May 14, 2013 An interview with Jon Hershfield We spoke to Jon via skype and here’s the transcript of the conversation:
SKINPICK: Maybe we can start with a little info about yourself, about your professional background. Can you throw a few words there?
Jon: So, I’m a licensed psychotherapist in the state of California in the US. My license is MFT – Marriage and Family Therapist, and I specialize in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder. In my work, treating OCD, I’ve come across related disorders that I’ve also treated that tend to coincide with OCD and Anxiety-based disorders like Social Anxiety, Body Dysmorphic Disorder, Panic Disorder and what they call Body Focused Repetitive Behaviors which includes Trichotillomania and Dermatillomania. So, let’s see… right now I’m in the private practice and I also work at UCLA as the associate director for the Pediatric OCD Intensive Out-patient program.
SKINPICK: Okay. Great! So, let’s dive into our theme here which is going to be obviously, skin picking – dermatillomania. So maybe we’ll start with the general topic of OCD. How common would you say this disorder (or scope of disorders) is?
Jon: It’s a relatively common disorder compared to other disorders. Different studies will show different prevalence rates but I think most people figure that it’s somewhere between 2% and 3% of the population. So, one way of looking at that is if you’re in a room with a hundred people there’re very likely 2 or 3 people who would meet the clinical diagnostic criteria for obsessive-compulsive disorder.
SKINPICK: Oh, okay. What about compulsive skin picking? How common is this disorder according to your experience?
Jon: Well this doesn’t have to be based exclusively on my experience because I don’t know of any research study, perhaps there are some out there but I don’t know of any research studies that have really good numbers on the prevalence of skin picking as unique subset of symptoms. In my professional experience I would say that, again, it’s not an incredibly uncommon thing. I’ve had a lot of clients who come for treatment with obsessive-compulsive disorder who also have problems with skin picking and I’ve had a lot of clients who come in for treatment for their skin picking and you later discover that they have obsessive-compulsive disorder. That being said, they don’t always come together. I wouldn’t say that the majority of people with OCD have skin picking problems nor would I say that majority of people with skin picking problems have OCD. So, sometimes they collide, sometimes they don’t.
SKINPICK: This actually brings me directly to the next question which is, would compulsive skin picking be a subset or a type of OCD? How is it classified? I believe there are several different opinions on the subject out there - what would be your opinion?
Jon: My opinion is, it really comes down to the mechanism by which you’re making the ultimate decision to pick, what is sort of leading you towards that behavior and I see it occurring in 3 different ways in my patients. So, in the most obsessive-compulsive way, the way in which it is most like OCD, you’re having an obsession that something either looks or feels wrong about your skin and this is coinciding with an emotional state of discomfort and anxiety whether or not you can tolerate this thing, feeling or looking wrong and then the compulsion is to relieve that discomfort by picking at the skin, either try to get it to look right or to get to be smooth or you might be picking as a coping mechanism simply to stop feeling. A lot of people with dermatillomania report feeling numb or trans-like. You hear this with people with trichotillomania as well, hair pulling, that when they’re doing it, they’re not really feeling anything and that that emptiness, that lack of feeling is relief from the discomfort that they’re feeling from their obsession – something is wrong, something is wrong, something is wrong with my skin, with the way it looks, the way it feels, I have to fix it and then the “fixing it” creates this feedback loop so, OCD operates on what they call a “Negative Reinforcement Schedule”, meaning, the compulsions whether it’s to pick your skin or wash your hands, or avoid something that triggers you, relieve you from a state of discomfort, however, temporarily. And that relief is interpreted in the brain as something good, as a reinforcement. So, it’s a negative reinforcement, meaning it’s taking something bad away which makes you more and more likely to rely on it next time you feel that way and so, picking leads to more obsession about your skin which leads to more picking and so on and so forth. So that’s the OCD route. The other way that I see it come up is more similar to addiction in a sense that it’s really just started as a coping mechanism to stop feeling in general. So, it’s not necessarily that something is wrong with your skin or that you’re thinking that looks wrong but that the physical act of picking is releasing chemicals in your brain that are making you feel some relief from the stress in your life and it becomes harder and harder to achieve that relief without doing more and more picking. And then the third avenue is really just bad habits – [sometimes] people with dermatillomania are “accused” of just having a bad habit, and while I think that this is certainly something that occurs, I think it’s probably less common than the obsessive-compulsive [factors] or the pseudo-addiction to that feeling. But still when it does occur it’s basically something you picked up when you were young, you just picked at your skin for no apparent reason. Maybe you had acne and you were picking your pimples or maybe you’re picking or scratching just because you saw somebody else doing it and you did it and it felt good and then it just became something that you did every time you’re in the car, every time you watch TV or every time you’re in a certain environment you just notice yourself picking and so, the treatment for that is a little bit different from the treatment for the obsessive-compulsive form of picking, in the sense that you’re really going to focus more on habit blocking and habit reversal then cognitive behavioral therapy.
SKINPICK: Could you describe your treatment methods and what proves to be effective specifically for dermatillomania?
Jon: What seems to be the most effective for dermatillomania in my experience is a combination of three factors. Cognitive Behavioral Therapy which is a form of psychotherapy in which you, on the cognitive side are challenging distorted thinking. An example of distorted thinking might be something like, “If I don’t pick this I am never going to feel relaxed again.” or another example of distorted thinking might be, “Because I have this pimple, everybody in the room is thinking that I’m terribly ugly and disfigured”. So, challenging that way of thinking and trying to address it with more rational, more objective thinking so that you don’t succumb to the OCD mind or the dermatillomania mind in this case. That’s the cognitive side. And then the behavioral side would be, you know, looking at behaviors in which you are making it very easy for the disorder to get at you. In traditional CBT for OCD there’s a heavy focus on something called “Exposure with Response Prevention” which I think anybody who seriously treats the disorder sees this as the real meat and potatoes of treating OCD, which is basically grounded in the idea that if you gradually confront or expose yourself to the thing that you’re afraid of while resisting the compulsive response, you’ll begin to habituate to it and you’ll find that you’re less afraid of it and less reliant on the compulsive response. It’s difficult to do exposure with response prevention for skin picking; obviously, you don’t want to encourage someone to get really, really close to picking their skin and then tell them not to do it. So, the way you would do some form of exposure in response prevention for skin picking would be for example, the social anxiety element of it, so someone believes that they can’t go outside because they have a blemish on their face, the exposure would be going outside and accepting that, “Who knows what people are thinking? But I’m gonna go ahead and live my life and if somebody has a thought about it, I’m just gonna tolerate it” and by cutting out the avoidance and the hiding, your brain eventually begins to switch and say, “You know what? Pimple or not, I shouldn’t be keeping myself from going to the grocery store because the sun is out”. So in that way it can become very effective. It won’t necessarily stop you from picking but it could certainly improve your ability to function with discomfort, with uncertainty about your appearance. So, the other important element of course, is habit reversal training or habit reversal therapy which focuses on documenting your experience, what was going on before, during and after the picking event, what were you thinking, what were you feeling, what environment where you in, because for different people there’re different factors at place. Some people are picking because the way it feels physically, some people are picking because their emotional state, some people are picking because they can’t help themselves when they’re around the mirror and so, you want to look at all of those factors and see how could we make it easier to resist picking so that you can do the work. If you’re very much affected by your environment and there’s an environment that you don’t need to be around, well, maybe don’t be around that environment or if you know you’re going to be around that environment maybe you can mentally prepare yourself. So, someone for example might be covering mirrors in your home so that you’re not constantly dealing with this urge to look at your skin in the mirror. But that’s obviously not gonna be as effective in terms of – if you’re gonna drive a car, you can’t really cover the mirrors in the car, that wouldn’t be safe, so you might prepare yourself by documenting your experience. You might [say], “Okay, I’m particularly susceptible to picking when I’m around mirrors, I’m gonna drive a car now and I’m gonna be around mirrors, so I need to sort of have that in my mind before I get in the car, so that if I’m gonna have an urge to check, I can put some effort into resisting that urge.” This is where you would also see a lot of habit blocking techniques. So, wearing gloves, putting lotion on your skin, having habit replacers, things that you can play with in your hands that keep your hands occupied, they just give you some distance from the disorder. I think, ultimately, these things when they’re effective, what they’re really doing is they’re giving you some space between you and the picking and in that space, when you’re not picking, you can more effectively do the cognitive behavioral therapy and reduce the urge and the sort of obsessive-compulsive cycle of picking. It’s one of the frustrating things about treating the disorder, [and] about having the disorder, you essentially have to stop picking first in order to get enough distance from the disorder, to then learn how to stop picking in the long-term.
SKINPICK: Yeah, and does it really happen that people actually get cured 100% and stop picking forever? What would be the success rate that you see in your patient?
Jon: Well, let me just make sure I finish this one point and then I can answer your question ‘cause I said there are sort of three elements to therapy. One was cognitive behavioral therapy, one is habit reversal therapy and the other is this thing called “mindfulness”, which your readers have probably heard a lot about and I think in the end, plays the most important role in treating compulsive skin picking because the core concept of mindfulness is the ability to look in at what you’re doing from a nonjudgmental, observational third person perspective. So, you can do this for your thoughts, you can do this for your feelings and you can do this for your urges, so if you’re able to be aware, “Oh, I’m having an urge to pick” and you can feel that urge in your body and actually learn to stop judging it and trying to suppress it and shut it down but actually accept it as just something that’s happening and say, “Oh okay, there’s that urge” then you can train yourself to actually ride it out, like someone when they’re surfing, they ride the wave and it goes up and it goes down and if you can make it through that wave without picking, that reinforces all the other healthy behavior that you’re doing.
SKINPICK: It’s basically like being generally more aware?
Jon: Yes, more aware and less judgmental. And one of the tricky things about compulsive skin picking and I’ve noticed this also in Trichotillomania, is that the disorder has a way of really targeting your self-esteem. Your sense of self-worth. And the way I’ve always looked at it is that this is actually part of the disorder. If you’re to look at the disorder as something that is in you that is trying to get you to pick – you know, “It’s not me, it’s something that’s in me that’s trying to get me to do compulsions”, it has a way of attacking your self-esteem so that you feel so low, that the only thing you can think of to do is self-soothe and the self-soothing behavior that you’re most likely to choose is picking of your skin. So, that is, I think, one of the interesting things with mindfulness. You can actually look at what the disorder is doing to you and how it’s putting you in this place where you’re treating yourself in this way , and you don’t fall for the traps as easily when you’re being more mindful. So, to your follow up question about success rates, like with OCD I think that success largely correlates with how active the patient is in the therapy experience. So, this is a kind of therapy, cognitive behavioral therapy, habit reversal training and mindfulness training that involves homework. It involves a lot of out of the office work. A lot of times you come into the office and you learn what you need to do and then you go home and you do it and you do it every day. And, the more vigilant you are about doing your habit reversal logs, doing your exposure assignments, doing your thought records and challenging your distorted thinking, the higher the success rate. I’ve definitely seen a general problem with sufferers of dermatillomania in homework compliance. I think because it’s really hard to accept that you know, you have to take a pen out or write down on a piece of paper this thing and you already feel so bad about having this thing and writing it down makes you feel – it does – it makes you feel worse in the beginning. It’s just that it works and you have to sort of use the therapy to put up with the therapy until the therapy is really producing results. The people that I’ve seen to be the most successful are the people who do the most homework and they also incorporate other elements of healthy living, so they tend to get very involved in things like yoga and exercise and eating healthy, and not so much about being a perfect person. In fact, the opposite, accepting your imperfections and actually being more mindful and acceptant of who you are and what your personality is, but really just taking care of yourself, and the people who really get used to taking care of themselves in a positive way through therapy and through other positive things they put in their life, they start to see the skin picking as more of a punishing thing instead of a relieving thing and it kinda loses its appeal.
SKINPICK: From my experience of researching this subject, I noticed that often a patient might get better temporarily, due to counseling and turning to a generally more healthy and positive life style. The urge to pick goes away maybe not totally but it reduces substantially, but on the long-term I see in most cases that it somehow finds a way back.
Jon: Yeah. I agree with you. I agree with you and I think that part of the issue is the strategy cannot be the absolute removal of the urge, it just doesn’t work. The strategy has to be the acceptance of the urge and the ability to see the urge and make a choice not to respond to it and this is very sensitive because you’re telling someone to make a choice that at that time they often feel there’s not a choice. They feel it’s just something that’s happening to them. And, this is where again, where mindfulness comes in. I think that people with dermatillomania, there’s something going on inside their body physically and this is just based on my experience talking to people with dermatillomania. I’m sure, hopefully, one day we’ll have some research to really better explain this disorder. But there’s something going on physically where it’s almost like there’s a river of urge, like under the earth there’s a river of molten lava. And it’s always there. It never really goes away. But you also don’t pay attention to it all the time and then what happens is something brings your attention to it, some event, it could be stress, it could be the presence of a blemish or something with your skin and it makes that urge which is always running underneath you, like a river, rise to the top and when it rises over that fray and it’s right there in your face, in your presence, that’s when you need to pull out all your tools and be prepared and say, “Okay, here’s that urge. I’m gonna have to figure out a way to tolerate this urge. I can use my mindfulness skills. I’m going to use my cognitive behavioral therapy skills and it’s gonna be there, for however long it’s there and then it’s gonna go back underground.” And so, in a way, I think you’re right that it’s not something that really goes away a 100% because it’s a part of you. It’s a part of who you are but I think it’s something that you can learn to incorporate as a part of who you are like a lot of different disorders where you need to deal with it when you’re symptomatic and you need to accept it when you’re not symptomatic.
SKINPICK: Okay and so, there are a few other things I want to ask you on the topic. You mentioned that, well, in our initial correspondence, in your professional description, you mentioned that you embark in forums online and also in teletherapy. I’m really curious and I’m sure our readers as well. Let’s start with the forums part. We have a forum on skinpick.com as well, so I can relate to this. Can you describe your experience with forums online?
Jon: I think that it’s absolutely wonderful that we have the technology to allow people to communicate with one another about mental health issues and in many cases like the OCD forums that I typically contribute to, it provides access to professional advice, or maybe “advice” isn’t the right word, but sort of professional guidance that they might not otherwise be able to access in their community. This could be where to get treatment or what books to read or just some basic strategies or maybe if someone who is in treatment who’s just wondering, you know, “does my therapist know what they’re doing? Or am I doing this right?” and to be able to have someone in a semi-professional capacity reply to them and say, “Yeah, that sounds right.” Or “you might want to ask your therapist about this. You might want to modify it in that way” and then of course, the support that you get from other sufferers I think is immensely important. Dermatillomania is an extremely isolating disease as is OCD. I think OCD is becoming more, for better or worse, I think it’s becoming more of the part of the mainstream lexicon but dermatillomania, it’s something that people get very frustrated trying to articulate because they’re often met with, “Well, that’s not a real problem. Just stop picking” it’s what they’ll say, “Just don’t do it and then you’ll be fine”, which if you’re suffering from the disorder is very painful to hear and then, on top of that – your skin may be damaged in ways that people notice and people will ask you questions, “What is that?” or “Why would you do that to yourself?” or, having to come up with an explanation for being the way you are actually gets in the way of feeling good enough about yourself that you’re thinking, “you know what? I deserve to be able to fight and beat this thing, I’m gonna go get help”. So, the fact that we have things like online forums where people can talk about their experience without being judged and in an environment where the assumption is that people get where you’re coming from, I think that’s invaluable. It’s not therapy but I think it’s an important part of treatment. I would encourage anybody who’s getting treatment for OCD or for dermatillomania to take a look into a discussion board as well just to be a part of the community of sufferers, stay up to date with the research and also know that you’re not alone. The downside to online forums, the tricky part is they could sometimes be utilized primarily for reassurance seeking, which is not a good thing if you have OCD, and so you need to be careful about, you know, maybe really just try and to get people to tell me “I’m okay” instead of learning to tolerate the uncertainty. And also, it’s asynchronous communication, meaning right now you and I are having a phone conversation so it’s synchronous, you ask me a question, I think about it and I reply within a matter of seconds which is different from you sending me an email and me spending a long time thinking about it and then constructing my reply and while I’m constructing my reply you’re thinking, “what is Jon thinking and what if I sent him the wrong thing? Should I have sent him that email?” and having to go through all of that so, asynchronous communication also has its downside.
SKINPICK: You mentioned that you are a moderator in these forums, what is your role as a moderator? What activities do you do?
Jon: So the site that I moderate is a Yahoo group, it’s called pure_o_ocd, it's a misnomer for obsessive-compulsive disorder where the compulsions are covert or unseen, so people are engaging in mental rituals as opposed to physical ones. What I do on that site is, well, the basic administrative work, approving subscribers, making sure that people who are subscribing are people who are saying that they have OCD and are looking for support, the sort of boring work of deleting spam that comes through and things like that and then, really just replying to as many people as I can when I think that I have something to say that hasn’t already been said by one of the other members. So sometimes people will come to this forum and ask me a direct question, you know, “Jon what do you think of this?” and sometimes people will, most of the time, I think people will just be writing about something in general and if I feel that there’s something I can add to the discussion then I will. So that’s really my role as moderator. I guess there’s also the unpleasantness of having to remove someone if they’re breaking the guidelines or something like that, but the truth is that’s very rare.
SKINPICK: Okay. I’m very curious about another topic which is teletherapy. What do you basically mean by “Teletherapy”? Therapy over the phone?
Jon: Telephone or online video conferencing like Skype for example. I think it’s just again, it’s wonderful that the technology is moving as quickly as it is. My hope is that the mental health community and particularly the mental health regulation systems that we have in the different states in the United States and in different countries will keep up with the technology, so that people aren’t inhibited from providing a service that might not be otherwise available.
SKINPICK: From your experience, I want you to describe the differences between face to face sessions and teletherapy. Are there differences? What can you say about it?
Jon: There are actually a couple of research studies showing that in terms of the effectiveness of cognitive behavioral therapy that it’s really the same, which is great news because there are a lot of people who through no fault of their own just happen to reside in a place where for them to see someone who specializes in cognitive behavioral therapy and really knows what they’re doing, they might have to drive 10 hours or there might not be someone in their country. I mean, it just depends, so for them to be able to have access to treatment it’s really important. On a personal note, I personally prefer to do face to face in the office. I think that there’s a quality to that, that Skype for example doesn’t allow you to have, also, especially if you’re doing exposure therapy you are gonna end relying more on the client to do what you’re suggesting that they do whereas if they’re there with you in the office you can say, “Okay, let’s try this thing together. Let’s do this right now and I can sit here with you while you cope with whatever discomfort it causes you.” So my personal preference is face to face, but my personal preference is also to help people who are in need, who I’m legally allowed to offer help to.
SKINPICK: I’m very interested in what technology has to offer here, and I’m sure that people with different disorders have a difficult time finding professionals who really can understand their situation and again, the internet is a great tool to find help, and I’m sure it’s not utilized to the fullest today. I’m really interested in this. Maybe you noticed that on the skinpick.com website we’re offering Online Counseling (which is just another term to describe teletherapy). I’m really looking into maybe extending it not only to skin picking but also to other disorders and with other online projects.
Jon: Yeah, I think it’s definitely the direction that we’re all moving in. I think that there are people who are excited about it and utilizing it to the best of their abilities and I think that with any new movement in the mental health world there’re gonna be people who are resistant to it, who are going to say, “What we have works fine and we don’t need to change it.” Technology can be scary and technology isn’t perfect either. I mean people have concerns about what is safe with online therapy, different people have different policies about whether it’s safe to work with a therapist that you haven’t met in person. Or vice versa, whether it’s safe to work with a client that you haven’t met in person and there’re safety concerns about how to deal with people who are in crisis who aren’t necessarily local, do you know who their local treatment provider is and where their local hospital is and things like that? So there’s a lot of, I think legitimate concerns that need to be ironed out before we fully embrace this technology. I for one would like to know what to do when somebody cries, will I just hold a Kleenex up to the camera? But in seriousness, I think that we’re already seeing therapists popping up around the world who exclusively do online therapy that don’t even have an office to speak of. I don’t think I could, personally, I don’t see myself being able to do that. I can’t articulate how it is different but it is a slightly different way of communicating than being in the room with a person and really feeling their physical presence. I’m not saying one is necessarily better than the other but they’re just different. I just want to throw this out there, that something like dermatillomania, I do think that it can be treated via Skype or teletherapy or whatever we want to call it. I think it really just comes down to: are you getting the right kind of treatment and are you doing the homework?