An Urge Is Nothing to Be Afraid of: ACT-Informed Exposure for Skin Picking

acceptance and commitment therapy (act) brian thompson phd exposure habit reversal training skin picking Aug 29, 2022
Hands holding flower

For several years, I’ve been working with people who struggle with hair pulling (trichotillomania) or skin picking (excoriation disorder). Many made good progress resisting urges to pull or pick with the best supported treatment: habit reversal training (HRT). With HRT, people learn to do something with their hands that’s incompatible with picking at their skin and pulling at their hair when they notice an urge. As effective as this treatment could be, I noticed a few shortcomings with HRT:

  • For one, and this was particularly true for people that picked their skin, once they sighted a target—a pimple or other blemish—their minds wouldn’t let go of it. They’d heroically resist the urge—until they couldn’t anymore. Often this happened at the end of the day, after work, when they were tired and exhausted. Almost automatically, their fingers would find the blemish and tear into it.
  • Secondly, they would become afraid of their urges. They engaged in HRT with gritted teeth. This just tired them out all the more, making them prone to losing control of their fingers as in the scenario above.

As acceptance and commitment therapy (ACT) is about helping people learn to respond more flexibly with uncomfortable internal experiences, I experimented with a procedure to help clients accept their urges and allow them to pass naturally. After years of experimenting, I created a study to test it.

I focused on people with skin picking, as I had noticed this pattern more commonly in picking than hair pulling. It’s easier to remember a blemish and find it again than a particular strand of hair. Using ACT as a model, I taught people to engage in a form of exposure therapy with their urges. They would practice deliberately bringing up the urge to pick by looking in a mirror or scanning their skin with their fingers. Once they triggered an urge to pick, they’d practice ways of being mindfully present with the urge until it passed. In sum, they engaged in ACT-informed exposure with their urges, repeatedly triggering the urge, and then allowing it to pass. By contrast, it seemed as if urges stuck around longer when they were afraid of it and trying to power through.

In the study, I experimented with alternating the order. Some people started with HRT and then learned ACT-informed exposure, and some people started with ACT-informed exposure, and then learned HRT.

So as not to oversell my contribution, I’ll note here that people made greater improvements with HRT regardless of the order. HRT remains the first-line treatment for picking. This finding didn’t surprise me, as HRT is much easier to learn than exposure. However, people seemed to show some additional gains with ACT-informed exposure, especially when it followed HRT. When I asked for feedback from the study participants, they found both treatments helpful.

In sum, HRT remains the first-line treatment for skin picking. However, the study suggested that ACT-informed exposure may allow people to reduce picking further than HRT alone. When it comes to skin picking, any improvements—however big or small—may be important.

If you’d like to read the study, you can download a copy here.

Author: Brian Thompson, PhD


If you liked this post, check out Dr. Thompson's upcoming workshops on ACT-Informed Exposure. 

Using ACT to Guide Exposure Therapy: The Basics

Overcoming Barriers to Effective ACT-Informed Exposure Therapy


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