THE FOUR PHASES OF COMB TREATMENT

Phase 1 – Assessment (Functional Analysis). ComB treatment pays attention to the factors that foster and maintain BFRBs: behavioral, emotional, cognitive, and sensory variables identified in prior research on HPD (Mansueto, 1991). This approach emphasizes relationships among these categories to provide a detailed picture of the internal and external factors that make it more or less likely that a BFRB will occur, and this guides the assessment phase of treatment. Here ComB uses what is considered a traditional behavioral framework that identifies which antecedents (A) instigate and make the behaviors more likely to occur, what behaviors (B) constitute the actual pulling of hair and picking of skin, and the consequences (C) that maintain the behaviors (in other words, make the behaviors more likely to occur again in the future). We focus on those variables that appear to promote more BFRB episodes (A’s and C’s), and these are grouped into five categories:

Sensory (i.e., sensations) – Antecedents can include trigger sensations (hairs or skin that appear “wrong,” out of place or unpleasant to sight or touch, tingling, burning or itching at the site, or impulses to pick or pull in anticipation of pleasure or otherwise desirable sensations that are attained by those activities, etc.). Consequences can include pleasurable sensations experienced during or after pulling or picking. These pleasurable sensations may occur while handling hair or skin products; visually examining the hair or skin; chewing on or swallowing the hair, hair root, dry skin pieces or scabs; rubbing hair or skin across face, arm or lip, etc.

Cognitive (i.e., thoughts) – Antecedents can include ideas, thoughts, or beliefs that trigger pulling or picking, such as: “Kinky hairs are ugly and have to go,” “My pimples have to be popped to heal,” “My eyebrows or lashes must be symmetrical,” “I won’t be able to study if I don’t pull out these stubby eyelashes.” Consequences can include satisfaction gained from completing the goal (e.g., popping the pimple, eliminating unwanted hairs, finding a hair with a big root, etc.).

Affective (i.e., emotions) – Antecedents can include feelings that trigger pulling or picking behavior, such as: boredom, anxiety, frustration, depression, tension, indecisiveness, excitement, etc. Consequences can include the effect of reducing unwanted feelings, getting an energized effect when feeling bored or lethargic, or experiencing satisfaction following the action, etc.

Motor (i.e., behaviors) – Antecedents can include motor habits and body postures that encourage an individual to stroke, examine, or remove hair or pick at skin, often without full awareness (i.e., automatically). In the case of habitual behavior, Consequences can include repetition of the behaviors, establishing well-practiced movements that establish and strengthen habitual behavior.

Place (i.e., environment) – Antecedents can include cues in a particular space that trigger the behavior such as: being alone, being sedentary or not moving around much, sitting in a familiar spot where picking or pulling often occurs, the presence of mirrors, tweezers, or pins, etc. Consequences: The place domain does not typically have a reinforcing function, except for the rare attention-seeking adult, or more frequently, in children desiring attention.

In order to provide a quick and easy way to remember these domains, they are often referred to by the acronym SCAMP.

Phase 2 – Identification and Selection of Target Domains. ComB treatment emphasizes the learning and practice of strategies to target problematic behaviors as well as the thoughts, feelings, and sensations that contribute to their persistence. Each individualized plan is designed to interrupt problematic habits by providing healthier alternatives. These are organized within the five SCAMP domains and reflect the specific functions served by hair pulling or skin picking for each person. Once the BFRB has been thoroughly assessed using the SCAMP model, it becomes clearer how and why the problem behaviors show up and how they are maintained (i.e., by looking at how the antecedents and consequences are connected to the problematic behaviors). Now the therapist and the patient can work together to identify specific targets that are contributing to that individual’s pulling or picking.

Phase 3 – Implementation of Specific Interventions. At this point in treatment, individuals will explore the use of a variety of specific interventions designed to decrease their BFRB symptoms. Interventions are chosen based upon their ability to affect the targets identified in Phase 2 by modifying the antecedents and consequences that trigger and maintain the BFRB. As stated above, many of the interventions include standard behavioral and cognitive strategies previously described in the cognitive behavioral literature, but there are others that address targets not typically emphasized in behavioral interventions (e.g., the sensory components). Examples of standard CBT techniques used and less familiar ones that address the targets include: 

Cognitive restructuring, coping self-statements, and mindfulness and acceptance strategies to address cognitive targets

Relaxation, controlled breathing, positive visualization, and dialectical behavior therapy skills to address affective/emotional targets

Awareness training, competing response training,
and response prevention to address motoric/behavioral targets

Stimulus control and contingency management to address place/environmental targets

Sensory substitution techniques (i.e., activities that do not require the removal of hair or skin) are used to address sensory needs previously addressed in the individual’s BFRB, and sensory distraction techniques are taught in order to provide alternatives to soothe, invigorate, and provide pleasing sensations impacting the nervous system in ways that divert the individual from pulling hair or picking skin

When potentially useful interventions have been identified, the individual, in consultation with the therapist, chooses several to try out over the next week focusing on high-risk situations. For example, while driving to work the client might wear driving gloves (stimulus control, response prevention), listen to relaxing music (sensory distraction), breathe deeply and slowly (controlled breathing), and keep both hands gripped to the steering wheel (competing response). Other situations in which pulling is probable will likely require a different set of interventions, for example, while working on the computer at the office. Choices of interventions should be carefully fitted to the lifestyle and preferences of the client. The usefulness of the interventions will be determined once they have been tried and their impact on hair pulling has been reviewed. During each session, the client and therapist decide together how to modify the intervention to maximize control of hair pulling.

Phase 4 – Evaluation, Termination, and Relapse Prevention. In the final phase of formal treatment, the client is encouraged to continue with ongoing assessments of progress and to modify the use of interventions as needed. A shift is made from reliance on therapist guidance toward self-management and utilization of skills and techniques learned during formal treatment. The focus is on maintenance, extension of the gains achieved during formal therapy, and preparation for setbacks that are common during the recovery process. Relapse prevention training provides a systematic approach to minimizing setbacks and keeping them from leading to a full-blown resumption of hair pulling or skin picking.

In habit reversal training, we work on building awareness and understanding of what maintains the body-focused repetitive behavior. In treatment, clients engage in self-monitoring of the behavior to build lasting awareness. Once you develop awareness about your body-focused repetitive behavior, then we focus on coming up with competing responses that block the engagement of the BFRB. This will help you learn to tolerate the distress of the urge to engage in the unwanted behavior.

KEY ASPECTS OF HABIT REVERSAL TRAINING

• Self-monitoring: track the frequency and triggers of the unwanted behavior to identify patterns.

• Awareness training: identify the early signs or sensations that happen before the unwanted behavior, such as a feeling of tension or an urge. 

• Competing response: Practice a deliberate, incompatible behavior to replace the unwanted habit when the urge arises. 

• Use relaxation techniques, such as deep breathing tools, meditation, & other mindfulness activities to manage stress that might trigger the habit. 

The BFRB Recovery Workbook by Deibler & Reinardy

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