How To Stop Skin Picking and Hair Pulling: A 4-Step Habit Reversal Training Guide

This podcast episode by Dr. Tracey Marks, a psychiatrist, delves into body-focused repetitive behaviors (BFRBs) such as hair pulling, skin picking, and nail biting, emphasizing that these are compulsive behaviors distinct from simple nervous habits. She highlights that these compulsions are generally unresponsive to medication but can be effectively managed through a behavioral therapy called Habit Reversal Training (HRT). The episode also notes HRT's utility for general nervous habits like face touching, a relevant point given public health concerns like COVID-19, and stresses that while a trained therapist offers the most customized approach, individuals can apply HRT concepts independently.

The core of HRT is broken down into three phases: Awareness Training, Competing Response Training, and Establishing Motivation and Support, with an additional technique called Stimulus Control. Awareness Training involves three steps: first, identifying the specific problematic behavior; second, recognizing when and where the behavior occurs and its triggers (e.g., stress, boredom, mindlessness); and third, identifying the earliest physical sensations or urges, known as early warning training. Journaling is recommended to track these observations, fostering a comprehensive understanding of the behavior's patterns and precursors.

Competing Response Training focuses on substituting the undesirable behavior with a new, less harmful one. This involves engaging a body part typically involved in the BFRB with an alternative action, such as squeezing a ball or fiddling with yarn, for at least one minute when an urge arises. The primary goal is not to eliminate fidgeting but to redirect the energy into an activity that prevents negative consequences like skin damage or hair loss, while ideally being unnoticeable to others. This interruption technique is crucial for weakening the compulsive urge.

The final phase, Establishing Motivation and Support, involves two key components. Motivation is cultivated by documenting all the negative consequences and inconveniences associated with the behavior, serving as a constant reminder of the reasons for change. Support comes from enlisting a trusted individual who can help detect warning signs, remind the person to use competing behaviors, and provide positive reinforcement. The episode concludes by introducing Stimulus Control, a complementary technique that involves modifying the environment to reduce triggers, such as covering mirrors, discarding instruments used for picking, or wearing gloves at night, further reinforcing the overall strategy for managing BFRBs.

"These are compulsive behaviors that can cause a lot of problems and are much more than just having a nervous habit."

"These compulsions don't respond well to medication, but can respond well to a therapy called habit reversal training."

"The most effective way to use this technique is with a trained therapist, who can create a customized plan for you, but you can apply the concepts on your own."

"The first step is to identify the habit or the problem behavior that you want to break."

"By the time you complete these steps, you should be fully aware of the problematic behaviors, when and where they happen, and under what circumstances they're most likely to happen."

"Here, you substitute a new behavior for the old one that you want to extinguish."

"The goal is not to keep your hands still, but to keep them busy with something that doesn't produce a negative consequence like bald spots, chewed fingers with sores, viruses in your eyes."

"That one minute interruption takes some of the wind out of the sails and lessens the urge."

"With stimulus control, you take a list of the triggers and situations that you made in the awareness training phase, and then put blocks in place to make it harder for you to be triggered."

"Keeping up with all of this is where journaling comes in handy so that you're not having to keep it all in your head."