The most effective forms of therapy for body focused repetitive behaviors (BFRBs) like skin picking, has been found to be a combined approach, using various methods of cognitive behavioral therapies. In our online therapy we subscribe to this practice by incorporating habit reversal training, mindfulness, acceptance and commitment therapy and cognitive diffusion. In one aspect of the program we spend an extensive time with the client exploring and reflecting on their ‘values’. Everybody values something, it’s what defines us as human beings. However, our values are often not always overt to us as it is not necessarily something we reflect on, and therefore sometimes we make choices or engage in behaviors that are not congruent or aligned with these values. For example, "I hold spending time with my dog to be important". This is one of my values in life. However, my action is not consistent with my value if amidst my job and family responsibilities, I spend a lot of time skin picking and thus neglects my dog.
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Choosing your values is not a reasoned, rational judgement per se. It combines your upbringing, past experiences, historical context, culture, social and personal relationships. They are free from "musts", and "should do". It is something that you want to be or do. Then based on these chosen values, you engage in actions that are consistent with them. This is known as Behavioural Commitment. Therefore in a therapy context when you are tasked with reflecting on your values and what these mean to you, the purpose is really to draw out your focus to the process of living, and allow you to see yourself in the present moment. The belief is that by living a life directed by values, rather than being pre occupied with thinking "when can I stop my skin picking", it can be about "what can I more meaningfully do in this moment?" While “stop picking” might be the overall goal, a strong attachment to that goal can draw your attention away from living in the present moment and instead focussing your attention to an outcome that is always in the future.
One of the pioneers in the field of CBT, Dr. Aron Beck, speaks about the use of a pie chart to help a client assess how important various aspects of his life were to him. Dr. Beck developed Cognitive Therapy (CT), also known as Cognitive Behavior Therapy (CBT) in the 1960s. The original Center for Cognitive Therapy at Penn served as an important training ground for cognitive behavior therapists. Together with his daughter they founded the Beck Institute, which provides clinical mental health services and consultations and promotes research in the field. In this Beck Institute podcast he describes how the use of a pie chart helped his client gain a different perspective on a loss he had experienced (transcript available below):
There was an economist who was up for, or he thought he was up for a Nobel Prize, and he didn’t get it and so he got depressed. So I drew a pie chart for him and I said to him, okay well this is a disappointment and how important is this career, your career and getting recognition. And I said, on the pie chart how much is it important. And he drew in and it was about 85%. And then I asked him, I asked him, do you have a family. And he says, yes I have 3 children. And I said, how important are they to you. And at this point, I hit a nerve, because he started to weep. And I said, what was going through your mind? And he says, it just came to me, that when I was growing up, my father neglected me and I resolved that when I grew up I was going to have children, be a good father. And I let him talk about that for a while, and he talked about his children and things that he could do with them and so on. So now we redo the chart, and it was now…60% was for the children, and the rest was…40% was for the career. And then I asked him about his friends, and they took up a certain percentage, and then his hobbies, and then we covered about everything and now he was up to 100%. So then I asked him, I said, what about your wife? (laughs) I said how you gonna squeeze her in? (audience laughs) So he had to redo it (laughs). But by now his career had shrunk to 10%. So, it’s a question of trying to give the person perspective on what is really meaningful in life. We all have serious disappointments and being bumped down I’m sure is a real serious thing, but it isn’t life itself. It Is just an event in life that’s unpleasant, unfortunate; but it doesn’t undo everything else…
In this podcast Dr. Beck highlights that sometimes we are not aware of what our highest values are and therefore cannot act in accordance with those values.
Once you have identified your highest values you then need to use that insight to guide, inspire and motivate you to change your behaviors. In CBT we refer to the use of Acceptance and Commitment Therapy (ACT). The focus of ACT is to accept what is out of your personal control, and commit to action that improves and enriches your life. There is a growing amount of empirical evidence indicating that ACT can be very effective in the treatment of body-focussed repetitive behaviors (BFRBs) such as skin picking disorder.