TPC-Journal-V6-Issue1

The Professional Counselor /Volume 6, Issue 1 56 picking, and activity replacement such as reading a book, cleaning or watching television instead of skin picking. CBT also places a heavy emphasis on relapse prevention, or the preparation to prevent future urges to pick. Habit Reversal Training Habit reversal training (HRT) is an effective strategy for working with clients who have excoriation disorder (Capriotti et al., 2015; Grant et al., 2012; Teng, Woods, & Twohig, 2006). HRT is a behavioral approach that involves helping clients gain awareness of their skin picking and then replace the picking with more adaptive behaviors (Grant et al., 2012; Ravindran et al., 2009; Snorrason & Bjorgvinsson, 2012; Teng et al., 2006). The first step of treatment is awareness training, which helps clients who are often unaware of their skin picking to associate factors, such as time of day and specific situations, to skin picking behavior (Teng et al., 2006). To facilitate this awareness, a counselor may point out in-session skin picking behavior. After developing an awareness of antecedent situations (i.e., the situations that precede picking incidents), the counselor and client collaboratively develop a competing response, or another behavior that is inconsistent with skin picking, to substitute for the skin picking behaviors (Teng et al. 2006). An example of an alternative behavior would be clenching one’s fist each time a client notices that he or she is picking. This competing response, which should be one that is easily applicable in a number of situations, diminishes the urge or reduces its intensity. The next step in HRT is the establishment of a contingency management system or token economy involving rewards and punishments. This type of treatment approach allows the clients’ behaviors to be rewarded as they make successive approximations toward the goal. Rewards and punishments must be meaningful to clients, and they also must be specific and timely. At first, rewards are extrinsic, such as verbal praise or toys with children. As target behaviors are reached (e.g., reduced skin picking), clients begin to access more intrinsic reinforcers (e.g., an increased sense of self-esteem, feelings of belonging within the community/society). Finally, clients are coached to consistently implement these operant conditioning strategies outside of session and to eventually apply them to new behaviors (Capriotti et al., 2015; Teng et al., 2006). The client gradually realizes that skin picking is not a necessary coping skill, as other, more adaptive behaviors can be used to effectively reduce stress. Teng et al. (2006) conducted a controlled study in which they compared HRT treatment to a waitlist control group. These researchers demonstrated a significant reduction in skin picking behaviors at the termination of treatment and upon follow-up assessment, as compared to the control group. The research on HRT suggests that it is a promising approach for use with those who have excoriation disorder. Acceptance and Commitment Therapy Acceptance and commitment therapy (ACT), when used in conjunction with HRT, demonstrates clinical promise in treating those who have excoriation disorder (Capriotti et al., 2015; Flessner, Busch, Heideman, & Woods, 2008). Capriotti et al. (2015), through the use of multiple clinical case studies, demonstrated that Acceptance-Enhanced Behavioral Therapy (i.e., ACT plus HRT) decreased excoriation symptomology in three of four participants in their case study research. These results support the findings of a similar case study done by Flessner et al. (2008), which demonstrated decreased symptomatology of excoriation disorder when ACT was incorporated with HRT. ACT uses mindfulness techniques to teach acceptance of negative thoughts and emotions and then combines behavior-change techniques to address unhealthy behaviors (Flessner et al., 2008). Initially,