This article was written by a BFRB community member who participated in a small group of skin pickers that met daily with Charley Mansueto, Ph.D., Suzanne Mouton-Odum, Ph.D., and Sherrie Vavrichek, LCSW during a TLC Conference.
The COMB model has 5 categories (SCAMP), so my notes are divided into sections:
- Affective (emotions)
- Place / environment
Writing this out has been really fun! It's also powerful to notice that I've incorporated nearly 50 practices into my daily routine. I'm really making this a priority, and it's good to notice that it's working! My picking is dramatically reduced from 3 years ago, when I was doing only 2 or 3 of the strategies.
SENSORY – Strategies I'm Using (6)
One of my skin-picking buddies gave me this little skin-stimulator, a flat palm-sized thing with short plastic bristles. When I rub it on my face, it creates a pleasant sensation, stimulating the nerve endings in the face gently.
- Touch-toys / fiddle toys
- Face-care routine
Having a regular routine of cleaning and caring for my face and skin gives me ways to touch my face, in a loving caring way.
- Weeding instead
Weeding is SO satisfying! Especially pulling up weeds by the roots, it's a lot like hair-pulling, but good for the world!
SENSORY – Strategies I could try (12)
- Use face-stimulator more often
- Cleansers with abrasiveness
- Remember: fingertips are not my friend!
- Avoid using fingertips
- Hand cream / cuticle cream
- Drinking water
- Floss instead
- Bubble wrap!
- Pay attention to sensory experience of other tasks or chores
Like the Zen practice of washing dishes with focus.
COGNITIVE – Strategies I'm Using (11)
These are things I say to myself, to help prevent and resist urges:
- If I don't want to pick, hands down!
This is practice for not following urges.
I remind myself that if I avoid picking now, I'm strengthening my capacity to resist. It's practice. It's like exercising a muscle.
- What am I worried about?
If I ask myself this, it gives me insight into what's actually going on for me at the moment. I can follow this up by paying attention to or dealing with the issue causing the worry.
- Beat the Boo Voice
I learned about the Boo Voice in a CBT course I took from "Dr. Fear." It was amazing. Check out http://angelnet.com/fear.html and http://parents.berkeley.edu/recommend/therapy/liebgold.html
- It will be worse if I pick, harder to resist later.
- Differentiating between A/B/C spots.
At The TLC Foundation for BFRBs' 2006 Conference in LA, Charles Mansueto explained that some skin-pickers find it useful to think about different levels of picking. "A" spots are like the whitehead on the end of your nose; spots that most humans would clear out. "B" spots are sore or infected, but are better off left alone; they will probably be worse if you pick at them. "C" spots are healthy skin.
- It's not an A spot. I don't need to pick it.
Telling myself that the spot I'm noticing is not an "A" spot, that it is something I ought to leave alone, is a helpful way to talk myself out of picking.
- Use others' decisions as a guide.
Talking to non-pickers has helped me grasp the idea that there are other choices besides picking at a spot that is sore. Seeing other people demonstrate that they don't choose to pick infected spots helps me visualize that there, are, surprisingly, other ways to respond to skin blemishes.
- Identify/address source of worry.
Being able to identify the thing that triggers my urges is immensely helpful. Not only does it mean I pick less, but it also helps me pinpoint the places where I have trouble getting through the day, and I can learn to develop successful strategies for dealing with those struggles.
In this way, picking has actually helped me become more the person I want to be. It serves as a red flag, helping me see where my struggles are so I can address them instead of ignoring them.
- Noticing ruminations.
Often a precursor to picking is ruminating. I try to pay attention to my thoughts, especially those ones that go around and around without getting anywhere.
- Rule: No picking on impulse.
Sometimes when I have the urge to pick, I'll tell myself that picking 1-2 spots is okay, but not if it's just on impulse. I'm trying to interrupt the feel-stressed-so-I-pick pattern. (Setting a once-a-day defined 2-3 minutes to pick, for example after I get out of the shower, can be a good way to learn to resist the urges at other times.)
- Visualize using my tools.
Imagine being in a high-risk situation, seeing a spot, and using tools / deciding not to pick.
COGNITIVE – Strategies to Try (8)
- Book: Radical Acceptance
Lots of people keep suggesting this book. It must be good.
- I deserve to heal.
- Is it really true that I can't concentrate until I pick?
- I deserve to be healthy.
- I deserve to be happy.
- Chances are more than 50% that I'll be sorry I did this.
- Talk to a friend first.
- Wait 15 minutes
AFFECTIVE / EMOTIONAL – Strategies I use (12)
I'm a big fan of focusing on the positive. This started when a non-profit I worked at used Appreciative Inquiry for their strategic planning process, and I heard examples of how focusing on the positive can be dramatically more effective than focusing on the things going wrong.
- Daily Calendar
Since the start of 2005, I've been keeping a daily calendar for trich.
Each day has one line, like "Mon Sep 19______________________" On the line I write one positive thing I did that day related to trich. I think this tool has been incredibly helpful.
I also put a little star if I didn't get stuck for an extended period of time (15 minutes or longer), and a star with a circle if I was pick/pull-free.
I do a kind of peer counseling, called Reevaluation Counseling or Co-Counseling. This has been remarkably helpful by providing safe space to express feelings, and break the pattern of shame and silence.
- Hula hoop analogy / reality.
I heard about someone in AA, who's a sponsor for others, and with all her new sponsees she takes a hula hoop, puts it over their head and around them, and says "See everything inside in the hula hoop? That's yours – you are responsible for it, for making sure things go well. Others don't get to do it for you. Now, see everything outside the hula hoop? Not yours!"
This analogy reminds me that many things I worry about are actually outside my metaphorical hula hoop.
Getting facials has been really helpful in reducing my isolation regarding caring for my skin. Having an aesthetician I like and can talk with, someone who understands the addiction has been important.
- Support Group
Without my support group, I wouldn't be where I am today. Not much more to say except that those Monday nights have made more of a difference for me than I could have ever imagined.
The foundation ran a fundraiser June-Sep 2006 that had participants set daily goals, and collect donations based on the number of days the goal was reached. Participating in that has brought my picking more under control than ever before.
- Recognizing challenge with downtime
Realizing that I have trouble with downtime, I'm starting to practice having downtime.
- Recognizing challenge with going to bed
It's often difficult for me to get to bed, and it's one of the times when I'm more vulnerable to picking urges. Recognizing that has helped me address that time with more intention and find successful strategies.
Tell myself I can pick – but later, not now. I can then learn other ways to respond to the urge.
- Set alternate time to pick
Set a specific time when I will allow myself to pick. This makes it easier to practice delaying, knowing I am allowed to pick another time.
Since nighttime is so difficult for me, it's been useful to practice delaying the response at night, but knowing I will allow myself to pick in the morning.
AFFECTIVE / EMOTIONAL – Strategies I could try (7)
Call a co-counselor whenever I have the urge to pick. Every time.
- Breathing Exercises
- More practice with downtime
- Develop an evening routine – light candle, have tea
I got a "finger labyrinth" at The TLC Foundation's 2006 Conference. When I do it, I find I'm easily relaxed at the end. I could do this more often.
- Look into non-violent communication
- I keep hearing good things about this. I bet it would help my approach in the world and my approach to me.
- Clothes set up the day before
Picking out clothes is less stressful if I do it ahead of time
MOTOR – Strategies I'm using (6)
- Fiddle toys
- Rubber bands
- Put ointment on sore spots instead
- Putting Clear-it or acne ointment on sore spots attends to the physical discomfort by doing something positive.
- It seriously helps!
- Cross-stitching or other crafts
MOTOR – Strategies I could try (4)
- Band-Aids – on my fingers
- Fiddle toys in the bathroom
- Chew on pasta
- Controlled breathing
PLACE / ENVIRONMENT – Strategies I'm Using (13)
- Remove mirrors
I removed big mirrors on my bedroom closet doors by turning the doors around. This changed my environment so I'm not as likely to see my face and skin.
- Bathroom lights off
I often go to the bathroom or shower with the lights off, or with only one dim light on.
- Out before flush done
Make a rule that I have to be out of the bathroom by the time the flush is done. Sometimes I plan this before I go into the bathroom, sometimes I remember it after I'm done as I notice my face in the mirror and start to get distracted.
- Remove strong lights in bathroom
I've intentionally NOT replaced several of the light bulbs directly above the bathroom mirror, so there's less opportunity for me to examine my skin/face under bright lights. (I think this makes a big difference, because when I go to friends' houses where they have really good light in the bathroom, I notice how much harder it is for me to avoid peering at my reflection.)
- Candle in bathroom
- Lighting a candle in the evening in the bathroom helps make that place less of a trigger place in many ways – it serves as a reminder of my intention to not pick; it provides light so I don't turn on the regular lights; and if I get too close to the mirror I would get burned from its heat!
- Toys in obvious trigger spots
I have a pile of fiddle toys and things to keep my hands busy right near my bedroom door. So they're always available, and they're also right near the bathroom.
I have a postcard in the bathroom with the words "Respect your body; it is your vehicle to liberation" or something like that. When I take time to read it, it's a great reminder!
- Get company
When my girlfriend is around she always comes with my when I brush my teeth and wash my face, keeping me engaged with other activities and feeling love and connection during one of my most trich-prone situations.
- Removed tweezers
I've recently thrown away some tweezers that were in the back of the drawer.
After thinking about it carefully, I decided to permanently remove hairs on my chin, which eliminated my "justified" reason for picking up tweezers and paying attention to my face. Now I have one less temptation or reason to engage in similar behaviors. (I think of this as Environment, since I've removed a trigger. However, the fact that I felt compelled to not have chin hairs could undoubtedly be considered Body Dismorphic Disorder, since we all know our bodies are fine the way they are...this is a longer discussion.)
- Eliminate sugar
By eliminating sugar, my body's been less likely to get revved up and eager to pick.
- Eliminate wheat
Eliminating wheat from my diet reduces a couple triggers. First, I can get really tired after eating wheat, and my capacity to resist urges is lower when I'm tired. Second, eating wheat can upset my stomach, and when I'm in physical discomfort I'm more likely to pick, probably to numb myself out from feeling that discomfort.
- When you gotta go, you gotta go
I've got a tendency to ignore my body when I have to go to the bathroom, and just keep working on whatever I'm occupied with. Doing this means I'm all tense and wound up when I do get into a bathroom and in front of the mirror, which is of course a bad set-up. I can avoid that situation if I go to the bathroom when I first need to.
PLACE / ENVIRONMENT – Strategies I Could Try (11)
- Band-aids or tape on fingers
Putting Band-aids or first aid tape on the tips of my fingers/thumbs would be helpful. At least, having it around would be a good idea.
- Tape down light switch
I haven't done this in a while, but I could tape down the light switch in the bathroom, especially in advance if I know I'm having a lot of strong urges.
- Remove mirror
Removing the mirror in my bathroom entirely would be great. If I ever make big changes to my bathroom, I'll certainly do this.
- Have toys in bathroom
I have toys in the bedroom. Why haven't I put any in the bathroom?
- Sunglasses near/in bathroom
This was a great suggestion from the workshop leaders. I haven't thought of it, but if I put on sunglasses every time I went into the bathroom, that would reduce the likelihood that my reflection would be tempting for picking.
- Light on timer
I could put a timer on the light switch in my bathroom, so that it would turn off after 5 minutes, and therefore interrupt me if I did get stuck.
- Throw away tweezers
It's true – now that I've stopped pulling chin and eyebrow hairs, I really don't have any reason to have tweezers around.
- Freeze tweezers
This is a creative one. If I froze tweezers in a block of water/ice in the freezer, then any time I did get out tweezers, it would take forethought and preparation.
- Find lotion for hands
I've been worried that many lotion ingredients might actually trigger urges, so I've had trouble finding a lotion that I am comfortable using regularly. But if I did find such a lotion, it would be great to have lotion to put on my hands whenever I'm struggling with urges.
- Lotion for body
Putting lotion on my body would be a great alternative to picking, as a self-care activity that involves self-soothing touch.
- Eat/pee when I need to – always!
While I'm getting better at this, I sometimes postpone taking care of my body. I could continue to work on this.