Effects of Discontinuing An Internet Based Program for Skin Picking Disorder

Skin picking, clinically known as Excoriation Disorder, is characterized by repetitive picking that results in skin and tissue damage, emotional distress, and impaired psychosocial functioning. Skin picking is also highly heterogenous meaning that people experience skin picking in different ways. For some, the experience can be quite distressing. Feelings of guilt, shame, and embarrassment are often reported. Others feel somewhat resigned to picking, that it is somehow inevitable, tolerable, or manageable.

Skin picking is thought to be under-reported and many people who have skin picking avoid or are unable to access treatment. In fact, studies suggest that only about 50% of people with skin picking seek help. Some of the reasons people cite for not seeking help include:

• Doubts about the severity of their condition
• Feeling embarrassed about their skin picking
• Not knowing where to find help
• Doubts that a doctor or therapist will have the expertise to treat their condition

While skin picking can be successfully managed through treatment, there is no “cure”. Approaches like Habit Reversal Training (HRT) are considered the gold standard in treatment. More recently, there have been a number of self-help and online approaches developed that have shown some efficacy in managing symptoms too. Online programs offer greater access and flexibility for people seeking help and remove many of the barriers that can discourage treatment.

However, even with treatment options, not everyone who starts treatment finishes their program. In fact, dropping out prematurely is common in both medical and mental health treatments. For internet-based programs, the attrition (drop out) rate is particularly high, despite their efficacy. Surprisingly, there is very little research that examines the effects of stopping treatment prematurely.

Just why someone drops out of treatment isn’t exactly clear. However, two factors seem to play a key role in adherence and treatment outcomes: motivation to change and self-efficacy.

What Is Motivation?

Motivation is a person’s desire to change some aspect of their thinking, emotions, or behavior. Motivation can come from inside (intrinsic motivation) and is done for the sake of happiness or well-being. Motivation can come from the outside too (external motivation) in the form of getting some reward or desired outcome.

In the beginning, the excitement and hopefulness that comes with starting a treatment program can be highly motivating. After all, you’re doing something that may help you get where you want to be and reach whatever goals you may have. You want this! But change is hard and takes some hard work. Motivation and readiness to change has been linked to successful program completion.

What Is Self-Efficacy?

Self-efficacy is a person’s belief in their ability to complete a task or achieve a goal. It reflects confidence in their ability to stay motivated, control their behavior and their environment. In short, it’s the belief that “I can do this!” and the ability to keep going even when things get tough. And treatment can sometimes be hard.

How do motivation and self-efficacy affect adherence to treatment? Just what are the risks of early discontinuation?

A recent study using an internet-based self-help program for skin picking found that people who did not complete the program reported lower motivation for treatment and lower treatment-oriented self-efficacy than those who completed the program.

Both completers and non-completers experienced some reduction in symptoms suggesting that the program offered some benefit even for those who terminated early. The researchers speculate that this benefit may have contributed to early termination due to the behavior change made at that point. 

Participants who completed the program reported a significant decrease in skin picking and an increased level of skin picking-related self-efficacy as well as general self-efficacy. The researchers suggest that being able to change their own behavior by implementing the program activities may have improved their confidence to deal with difficulties.

Those who did not complete the program reported a decrease in motivation to change their picking behavior.

Implications for Treatment

Early withdrawal from the study program resulted in less symptom reduction, lower treatment-oriented self-efficacy, and decreased treatment motivation. Just why participants didn’t complete the program is not entirely clear.

It is also important to note that some participants who initially were considered non-completers at the post-assessment continued using the program beyond the 12-week period and would subsequently have been identified as completers. The reason for that renewed participation is not clear.

One of the risks of self-guided programs is that there are a lot of unknowns. There is often no clear reason for discontinuing. There may also be little or no clinician oversight. There may be no way to determine how effectively a person is using the tools they’re offered.

The study authors suggest that the negative impacts of early withdrawal should be taken into consideration by treatment providers when offering internet-based self-guided interventions. Keeping these effects in mind is important when considering treatment options and should be addressed with the person seeking help. The authors also note that the wide availability of online interventions should be approached with caution.

While more research is needed to better understand the dynamics of early discontinuation of treatment, findings like these add to the understanding of different treatment modalities and individual experiences. They also highlight the need for caution and care when choosing a treatment option.  individual’s unique needs and strengths should guide the approach to treatment increasing the chances for a successful treatment outcome.

References

1. Anderson, S., Clarke, V., & Thomas, Z. (2022). The problem with picking: Permittance, escape and shame in problematic skin picking. Psychology and Psychotherapy: Theory, Research and Practice, 96(1), 83-100. https://bpspsychub.onlinelibrary.wiley.com/doi/10.1111/papt.12427

2. Gallinat, C., Moessner, M., Haenssle, H. A., Winkler, J. K., Backenstrass, M., & Bauer, S. (2019a). Help-seeking attitudes and experiences in individuals affected by skin picking. Journal of Obsessive-Compulsive and Related Disorders, 23, 100483. https://www.sciencedirect.com/science/article/abs/pii/S2211364919301034?via%3Dihub

3. Mehrmann, L. M., & Gerlach, A. L. (2023). The challenge for successful self-help: Side effects of discontinuing an internet-based program for skin picking disorder. Cognitive Therapy and Research. https://link.springer.com/content/pdf/10.1007/s10608-023-10430-4.pdf