An overview of Habit Reversal Training
You go to brush your teeth. You’re stuck in the mirror for 20 minutes. Your significant other knocks on the door. You wonder how the time passed and your face is in worse shape than you realized….
You look down to see your nails are bit to the quick, and realize your cuticles are bleeding due to the recent picking. It's painful, hard to look at, and you are frustrated.
Do either of these situations sound familiar? Skin Picking Disorder, otherwise known as Excoriation Disorder, affects nearly 2-5% of the population. It is under the category of disorders called Body Focused Repetitive Disorders (BFRBs) which includes skin picking, hair pulling, nail biting, and cheek biting.
BFRBs can be incredibly frustrating and often happen with a lack of awareness. One might pick their scalp while watching TV, pull hairs while driving, or bite their nails while waiting in line. They can elicit strong feelings of shame due to marks on the face, missing patches of hair, and feeling out of control while engaging in the behavior. Luckily, there are evidence based treatments for BFRBs, and with a little time and patience, recovery is possible.
The treatment I’ll outline below is called Habit Reversal Training (HRT). HRT was developed in the 1970s by Nathan Azrin and Gregory Nunn. It is an evidence based treatment for BFRBs and tic disorders. Habit Reversal Training has 3 main parts:
1 - Awareness Training
Step number 1 is awareness training. Building awareness into triggers and situations that exacerbate the issue is key. Your therapist might have you make a weekly log to track picking sessions, emotions noticed, and triggers.
Many want to skip this step and jump to a competing response. Although that is understandable, it is highly encouraged to take your time with awareness training and build a strong foundation. It’s hard to have sustained success without it!
2 - Competing Response Training
Step number 2 is to develop a completing response. Ideally, we want this to be using the same muscles that you would use when you pick. For example, if you pick with your right index finger and thumb - we’d want to use those fingers in our competing response. It is also preferable to have a competing response that is subtle, so it can be done in a variety of settings.
There are a variety of options for competing responses, and it make take several tries to determine your ideal movement. If one doesn’t stick - keep trying.
4 - Social Support
Step number 3 is adding in social support. This can be a single support person or multiple. The goal is to have reinforcement on both ends. On one end, providing praise and encouragement when the individual is using their completing response. This is hard work! Letting your loved one know you're proud of them can increase motivation.
On the flip side, a support person may cue a completing response when they notice their loved one picking (pulling, chewing, etc.). This gentle reminder can build awareness an help with accountability.