own creative imagination of how to meet her needs. So my job was just to help her get in touch with what needs needed to be met.
So she was really easy to, this does not always happen, but when you ask, you know, what, what was the, The moment that you really started leaning into picking and biting as a coping mechanism. And she was able to say right away that it was when her parents divorced when she was an adolescent and her mom abandoned the family.
So that was very clear. We had grief to work on. So I work with the same phase kind of trauma informed. And so we kind of bookmark that. We have some grief to, to uncover and, and work with, but only once we feel comfortable with each other. And you already trust me. So that's sort of the first phase of her treatment.
But she was also able to tell me even in that first session that the picking had gotten a lot worse since the death of her father. And that had happened two years before. And so again, she was really sort of, it was easy to link that those, those things were disruptive to your attachment structure and you needed to find another way to cope.
And so your your hands really became your kind of best friend and enemy all at the same time as. Mm hmm. And so once we kind of got to that part where we really grieved that loss and, and I feel like you need to grieve it physically. So there needs to be some release, either tears or yelling or whatever it may be.
And then you can sort of work it out of the body. And we had this moment where she was really, really crying because she had realized. in, in still having a relationship with her mother, that she's sort of the mother to her mother who still has mental health issues that keep her from really showing up.
And so my client said something, Sadie said something like you know, I realized that I think my hands were my mother when my mother couldn't be my mother. And so I suggested, cause she's a real creative person. I suggested she'd do something creatively with that. And she ended up Painting a picture of a rocking chair, that was a hand.
So the hand was a little baby and the baby was all merging into the chair. And we, we talked about that and just how, how that was such a pivotal moment and building self compassion for herself, recognizing how resilient she was and not seeing herself as, as sort of this. This person who needed fixing with these problems she had, but really as somebody who was doing her best to cope.
And that was for the treatment. And she really let go of her, her picking biting behavior from then on discovered that she loved doing nail art. So then she, she brought in a whole nother element, which I encourage people to find ways of sort of healthy grooming to replace these over grooming behaviors, focus in on the nail art.
and really enjoy all the sensory pleasure of looking at her nails, painting her nails, then looking at the product, feeling it. And so she really did find a replacement. And you know, as we've gone along she still sees me for maintenance treatment and she finds that, you know, if she doesn't have time one week to do her nail art, maybe she'll do a little bit of picking, but it never gets to a point where she feels sort of caught in the cycle of shame and picking and then shame and picking.
Gordon Brewer: Yeah, yeah, that's, that's a, that's a wonderful story. I mean, that's just it's, it's always very touching when people can make those connections to what they're doing and find different really, you know, thinking about kind of a narrative kind of way of thinking of things just changing the narrative about what has happened.
And seeing it in a different way. Yeah,
Stacy Kim Nakell: exactly. Gordon, I call it embodied narrative therapy in the book because yeah, it really, it really is. You have to be embodied and kind of go back to those feelings in order to change the story with a trusted other, and then it can be, and then that story doesn't have to hold so much power.
Gordon Brewer: Right, right. Yeah. Yeah. It's fascinating things. What you know, with the with what you've learned so far, how do kind of these things develop in people? I mean, what is it, what seems to be the link with all of that? You know, you mentioned trauma and grief and yeah.
Stacy Kim Nakell: Yeah, well, you know, and I have hypotheses of my own that, that I explore a little bit in the book.
There's no, no sort of across the board for everyone. Way that people develop body focused behaviors. If you think about it again, we all have dermis, right? We all have this thing that kind of sloughs off and we all engage in some kind of. grooming, right? So all of us might pluck a hair or two or you know, pick a pimple.
So it's so accessible that it can start to stand in for any number of, of things that, that are feeling sort of dysregulated within us. We can mediate that through picking and pulling. But what I find is there are a number of, of really interesting common characteristics that could use more exploration.
So one is that people tend to be really Physiologically sensitive, and that often includes skin sensitivity when they're really young, like not liking the tags on the back of clothes or the lining on socks. And so there's something there. Why is this population whose parents might say, yeah, that was true for them.
And then later in adolescence, they start picking and pulling. And to me, that means there's. It's just some nervous system dysregulation from early in life and sort of look into and study what that might be. And there's certainly a genetic piece that they are also looking into. It looks like maybe there's some kind of mutation on the same gene that's implicated in Tourette's.
So they're looking into that. But I've, my sense is that it's already harder to calm this child's nervous system. And so, especially if parents are. Rest, then this child becomes a harder child to soothe. And maybe there's a stress in the family around that. And that somehow this child isn't getting a sense of that, that deep awareness that not only am I okay.
Everything's going to be okay. But also all my feelings are okay. Cause it may be that this kid's feelings are just too much for the family. And so for whatever reason, this kid learns to sort of tuck a lot of those feelings away.
Speaker 4: So the
Stacy Kim Nakell: big one is anger. And it was a study in 2016, curly at all, looking at.
internalized anger as a major trigger for picking and pulling. And then, if you look at that, you also can connect it with some of the other characteristics, like perfectionism and overachieving. So these are really high functioning people. And that's a lot of why their needs don't get tended to. A lot of my clients are actually the sibling of a high needs sibling.
Child and so they learned this child needs a lot of the attention. So I'm going to just Make mom and dad happy get straight a's be the head of the the president of my class all these things But in that you don't get noticed that you also have struggles and you also have And so a lot of times that's the work that I do with families.
If I have a teenager and the teenager being able to say, yeah, I haven't been okay. And the parent being able to usually want to hold that kid while that kid cries and gets some of those needs tended to that they've been pushing down. So that's a big part of what I notice. And, and then the perfectionism really can Play into picking and pulling.
Cause as I mentioned, it's like, you're never going to look perfect. And so if you're looking in the mirror and you're going to find the sections, and if you're trying to be perfect that's going to be a real recipe for, for, for doing some of that damage while you're in the mirror.
Gordon Brewer: Right. Right. Yeah.
It's yeah, it's one of the things that I heard when you were talking about high achievers, I think it was A book I was reading here recently, but there seems to be a correlation between higher suicide rates among high achieving children than those that don't seem to seem to fit that demographic.
Stacy Kim Nakell: Wow. I hadn't heard that, but that makes a lot of sense. Yeah. Yeah,
Gordon Brewer: it does. Yeah. I mean, it's kind of like they they achieve, you know, once they achieve everything and then they feel like you know, then there's really Still no sense of happiness or whatever with with those things. So that was kind of the line of thinking.
I don't know if there's, I don't know if there's any data to back that up, but it makes sense when you think about it that way. It
Stacy Kim Nakell: does make sense. It sort of reflects, I think When adults come to me, what they're struggling with, because usually they've, they've been struggling with this since adolescence.
And what they found is that maybe they can keep up those appearances and they can get those kudos and those gold stars. But then once everybody starts partnering up the, the difficulty with intimacy both sharing feelings, but also things like maybe, maybe people have been camouflaging some of the bald spots or the, the scars.
And so if you want to be really intimate and you have to take off your, your wig or you have to take off your makeup can sort of get in people's ways. And that could be a motivator to seek treatment. Because something's missing, like you said.
Gordon Brewer: Right, right. Yeah, it's yeah, you know, the other thing that when you were talking about things where I could see where this could develop and maybe just to normalize a little bit is I think all of us do kind of tactile things that are self soothing.
Stacy Kim Nakell: Yeah, I mean, it's
Gordon Brewer: just you know, like for me, I know a lot of times all, Just rubbing, you know, rubbing the lips or something like that, you know, I'll be watching TV and just, you know, it was, it was called out to me and I thought, well, no, my lips don't hurt. I'm just, you know, just, and then same thing with rubbing, you know, rubbing a leg or knee or something like that, you know.
Stacy Kim Nakell: Oh, true. So true. And it is, I mean, we, we are sort of touching our skin as ways to regulate ourselves all throughout the day, which is not a problem in any way, unless it becomes something that has consequences that are negative. Right.
Gordon Brewer: Right. Right. Yeah. But
Stacy Kim Nakell: I've been watching lately. I've noticed that like Rachel Maddow touches one nail to one cuticle.
Interesting.
Speaker 3: Yeah.
Gordon Brewer: Yes. Yes. Yeah. I think there's all, all sorts of things. I mean, I was just, now I've become hyper aware. I've got a place on my hand that I know that a lot of times I'm just rubbing this little place on my hand. It's kind of a, I don't know. It's a little callous or, Mm-Hmm. A little cyst or something underneath the skin that's always been there.
It's nothing. I've had doctors check it and nothing wrong with it, but it's just, you know, that there's just so sort thing, something
Speaker 3: that, yeah. Touch kind get you something you can't quite put your finger on.
Gordon Brewer: Feels good. It
Speaker 3: soos you.
Gordon Brewer: Yeah. Yeah. All right. Yeah, it's interesting stuff. Yeah. So, well, let's see, Stacey, I've got to be respectful of your time.
This is, this is fascinating stuff. What, are there any kind of parting thoughts you've got around all of this and just thinking about how we can maybe be more informed just as clinicians and. People helping people.
Stacy Kim Nakell: Sure. Well, I guess I would say part of part of what I advocate for is that I do really advocate for a trauma informed perspective because traditionally sort of, there's been a a denial that trauma could be a precipitating factor.
And that's sort of the official stance of the TLC Foundation for BFRBs is that trauma does not seem to be a factor. Even so, a lot of evidence has shown more of a connection than they might like to acknowledge. And so Just really actually for anybody working with any behavior to remember that a trauma informed way of treatment is that you never discount the possibility that trauma could be a factor in a problematic behavior, because we behaviors are symptoms of something.
And so if we treat them as the problem, we might be missing the point and we might actually be doing more harm, especially to someone who's a perfectionist who might try really, really hard to be perfect and not pick or pull, which sometimes happens in the research with cognitive behavioral therapy.
Great. And they succeed and they get that a, and then they leave and they have a relapse. And it's so, so overwhelming how quickly all that progress can just be wiped out.
That would be one, one note. And the other note that I would like to just leave people with is that My goal is for as many people to get a little bit more of an awareness of how to work in this depth oriented way with this population.
And so the book that I wrote has really an outline in the first half of the book on how I understand the behaviors, but the whole second half of the book is how to apply these these Ways of uncovering and moving through feelings within that three part the safety phase, the exploration and skill building, and then termination or maintenance.
And so I really encourage people to actually read the book and there's an appendix that has and I tried to make it really accessible. I also offer training groups. My goal is really just to spread the word and have as many people being able to look at the roots of these behaviors. And in that way, I think really doing, doing a much more important service than just looking at the symptoms and trying to help people get rid of them.
Gordon Brewer: Right, right. Yeah. Yeah. I could say, you know, one of the, even though I do use a lot of cognitive behavioral therapy in my own work one, one of the things I have learned is, is that the more you think about something, the more you think about something. And so it becomes more of a challenge, to kind of cha change, you know, change things that you're thinking about and, you know, ruminating about.
Yeah. Right.
Stacy Kim Nakell: And really, if we think about. how to shift someone's cognitive way of relating to these behaviors. I would say we want to reduce shame and bring in self compassion. So what does it take that versus how can I just get rid of this, this negative voice? Where did it come from? Why is it clinging to me?
And is there a message maybe I can get from my therapist that I can internalize since I'm not going to come up with new messages all by myself.
Gordon Brewer: Right. Yeah. Oh, this is great stuff. Well, Stacy, tell folks how they can get in touch with you and find the book and all of that sort of thing.
Stacy Kim Nakell: Sure. You can find everything at www.
stacynakell.
com. And I also try to make myself available just if people have questions, therapists, parents, whatever I'm sort of dedicated to responding to my emails. So if anyone wants to reach out in any way I am happy to see what I can do to answer your questions.
Gordon Brewer: Well, Stacy, this was great. I hope that we can cross paths again and have more conversations.