Cultural Considerations for Body-Focused Repetitive Behaviors (BFRBs)

BFRBs like hair pulling (trichotillomania), skin picking (excoriation disorder), and nail biting often emerge as maladaptive strategies to regulate stress, but how these behaviors are interpreted, tolerated, or hidden varies significantly across cultures. Cultural stigma, family roles, mental health beliefs, and beauty standards all play a role in how clients understand and manage their symptoms.

1. Stigma and Shame: East Asian & Middle Eastern Cultures

In East Asian cultures, particularly among Chinese and Korean populations, emotional restraint and collectivist values are prioritized. BFRBs may be seen as signs of emotional weakness or poor upbringing. A study by Choi & Lee (2007) on Korean adolescents noted that visible signs of emotional dysregulation, like hair pulling or skin picking, led to internalized shame and secrecy, due to fear of dishonoring the family.

In Middle Eastern cultures, family honor is deeply rooted in social identity. As found in Al-Krenawi & Graham’s (2000)research, mental illness in general is highly stigmatized and often interpreted through spiritual or religious lenses, which can lead to delays in seeking psychological treatment for BFRBs.

2. Expression of Distress: Latinx & South Asian Cultures

In many Latinx families, distress is more likely to be expressed somatically (headaches, stomach issues) rather than emotionally or behaviorally. BFRBs may be misattributed to medical issues rather than psychological distress. Interian et al. (2007) highlighted that Latinx clients often prefer to discuss physical symptoms first, and culturally sensitive inquiry is essential to uncover underlying stress or trauma fueling BFRBs.

In South Asian cultures, emotional expression is often discouraged, particularly for women. A study by Rastogi & Wadhwa (2006) found that Indian American adolescents may resort to hidden repetitive behaviors (e.g., hair pulling in secret) as an outlet for managing stress, especially in high-pressure academic or family environments.

3. Cultural Beauty Standards: African American & Iranian Communities

Hair is culturally significant in African American communities, often tied to identity, pride, and social status. Thompson (2009) noted that hair loss due to trichotillomania can be particularly distressing and stigmatizing. Wearing wigs or protective styles may help conceal the behavior but also reinforce secrecy and shame, potentially delaying treatment.

In Iran, clear skin is highly valued in social and marital contexts. A study by Ghanizadeh (2008) on Iranian university students found higher rates of shame and concealment in individuals with skin picking behaviors. Participants expressed fear of judgment, particularly in relation to marriage prospects and family reputation.

4. Help-Seeking Beliefs: Somali & Haitian Cultures

In Somali culture, psychological distress is often spiritualized or attributed to jinn (spirits). According to Warfa et al. (2006), families are more likely to consult religious leaders or healers before mental health providers. BFRBs might be viewed as possession or spiritual imbalance, and ERP-based treatments may be rejected unless culturally adapted.

Similarly, in Haitian communities, mental health issues may be interpreted through religious or supernatural frameworks. Nicolas et al. (2007) found that many Haitian immigrants view symptoms like nail biting or skin picking as discipline problems or spiritual weaknesses, not clinical concerns.

5. Family Involvement and Support: Chinese American & Arab Families

In Chinese American families, filial piety (respect and obedience to parents) often guides behavior. Children may hide BFRBs to avoid burdening their families or appearing weak. Yeh et al. (2005) documented that adolescents in these communities often fear that disclosing mental health issues may reflect poorly on their parents' competence.

In Arab families, collective decision-making is the norm. Involving family in psychoeducation can reduce shame and increase engagement. However, family members may initially minimize BFRBs or attribute them to laziness or attention-seeking unless cultural framing is used during education.

6. Language and Terminology Barriers

Terms like “trichotillomania” or “excoriation disorder” may not exist in non-English-speaking cultures, which can hinder communication. In a study by Sue & Sue (2012), therapists reported difficulty translating mental health diagnoses to clients from refugee backgrounds where emotional suffering was understood through cultural idioms like “my heart is heavy” or “my blood is hot.”

Culturally Responsive Practice Tips (with Examples):

• Normalize behaviors using metaphors appropriate to the client’s background (e.g., “like picking at a scab on the soul” for Latinx clients).

• Offer alternative framing (e.g., “a habit of stress release” instead of a “disorder” for South Asian clients).

• Incorporate family or community when aligned with cultural values, and educate them in stigma-sensitive ways.

• Use translated psychoeducation materials or collaborate with cultural brokers or religious leaders where needed.

Conclusion:

BFRBs are shaped not just by individual factors but by the cultural contexts clients live in. Recognizing and adapting treatment to these cultural influences enhances engagement, reduces shame, and improves outcomes. ERP and HRT can be culturally responsive when clinicians listen with humility and adapt their tools accordingly.