Habit Reversal Training for Excoriation disorder

Tasneem Abrahams
Aug 24th, 2015

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Cognitive-Behavioural Therapy (CBT) is a form of therapy that seeks to alter behaviour by identifying the precise factors that trigger picking and then learning skills to interrupt and redirect responses to those triggers. Broadly stated, CBT is based on learning theory which has shown that as we practice new behaviours and thoughts in response to familiar emotions or situations, our brains physical structure actually changes too. We develop neural pathways and, with repetition, the new behaviour becomes an automatic response. CBT should be performed by a mental health specialist trained in this method and well versed in treatment of these behaviours – something that may be easier said than done as there is not an abundance of professionals who specialize in body-focussed repetitive behaviors (BFRbs). The therapist will encourage pickers to develop an increased awareness of the times of day, emotional states, and other factors that promote picking, as an important precursor to being able to control the behaviour. Some pickers have had success with simple behavioural devices such as putting bandages on their fingers, to interfere with picking, keeping records of their picking or changing environmental cues that can trigger pulling.

What is Habit Reversal Training?

Methods of CBT, such as Habit Reversal Training and the Comprehensive Model for Behavioural Treatment have shown to be the most successful treatments. Habit Reversal Training is a behavioural therapy that is effective in reducing tics associated with Tourettes Syndrome as well as troublesome behaviours associated with impulse control disorders such as trichotillomania and pathological skin picking. Habit Reversal Training, as a form of cognitive behaviour therapy, is a multicomponent behavioural treatment package originally developed to address a wide variety of repetitive behaviour disorders. In a nutshell, you learn how to break bad habits and form new positive ones in their place. Habit Reversal Therapy has four main components: Awareness Training, development of a competing response, building motivation and generalisation of skills.

Components of HRT

Awareness Training:

Awareness training is used to bring greater attention to picking and other behaviours so that the affected person can gain better self-control. Awareness training is usually carried out in a number of small steps:

  1. The person describes in detail each time they carry out the behaviour while looking into a mirror
  2. The therapist will tell the person whenever he or she carries out the impulse. This is done repeatedly until the person notices every time they do it
  3. The person learns to identify the earliest warning that an impulsive behaviour is about to take place. These warning signs can be urges, sensations or thoughts
  4. The person identifies all the situations in which the impulsive behaviour occurs

Development of a Competing Response

Once the patient has developed a good awareness of their impulse behaviour the next step is to develop a competing response that replaces the old behaviour. Usually the competing response is opposite to the impulse behaviour and is something that can be carries out for a longer than just a couple of minutes. As well, it is usually helpful to choose a response that will be more or less unnoticeable by others. The patient can clutch a small ball or paly with a “finger toy” instead of picking at the skin. In addition to this (sometimes called fidget toys), the patient can also find a hobby that keeps the hands busy, like knitting.

Building Motivation

To keep the impulse behaviours from coming back, the patient is encouraged to make a list of all the problems that were caused by their behaviour. Parents and friends are also asked to praise the person for their accomplishments thus far. In addition, it can often be helpful for patients to demonstrate their ability to suppress their impulse behaviours to others.

Generalisation of New Skills

In this phase of treatment, patients are encouraged to practice their new skills in a range of different contexts, not just those that they have mastered to date. For example, while it may be easy to learn to suppress an impulse behaviour in the relative safety of the doctor’s office, this also needs to be practiced at home, at school and other environments.

Does it work?

Empirical evidence relating to the efficacy of Habit Reversal Training for Skin Pulling is fairly extensive, and studies mostly combine those that suffer from excoriation and trichotilomania. Studies also indicate that HRT used in conjunction with other types of CBT is often more effective than when used in isolation. The key is to treat each person as an indivual and to treat the person holistically. Stopping the behavior cannot be addressed without considering the person as a whole for progress in HRT to be sustainable in the long term.

Tasneem Abrahams

Tasneem is an Occupational Therapist, and a graduate of the TLC foundation for BFRBs professional training institute. Her experience in mental health includes working at Lentegeur Psychiatric hospital forensic unit (South Africa), Kingston Community Adult Learning Disability team (UK), Clinical Specialist for the Oasis Project Spelthorne Community Mental Health team (UK). Tasneem is a member of both the editorial team and the clinical staff on Skinpick, providing online therapy for people who suffer from excoriation (skin picking) disorder.

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