Psychological interventions in dermatology.

The objective of this paper is to introduce and emphasize the importance of psychological interventions for those with dermatological conditions. In keeping with the current literature, the author envisages a two-tier approach in the provision of such psychological interventions. Firstly, most patients with dermatology conditions may not require psychological change. Instead, they could be approached with effective doctor-patient communication skills, within a context of empathy and positive regard. At the second tier, however, based on the clinical interview, some patients may require varying degrees of psychological change in order to better manage their illness. In such a context, a dermatologist with training in psychotherapy would be required. In the absence of such a person, the patient may be referred to a psychologist or another mental health professional trained in psychotherapy.

Introduction

The skin is an immediately publicly visible organ. Most humans, being “cosmetic beings,” greatly emphasize the importance of one's physical appearance. Testimony to this is clearly present by the multi-million dollar cosmetic industry, particularly that of skin enhancement lotions, portions and creams. Many people feel pressured to reach unreachable standards of physical appearance.[1] In advertisements for these products, one sees that those who use these products are beautiful, talented, socially accepted and popular.[2] These kinds of advertisements have an impact on most people, particularly those with skin diseases. Hence, in a world that greatly values beauty and youthfulness, there is bound to be a psychological impact on those who do not meet these societal expectations. And, this impact may be more significant in those who have an “undesired” change, in the form of a disease, in their most publicly visible organ, the skin. Hence, a psychologically based dermatology practice that acknowledges and responds to this association between the “mind” and the “skin” would be most productive.

Psychologically adapted care in dermatology

In practicing dermatology, one encounters several patients for whom the medical approach alone is not enough.[3] For instance, the primary dermatological disease may have a secondary psychological impact, such as general anxiety, low mood or social anxiety. Or, some patients may have a co-morbid mental illness such as depression. Or, some patients, because of their deficits in stress management, may experience an exacerbation of the symptoms of their skin condition in times of stress, such as worsening of psoriatic rashes. These types of patients need psychologically adapted care in dermatology.

Psychodermetological process: Two tiers

One could envisage a dermatology practice at two tiers. The first level could be termed “psychologically based dermatology practice”.[3] At this level, there is no need for psychological change in the patient. However, the nature of the doctor–patient relationship should be founded on effective communication skills, empathy and positive regard. Inculcating these communication and interpersonal skills are easier said than done. Such skills do not come naturally to most health professionals’ and many needs to receive explicit training in communication skills.[4] Even if students are trained in communication and interpersonal skills at medical school, the lack of role models in actual clinical practice has a negative effect on the development of these skills.[5] Hence, in order to establish a psychologically based dermatology practice – the first tier mentioned here – medical schools and post graduate medical institutes need to formally impart such training to their students. Such training is most effective if the senior clinicians themselves embody such communication and interpersonal skills. There is much literature on the tenants and development of effective doctor–patient communication and interpersonal skills, and the reader is directed to these.

The second tier of a psychodermetology practice involves patients whose illness condition is associated with psychological factors – as preceding factor, as an antecedent or as a co-existing condition. At this tier, psychological interventions are required. Counseling and psychotherapy are the two types of psychological interventions that would be useful with such patients. As discussed below, the decision on which of these two types should be used on a patient lie on a temporal continuum, based on the severity of the patient's psychological condition.

Counseling

Counseling is a process where the clinician is required to relate to the patient with three key personality attributes : Empathy, positive regard and a non-judgmental attitude. It is envisaged that these three attributes, when combined with effective communication skills and a particular mechanism of asking questions – to assist the patient to solve his own problems rather than the clinician solving it for him – will be therapeutic. Counseling is used with those psychological conditions that have as yet not reached a diagnosable illness (i.e., it has not met the minimum criteria of a mental illness as stipulated by an accepted classification system such as the International Classification of Diseases, ICD) but where the patient is having a certain amount of psychological disturbance nevertheless. For instance, counseling would be useful with patients who have a disfiguring skin condition and hence have some difficulty when “facing” the public, or with those whose skin condition has an impact on their relationships. A dermatologist with further training in counseling could manage such patients in his practice.

The accreditation qualifications for counseling vary from country to country. Typically, most countries may require at least 1 years’ training in counseling to be professionally considered a counselor. In Asia, where training in counseling is still not well established, it is commonly seen that there are, say, weekend courses in counseling where persons who have attended these refer themselves as a counselor. However, this is neither professional nor ethical practice.

Psychotherapy

Psychotherapy is a more involved process than counseling. It requires a greater knowledge on psychopathology. Psychotherapy is required of patients whose psychological condition have reached a diagnosable mental illness as per an accepted classification system such as the ICD. Hence, as opposed to counseling, psychotherapy is a process that addresses deeper psychological issues in a person and is used with those with a mental illness. In a mental health service, it is mostly psychologists that provide psychotherapy services. However, other mental health professionals who have training in selected psychotherapies, such as social workers, psychiatrists and psychiatric nurses, also provide such services. Hence, in a dermatology practice as well, dermatologists who have undergone training in psychotherapy could provide such a service to their patients. As with counseling, there are a stipulated number of hours and conditions a student should fulfill in order to be qualified to practice psychotherapy. These conditions vary from country to country.

Psychotherapy (and counseling) is suited for those patients who have some insight into the psychological nature of their skin condition. At times, this insight may be lacking in the patient – particularly at the initial stages of a consultation. The clinician should endeavor to induce insight in the patient by carefully guiding the consultation process (see below section). As most patients consult a dermatologist to cure their skin condition, rather than treat their mind, patients may not be favorable to a psychological explanation to their condition. Hence, the clinician should be patient and be aware that inculcating insight is not an easy task and that it could be met with resistance.

There are several methods of psychotherapy and some, more than others, are based on greater research evidence. Further, some psychotherapies are best suited to some illnesses while other illnesses should be treated by another type of psychotherapy. Certain psychological conditions, such as delusional parasitosis, are not known to respond to psychotherapy. Instead, these are best treated by pharmacological interventions.[6]

Introducing psychotherapy to a dermatology patient

The dermatology patient is not looking for psychotherapy. He is looking for a cure for his skin condition. Hence, the extent to which he may engage in psychotherapy may depend on the convincing ability of the dermatologist. The following diagram [Figure 1],[3] based on the neuro–immuno–cutaneous–endocrine model,[7] could be used to explain to the patient the complex relationship between the skin and the mind. Even a lesser educated/intelligent person may understand this connection – and hence show an interest in psychotherapy – if it is made clear in a simple manner.

Figure 1

Connection between the skin and the mind, with a view to engaging him in psychotherapy

Methods of psychotherapy

There are many psychotherapeutic methods. Four of the key evidence-based methods are presented here. However, there may be others, lesser practiced/known methods, which have shown favorable results in dermatological conditions.

Cognitive therapy

CT is based on the premise that most human beings have a certain amount of dysfunctional/maladaptive thinking and that those with psychological conditions have far greater amounts of such dysfunctional thinking.[8] CT seeks to help a patient overcome his psychological difficulties by identifying and changing these dysfunctional ways of thinking. Such a change in dysfunctional thinking leads to a consequent change in the patients’ emotional and behavioral responses. This interconnected changes in the person, from thinking to emotions to behavior, leads to (varying degrees of) amelioration of his psychological condition. Changing dysfunctional thinking however is not easy and involves several sessions of psychotherapy. Typically, CT involves helping patients develop skills for (1) identifying dysfunctional thinking, (2) modifying erroneous thoughts/beliefs about themselves, others and the world and (3) challenging these dysfunctional thoughts and beliefs by methods such as Socratic questioning and behavioral experiments.[9]

CT is most useful for those dermatological conditions that have been identified to be triggered by a psychological stressor or for those whose skin conditions gets exacerbated when exposed to stressful life situations.[1011] CT alters dysfunctional thought patterns that damage the skin or interfere with dermatologic therapy.[12] Responsive diseases include acne excoriée, atopic dermatitis, trichotillomania and urticaria.[13] CT could also be used to improve the self-esteem and coping of patents with a skin disorder.[14] Hence, in this latter context, CT is not aimed to improve the skin condition per se, but instead to assist the patient to cope with living with the condition.

Mindfulness-based therapies

Since late, psychotherapy practice has shown a growing interest in Buddhist practices, particularly that of the Buddhist practice of cultivating mindfulness (mindfulness “is cultivating our ability to pay attention in the present moment”).[15] Mindfulness, as used in psychotherapy, does not require a “commitment” to the composite of the Buddhist doctrine, and hence is used in a non-spiritual context. It aims to alleviate psychological distress and promotes the psychological well-being in the person.[15] It also aims to disengage individuals from automatic thoughts and facilitates acceptance of the situation in the present moment while taking mindful action toward desired change, where appropriate. These goals are therapeutic in the case of persons with stress-related skin conditions. Mindfulness can be developed by techniques such as mindfulness meditation and being fully aware when performing daily activities, such as walking, eating and talking.[16] As an individual increasingly lives mindfully, gradually, thought proliferation decreases and wisdom grows in its place.[17] It is this increased wisdom that makes a mindfulness practioner become more tolerant of stress, with a consequent ameliorating effect on stress-based skin conditions.

Mindfulness has been shown to be effective with persons with psoriasis, particularly when combined with light therapy.[18] Mindfulness practice has also been shown to be effective with Compulsive Skin Picking/Dermatillomania – for those with Compulsive Skin Picking, the ultimate goal of mindfulness is to develop the ability to more willingly experience their uncomfortable thoughts, feelings, sensations and urges, without picking their skin.[19]

Habit reversal training

HRT is a “multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders”.[20] Skin disorders treated with HRT include trichotillomania, tics, nail biting, thumb sucking and skin picking. It consists of several stages – (1) Firstly, it focuses on developing the patients’ awareness of the occurrence of his habit – HRT is based on the premise that habits are easier to control when aware of its circumstances. However, although many feel the urge or tension prior to “indulging” in the habit, many also do so at times when attention is elsewhere (e.g., watching TV). Hence, self-monitoring sheets could be used with a patient to bring insight to the extent of his problem by asking him to note such aspects as : When hair pulling episodes occur; how long they last; how many hairs were pulled; how strong the urge was; what he were doing at the time; and what his emotional state was. (2) At the second stage, the patient is trained in progressive muscle relaxation[21] in order to reduce some muscular tension, which would have a corresponding effect on his mental tension/stress. The patient trains himself on progressive muscular relaxation once a day, which takes about 15-20 min. Generally, after about 2 weeks, one becomes fairly proficient at it. Then, the patient is given an abbreviated relaxation technique – in which he compresses his relaxation skills into a roughly 60-s period. This is then practiced several times a day. (3) Training in the use of diaphragmatic breathing, the third stage, is also included as an adjunct to muscular relaxation as that too aids in achieving relaxation. Although this technique is similar to meditation, this is not mindfulness practice that is described above. (4) Once the patient becomes proficient in relaxation, he moves on to the fourth stage, which is acquiring of a muscle tensing activity known as a “competing response.” This involves training in clenching the fist with the hand that is used to pull hair → bending the arm at the elbow at 90° → pressing the arm and hand firmly against his side at about the waist level and → holding this position for 1 min. It is recommended that this competing response be practiced around three periods per day, of 10 repetitions each.

Stages two, three and four are assembled into a complete HRT response. The patient is instructed that whenever/wherever he gets the urge (e.g., to skin pick), he is to : Relax himself → simultaneously breathe from the diaphragm for 60 sec and, when this is done → clench the fist and press his arm to his side for 60 s → if already in a hair pulling episode, to interrupt this episode with the HR response → to practice the response even if he has already stopped pulling and the episode had just ceased.

Stimulus control

HRT is useful as a habit blocker, but it cannot account for all different inputs that lead to pulling/picking of hair or skin. Much pulling/picking is habitual, and occurs predictably in many locations and situations. SC helps identify and then eliminate/avoid/change particular activities and routines that have become associated with pulling/picking. SC includes (1) the use of substitute (non-destructive) forms of stimulation and (2) the rearrangement of routines and environments so that those situations that generally predispose a person to pick/pull are minimized.

An eclectic approach

In the above paragraph, four different forms of psychotherapies that could be used to manage the psychological aspects of various skin conditions have been described. And, as stated earlier, there are many other methods too – such as biofeedback, hypnosis, family therapy, psychodynamic therapy – which are beyond the scope of this article. In a practical situation, these are not used in isolation but are invariably combined to form an eclectic approach. Hence, in the treatment of skin picking, an eclectic approach where mindfulness therapy is combined with SC may be used. Or, in psoriasis, an eclectic approach of mindfulness therapy and CT could be used.

Clinician burnout

Those performing psychotherapy focus on other's problems may consistently fail to attend to their own needs. This neglect has led to an extremely high rate of mental health issues among psychotherapists. Consequently, the burned-out or impaired therapist provides ineffective treatment.[22] Burnout is a result of job stress stemming from the numerous hazards of the profession. It can happen not only with those who have been performing psychotherapy for a long time but also with those new to the profession. In burnout, the therapist feels drained and emotionally depleted. There is a general dislike of, and a disregard toward, the people served. He experiences low energy and reduced interest, and often does not look forward to work.[22]

Burnout is preventable

There are several ways in which one can avoid burnout, increase job satisfaction and provide better quality services to ones’ patients: (1) Use supervision regularly – it is best not to work in isolation. Instead, having regular meetings with colleagues to discuss ones’ psychotherapy practice and one's thoughts and feelings about it would be useful in reducing burnout. (2) Have an eclectic approach (discussed above) – rather than doing the same method of psychotherapy, it is best that one varies it. By doing so, there is novelty and intellectual stimulation in ones work. (3) Continuing professional education is essential – it introduces one to newer methods of practice and assists in one's eclectic approach to psychotherapy. (4) It is important that there are set times for work and leisure. Overwork has consistently been associated with burnout. And, (5) Warn friends and family about the hazards of the profession so that they would be understanding and supportive.