I have learned a lot, from my own personal experience as well as during my health coach training plus four years as a super-specialized health coach, about what it takes to get out of control body-focused repetitive behaviors (BFRBs) under control.
Here I offer some advice for therapists, as well as for therapy clients, regarding how I believe therapy for body-focused repetitive behaviors like skin picking might be made more effective.
The missing piece in therapy, which I gathered from speaking to skin pickers and confirmed in conversations with a few therapists specializing in BFRBs, is accountability. The therapists I’ve spoken to about this topic agree that accountability is not generally built into the therapy model but is a facet that needs to be emphasized more in the treatment of BFRBs.
I meet with over a hundred skin pickers each year in half-hour free video Skype Breakthrough Sessions (contact me for yours), during which they tell me their experiences. Frequently, even though some are seeing therapists that specialize in BFRBs, they may not be getting much better. Further probing on my part has uncovered that a lack of accountability built into their therapy process seems to be the reason.
It’s human nature to need accountability, and even the most mentally healthy among us find it difficult to make positive changes in our lives, even when we know what we need to do. (New Year’s resolutions fail, anyone?) And considering that a simple resolution like going to the gym a few times a week is SO much easier and less complex than stopping picking, it stands to reason that to recover from picking (or pulling or biting), we need as much external support and accountability as possible.
Accountability means we know someone is watching over us to make sure we take the actions that are going to result in decreased picking. Breakthrough Session attendees sometimes tell me that their therapists have told them to track their picking, or to take some other action(s), but the following week the therapist wouldn’t even mention it again. The therapist didn’t check to see if the “homework” got done, even though they would probably say themselves how important that sort of work is for success.
Maybe the reluctance to hold the client accountable is based on a thought that assigning and checking up on homework is akin to treating adults like children, but if so, I don’t think that’s how we should be looking at it. After all, an adult attending community college would still be expected to turn in papers and take tests. That’s a reasonable expectation that results in increased learning. Checking up on “BFRB Homework” similarly results in increased learning and eventual mastery.
Accountability breeds success. Think about it. If it were left up to us, would we have learned even our favorite subjects as well if we didn’t have assignments and tests to study for? Even if we like our job, would we get as much work done if we didn’t have a boss or need money? Would I have gotten this blog post written if I didn’t know there were a bunch of people expecting fresh content once or twice a month? (The answer is no, so thank you for the accountability!)
Most of us need some measure of external accountability to accomplish nearly anything in life.
What works in therapy now?
If gaining freedom from these behaviors was a one-week process, many people would be able to do it themselves. It’s the fact that it usually takes months that makes it challenging. If you were going it alone, you would most likely give up or simply forget to focus on it many times over the course of those months.
Because the process takes attention over a long period of time, regular therapy sessions force the client to pay attention to the matter at least once every week or two, certainly a good thing.
If there is good rapport between the client and therapist, the client will be naturally more convinced in the value of the therapy suggestions and more motivated to do the homework between the sessions.
In the case of a therapy group, such as the one I attended in 2009 at the OCD Center of Los Angeles, a sense of accountability is present when group members are taking actions and making progress. It is like positive peer pressure. Other members are inspired and want to be successful too. If instead, the group on the whole is lagging, not doing their homework, etc. that situation is de-motivating to individual members and there is effectively no accountability. A good group is like a tide that lifts all ships. A bad group I suppose is like a storm that sinks them.
What can be done better in therapy?
Clients need to go home from therapy sessions knowing specifically what they need to do in the week or two in between sessions. I make it as simple as possible in my coaching process: clients get my specific tailored numbered recommendations in writing, sent via coaching software to them as an email right after we meet. They can’t forget, and neither can I. If they are prone to forget, I will instruct them to print them out right away and keep them somewhere convenient to read every day. And they know I’m going to check in with them the next time to make sure they’ve done the actions, and we can then build on them.
Recommending a few simple actions each time we meet allows new habits to be built gradually; new habits are needed to decrease and replace the skin picking behavior. This process also allows us to figure out what works and to troubleshoot and hone in on the optimal techniques and times to use them. It’s got to be done little by little and consistently, much like cramming for a test is going to result in less retained knowledge than consistent daily studying.
Clients also benefit from daily accountability. Some way of quantitating the amount of picking in a day works well for this. While I originally had clients track their picking manually and report their numbers to me during their sessions, for the last year I’ve had them use a coaching software (Coach Accountable) that reminds them via a text each night to reply with a number reflecting their picking (a rating, or minutes, or number of times). The software graphs it automatically and that can be very motivating for clients to keep up their efforts, because they have this daily reminder every day. They can also use it to keep their “Positive Log,” as along with a number they can add a comment as well, recording what positive actions they took that day.
All my clients see the value in the daily accountability and find it easy to comply with the reminder text or email. The experience of using the software has made me even more convinced of what an important role accountability plays in recovery.
What do you think? I’d love it if you share your experience by commenting below.