What is Habit Reversal?

 This month's blog is about something that I spend time in my NHS job doing - habit reversal. In this context, it's specific to skin conditions, and can really help to manage the frustration that comes with having itchy skin - although habit reversal can be used with lots of different things. Read on to find out more.

Habit reversal training can be used to stop a number of difficult and distressing behaviours including trichotillomania (hair pulling), nail biting, skin picking (not just scratching), thumb sucking...you name it, you can probably use habit reversal on it! I work in a context where I'm working with people who struggle with scratching their skin, so that's what I use it for the most.

The itch-scratch cycle

​If you have an itch, you scratch it, right? That's a normal, expected human behaviour, and for many of us it solves the problem right away. If you've got a skin condition like eczema however, then scratching can cause even more difficulties over time.

Eczema itches because of a number of different things. One is inflammation, which stimulates nerve endings in the skin and causes irritation. Another, lesser-known cause of itching is psychogenic itch - put it this way, how many times have you scratched your skin since starting to read this article? Itch can be stimulated by a number of things, including stress or just because it's become habitual to scratch at a certain time of day. Heat can also make things more tricky, and make you itch more.

When you have eczema and you scratch, this can damage your skin - often intense scratching is needed to feel relief. This kind of skin damage can lead to broken skin, which can become even more irritated - leading you to scratch more to feel less itchy. This intense scratching can also cause thickening of the skin, which can take a while to fade.

This "itching - scratching - irritation - more itching" cycle is called, unsurprisingly, the itch-scratch cycle.

Things to do as well as habit reversal

It bears saying here that if you've got eczema and you're struggling with itch, there are things that you can do to help. Seeing a dermatologist can give you a range of options in terms of medications, and moisturising your skin with an emollient can help prevent water loss from your skin (as dry skin is likely to also be itchy). Reducing stress is also helpful, as is trying to stay cool - especially at night, as this is often the time that skin becomes more itchy and can make sleep more difficult.

Habit reversal

Habit reversal is a way of starting to take note of all the times that you scratch your skin, and then systematically tackling them. It's not about "just stopping scratching," as most people are likely aware on some level how much they are scratching and can't just stop.

The first step is to note how many times a day you're scratching. Most people think they've got a good handle on this - and most people are also shocked when they actually start to keep a tally. The easiest way to do this is to get a click counter (the kind of thing that bouncers use to count people into nightclubs) and click every time you scratch. One "click" equals one episode of scratching, no matter how long it is - and you can't "click" at night if you're scratching in your sleep, as you're not aware of how many times you've scratched. Once you have an accurate count of how many times during the day you're scratching, then you can start to pair this with what's going on.

Example

"I've found that I'm scratching a lot on a morning before work, especially when I think about the day ahead. I'm absent-mindedly scratching at lunchtimes whilst eating, and I'm also scratching more on an evening because I'm getting warmer and it really itches then. My partner also noticed me scratching when my cousin called me last week; whilst I was on the phone I was scratching the back of my neck and I didn't even realise!"

Competing stimulus, urge surfing and distraction

Once you've noticed how much you're scratching, you can try to use a competing stimulus to help combat the sensation of wanting to scratch. This can be anything (pinching your skin, clenching your fists, placing a hand over the area that itches) but you need to do it consistently until the urge to scratch goes away.

Often people think that the urge to scratch will climb and climb until it becomes overwhelming and unbearable. This is often not the case. Learning how to "urge surf" (or, sit with the itch and just notice it until it starts to subside) can be really helpful to prevent scratching. For those times when you just can't be mindful, distraction also works well. You can learn more about urge surfing in this short meditation here.

Ultimately, none of this is easy - but neither is living with broken, itchy skin all the time. Habit reversal won't stop the itching completely - but it helps you respond to it differently, and that can help you to stop scratching, which helps skin to heal up. This in itself can reduce itch over time, although of course you'll still have the eczema to manage.

Conclusion

Habit reversal training can be really helpful for a number of different things, and in this whistle-stop tour we've looked at eczema specifically. If you think that habit reversal might be helpful for you, there's lots of information about it online or you can ask your GP to refer you to a health-related psychology service which may be able to help.

I hope you've found this interesting - let me know in the comments!