CBT Manual for Moderate Symptoms of Excoriation Disorder (Skin-Picking Disorder)

Session Overview Plan

Psychosocial
Week Session Duration Therapeutic Intervention
Intervention
Session 45
1 Assessment and Rapport Building Supportive engagement
1 minutes
Session 45
2 Psychoeducation and Normalization Family support planning
2 minutes
Session 45 Functional Analysis of Skin-Picking Triggers and emotional
3
3 minutes Behaviors mapping
Session 45 Cognitive Restructuring – Part 1: Identifying Thought labeling and
4
4 minutes Thinking Errors tracking
Session 45 Cognitive Restructuring – Part 2:
5 Behavioral experiments
5 minutes Challenging Appearance and Control Beliefs
Session 45 Habit Reversal Training (HRT) – Awareness Self-monitoring log
6
6 minutes Training initiation
Session 45 Competing behavior
7 HRT – Competing Response Training
7 minutes development
Session 45 Environmental
8 Stimulus Control Strategies
8 minutes adjustments
Session 45 Distress management
9 Exposure and Emotional Tolerance
9 minutes skills
Session 45 Practicing acceptance
10 Mindfulness and Urge Surfing
10 minutes and presence
Session 45
11 Self-Compassion and Relapse Preparation Building self-kindness
11 minutes
Session 45 Relapse Prevention Planning and Future
12 Maintenance strategies
12 minutes Resilience

Session 1: Assessment and Rapport Building

[...Session 1 content remains unchanged...]

Session 2: Psychoeducation and Normalization

Therapeutic Objectives:
  Provide clear information about excoriation disorder (skin-picking) as a recognized
mental health condition.
 Normalize the client’s experiences and reduce shame or self-blame.
 Introduce the cognitive-behavioral model of excoriation disorder.
 Clarify that symptoms are understandable and treatable.
 Engage family/support persons if appropriate.

Rationale: Many individuals believe their behavior is a personal flaw or weakness.

Psychoeducation reframes symptoms as part of a known condition with effective treatments.
Understanding how the behavior is maintained helps shift blame and increase motivation for
treatment.

Session Structure:

1. Review of Homework and Logs (5–7 mins)

o Check in on Daily Picking Log.
o Look for common triggers, timing, or emotional patterns.
o Validate effort and curiosity.
2. Introduce Excoriation Disorder (10–12 mins)
o Core points:
 This is a recognized condition in DSM-5-TR.
 It is not about willpower — behaviors serve a short-term emotional
purpose.
 Picking may be automatic (without awareness) or focused (as relief from
tension).
 Common emotional triggers include anxiety, boredom, anger, or guilt.
o Use a neutral tone, avoiding any language that might suggest blame.
3. Present the CBT Maintenance Model (10–12 mins)
o Use a visual diagram:
 Trigger → Emotional State → Picking Behavior → Relief → Long-
Term Distress
o Sample Example:
 Trigger: Feeling anxious before bed.
 Emotion: Anxiety.
 Behavior: Picking at arms.
 Short-Term Relief: Anxiety decreases.
 Long-Term Outcome: Skin damage, shame, continued urge.
o Highlight how the cycle keeps itself going unintentionally.
4. Normalize and Foster Hope (5–7 mins)
o Statements like:
 “It makes sense that you turned to something that helped you feel in
control.”
 “You’re not alone—many people struggle with this, and we have tools that
can help.”
o Emphasize treatability and the evidence base of CBT.
5. Assign Homework (3–5 mins)
 o Read Psychoeducation Handouts: "Understanding Excoriation Disorder" and "The
Skin-Picking Cycle."
o Continue Daily Picking Log.
o Add a reflection section: What did I feel before and after the episode?

Therapist Reminders:

 Stay factual, calm, and validating.

 Avoid suggesting the client is responsible for having the disorder.
 Reinforce curiosity: “We’re learning how this works—not judging it.”

Materials Needed:

 Psychoeducation Handout: What is Excoriation Disorder?

 Diagram: The Skin-Picking Cycle
 Daily Picking Log (with added reflections)
 Homework Instructions Sheet

SESSION 2: WORKSHEETS & HANDOUTS

1. Handout: What Is Excoriation Disorder?

o A condition where a person repeatedly picks their skin, causing damage.
o Often triggered by emotional states or certain situations.
o Can be automatic (habitual) or focused (intentional).
o Not a sign of weakness — it's a coping strategy that has become unhelpful.
2. Handout: The Skin-Picking Cycle

Step Description
Trigger Internal or external (e.g., stress, boredom, urge to remove an imperfection)
Emotion Anxiety, tension, boredom, frustration
Behavior Picking skin to relieve emotion or perceived flaw
Relief Short-term emotional relief or satisfaction
Consequence Damage, shame, ongoing distress

✅ Goal of Therapy: Learn new responses to triggers and emotions to break the cycle.

3. Daily Picking Log (Expanded) | Date | Trigger/Event | Emotion Before | Area Picked |
Duration | Emotion After | Reflection (Thoughts/Insights) |
|------|----------------|----------------|--------------|----------|----------------|-------------------------
----| | | | | | | | |
4. Homework Checklist – Session 2

 Read handouts on Excoriation Disorder and the Skin-Picking Cycle.

  Complete the expanded Daily Picking Log for at least 5 days.
 Reflect on patterns or insights related to emotion or thought before/after picking.

Let me know when you’re ready to continue with Session 3.

Great — here's the full content for Session 3: Functional Analysis of Skin-Picking Behaviors
in your CBT manual for moderate excoriation disorder:

Session 3: Functional Analysis of Skin-Picking Behaviors

Therapeutic Objectives

 Identify specific antecedents (triggers), behaviors, and consequences (ABCs) associated

with picking episodes.
 Increase client awareness of patterns and functions behind their picking behavior.
 Introduce the idea that behavior serves a purpose — often emotional regulation or
sensory relief.
 Lay the foundation for targeted intervention strategies in future sessions.

Rationale

Functional analysis is a core component of CBT that helps break down problematic behaviors
into understandable sequences. For individuals with excoriation disorder, picking is often
automatic or emotionally driven. Mapping out when, where, and why picking occurs provides
critical insight for personalized treatment and empowers clients to regain a sense of control.

Session Structure

1. Check-in & Review Homework (5–7 mins)

o Review Daily Picking Log with reflection entries.
o Validate observations and any efforts at tracking.
o Reinforce curiosity and avoid any evaluative tone.
2. Introduce Functional Analysis (10–12 mins)
o Present the ABC Model:
 Antecedent: What happened before the behavior?
 Behavior: What exactly did the person do?
Consequence: What happened afterward (emotionally or practically)?
o Use client examples from the log to create 1–2 ABC chains.
3. Explore Functions of Behavior (10–12 mins)
o Ask exploratory questions:
 "What need was the behavior meeting in that moment?"
 "Did the picking help reduce any specific emotion?"
 "Was there a sense of relief, focus, or control afterward?"
o Identify primary functions: emotional relief, sensory regulation, perfectionism,
boredom relief, or avoidance.
4. Begin Pattern Mapping (5–7 mins)
o Start noticing themes across different ABCs:
 Time of day?
 Specific settings?
 Emotions most tied to picking?
o Encourage client to make tentative connections — e.g., “I often pick when I'm on
my phone at night.”
5. Assign Homework (3–5 mins)
o Continue using the Daily Picking Log.
o Introduce the ABC Worksheet for 2–3 episodes this week.
o Ask client to consider: What purpose might this episode have served?

Therapist Reminders

 Use a compassionate, collaborative tone: "We’re detectives, not judges.”

 Frame behavior as meaningful, not irrational.
 Reinforce that understanding comes before change — this is a key insight-building phase.
 Be alert to early signs of shame or self-blame and gently reframe.

Materials Needed

 ABC Worksheet
 Example ABC Chain (Therapist Copy)
 Daily Picking Log (continued)
 Homework Instruction Sheet

Session 3: Worksheets & Handouts

1. ABC Worksheet – Functional Analysis

 Behavior Consequence
Episode Antecedent Purpose/Function (What
(What You (Immediate
# (Trigger/Setting) It Did For You)
Did) Outcome)

2. Example ABC Chain (Therapist Demonstration)

 A: Watching TV, feeling bored, hands idle.

 B: Began picking at arm scab.
 C: Felt a bit of relief, more focused on the show, no more boredom.
 Function: Reduced boredom and provided sensory input.

3. Homework Checklist – Session 3

 Continue using the Daily Picking Log.

 Complete ABC Worksheets for 2–3 picking episodes.
 Reflect on:
o What seemed to trigger each episode?
o What emotional or sensory purpose did it serve?
 Bring the worksheets to the next session.

Let me know if you'd like a printable version or editable handouts for Session 3. Would you like
to move on to Session 4: Cognitive Restructuring – Identifying Thinking Errors next?

4o

You said:

yes move on
ChatGPT said:

Excellent — here’s the full content for Session 4: Cognitive Restructuring – Part 1:
Identifying Thinking Errors from your CBT manual for moderate excoriation disorder:

Session 4: Cognitive Restructuring – Part 1: Identifying

Thinking Errors
Therapeutic Objectives
  Introduce the concept of automatic thoughts and cognitive distortions.
 Help the client recognize how thoughts can trigger or maintain picking behavior.
 Begin developing skills for identifying and labeling common thinking errors.
 Foster a nonjudgmental stance toward internal dialogue.

Rationale

Many individuals with excoriation disorder experience distorted thinking patterns related to
control, appearance, failure, or emotional coping. These thoughts often occur automatically and
reinforce the urge to pick. Identifying these patterns is the first step toward reshaping them. This
session sets the stage for cognitive change by building awareness and insight.

Session Structure

1. Check-in & Homework Review (5–7 mins)

o Review ABC worksheets and logs from Session 3.
o Highlight any repeated or triggering thoughts noted.
o Ask: “Did you notice what you were thinking before or during those moments?”
2. Introduce Automatic Thoughts (10–12 mins)
o Explain: Our brains generate quick thoughts that shape how we feel and act —
often without our conscious awareness.
o Common examples before picking:
 “This bump needs to go.”
 “I’ll feel better if I just fix this.”
 “I can’t stop thinking about this imperfection.”
o Normalize: These thoughts aren't bad — they’re habits of the mind.
3. Explain Common Thinking Errors (10–12 mins)
o Introduce 4–6 key distortions relevant to skin-picking:

All-or-Nothing Thinking – “If I don’t fix it, I’m disgusting.”

1.
Catastrophizing – “Everyone will notice this spot — I can’t go out.”
2.
Emotional Reasoning – “I feel anxious, so something must be wrong
3.
with my skin.”
4. Should Statements – “I shouldn’t let my skin look like this.”
5. Perfectionism – “It has to look smooth or I’ll feel gross.”
6. Mind Reading – “They must be staring at my scabs.”
o Provide examples and brief role-play or reflection.
4. Practice Thought Labeling (5–7 mins)
o Use 2–3 real or hypothetical picking scenarios.
o Identify the automatic thought and label the distortion.
o Emphasize curiosity, not correction.
5. Assign Homework (3–5 mins)
 o Begin the Thought Tracking Worksheet for picking-related thoughts.
o Track at least 3 thoughts over the week and try to identify any distortions.
o Continue Daily Picking Log and ABC Worksheet if helpful.

Therapist Reminders

 Use gentle humor and relatability when introducing distortions.

 Reinforce that everyone has thinking errors — the goal is awareness, not perfection.
 Avoid prematurely challenging thoughts — focus is on identification only in this session.

Materials Needed

 Cognitive Distortions Handout

 Thought Tracking Worksheet
 Picking Scenarios for Practice (Therapist Copy)
 Homework Checklist

Session 4: Worksheets & Handouts

1. Cognitive Distortions Handout (Condensed)

Distortion Type Description Example Thought

All-or-Nothing Thinking Things are black-or-white “If I can’t stop, I’m a failure.”
Catastrophizing Expecting the worst “Everyone will judge me.”
Emotional Reasoning Feelings = Facts “I feel gross, so I must look bad.”
Should Statements Unrealistic expectations “I should have perfect skin.”
Perfectionism Over-focus on flaws “This mark has to be gone.”
Mind Reading Assuming others’ thoughts “They’re definitely staring at me.”

2. Thought Tracking Worksheet

Date Situation Automatic Thought Emotion Distortion Type Insight

3. Homework Checklist – Session 4

 Complete at least 3 entries on the Thought Tracking Worksheet.

  Try labeling the type of thinking error involved.
 Continue using Daily Picking Log (optional if helpful).
 Bring examples to discuss in the next session.

Would you like to proceed with Session 5: Challenging Appearance and Control Beliefs?

4o

You said:

yes
ChatGPT said:

Excellent — here’s the full content for Session 5: Cognitive Restructuring – Part 2:
Challenging Appearance and Control Beliefs, building on the previous session:

Session 5: Cognitive Restructuring – Part 2: Challenging

Appearance and Control Beliefs
Therapeutic Objectives

 Help clients examine and challenge unhelpful core beliefs related to appearance, control,
and self-worth.
 Teach techniques to evaluate and reframe automatic thoughts.
 Reduce the emotional impact of perfectionistic or shame-based thinking patterns.
 Practice thought challenging using guided techniques and behavioral experiments.

Rationale

Individuals with excoriation disorder often hold rigid or extreme beliefs about skin appearance,
control over their bodies, or worth tied to flawlessness. These beliefs feed distress and reinforce
picking behavior. Challenging them is essential for breaking the cognitive-behavioral cycle and
fostering self-acceptance.

Session Structure
 1. Check-in & Review Homework (5–7 mins)
o Review the Thought Tracking Worksheet.
o Praise insight and curiosity: “What did you notice about your thinking?”
o Validate how difficult it can be to observe and label thoughts.
2. Review Common Core Beliefs (10–12 mins)
o Introduce examples frequently linked to skin-picking:
 “If my skin isn’t perfect, I’m disgusting.”
 “I should be able to control this.”
 “Other people will reject me because of how I look.”
o Link these to thought distortions identified last session.
o Ask client to reflect: “Which beliefs feel most familiar or powerful for you?”
3. Teach Thought-Challenging Techniques (10–12 mins)
o Introduce Socratic questioning:
 “What’s the evidence for and against this thought?”
 “If a friend had this thought, what would I say to them?”
 “Is there another way to see this situation?”
o Emphasize flexible thinking over “positive” thinking.
4. Behavioral Experiment Planning (5–7 mins)
o Design a small experiment to test a belief, e.g.:
 Go out without covering up a mark and observe what actually happens.
 Leave a blemish untouched for one day.
o Use an Experiment Log to track predictions, actions, and outcomes.
5. Assign Homework (3–5 mins)
o Continue Thought Tracking with added reframed or alternative thought.
o Complete one Behavioral Experiment and log the experience.
o Bring both to the next session.

Therapist Reminders

 Use gentle questioning — avoid arguing with beliefs.

 Encourage a “what if that wasn’t true?” mindset.
 Reinforce that reframing doesn’t mean denying difficulty — just loosening rigid thinking.

Materials Needed

 Thought-Challenging Worksheet
 Common Core Beliefs Handout
 Behavioral Experiment Log
 Homework Instruction Sheet
Session 5: Worksheets & Handouts
1. Thought-Challenging Worksheet

Situation Automatic Thought Emotion Core Belief Reframed Thought Outcome

2. Common Core Beliefs – Skin-Picking Clients

 “My worth depends on how I look.”

 “I must have flawless skin.”
 “I should be able to control my urges perfectly.”
 “Flaws make me unacceptable or dirty.”
 “People will judge or reject me for this.”

3. Behavioral Experiment Log

Belief Being Tested Prediction Action Taken Outcome Observed Reflection

4. Homework Checklist – Session 5

 Continue Thought Tracking with Reframed Thoughts.

 Identify one core belief and challenge it.
 Complete one Behavioral Experiment (log included).
 Bring both worksheets to Session 6.

Would you like to continue with Session 6: Habit Reversal Training (HRT) – Awareness
Training?

4o

You said:

yes
ChatGPT said:

Perfect — here’s the full content for Session 6: Habit Reversal Training (HRT) – Awareness
Training in your CBT manual for moderate excoriation disorder:
Session 6: Habit Reversal Training (HRT) – Awareness
Training
Therapeutic Objectives

 Increase client awareness of the sensory, emotional, and situational cues that precede
picking.
 Help clients identify subtle urges, movements, or contexts that signal an episode is about
to occur.
 Lay the groundwork for introducing competing responses in the next session.
 Empower the client with a sense of increased control through mindful observation.

Rationale

Many skin-picking episodes occur with limited or no conscious awareness — particularly during
idle or automatic moments. Awareness training is the cornerstone of Habit Reversal Training
(HRT) and is crucial before teaching any competing response. It allows clients to catch the
behavior earlier in the cycle and intervene meaningfully.

Session Structure

1. Check-in & Homework Review (5–7 mins)

o Review Thought-Challenging Worksheets and Behavioral Experiment Log.
o Highlight any successes or surprises from experiments.
o Ask: “What did you notice before you picked this week?”
2. Introduce Habit Reversal Training (10–12 mins)
o Explain the three components:
1. Awareness Training (today’s focus)
2. Competing Response Training (next session)
3. Generalization of Skills
o Reinforce that this is a research-supported approach for body-focused repetitive
behaviors.
3. Begin Awareness Training (10–12 mins)
o Break down the steps:

 Identify early cues: urges, sensations (tingling, itching), hand movements,

environments, emotions.
 Use mirroring exercises to simulate common situations (e.g., sitting on the
couch, looking in a mirror).
o Ask:
 “Where were your hands?”
  “What were you doing just before the urge?”
 “What were you feeling in your body or mind?”
4. Teach Self-Monitoring Techniques (5–7 mins)
o Introduce the Self-Monitoring Log:
 Used to record each time the client notices:
 A picking urge
 A near-miss or moment of awareness
 An actual episode
o Explain that increasing awareness is progress in itself.
5. Assign Homework (3–5 mins)
o Use the Self-Monitoring Log throughout the week.
o Focus on noticing without trying to stop or change behavior yet.
o Practice observing urges as soon as they arise.

Therapist Reminders

 Reinforce that noticing is a skill — catching even one urge is a win.

 Stay nonjudgmental; focus on learning, not perfection.
 Reassure the client that this phase is not yet about control — it’s about learning patterns.

Materials Needed

 Self-Monitoring Log
 HRT Introduction Handout
 Awareness Cues Worksheet
 Homework Instruction Sheet

Session 6: Worksheets & Handouts

1. HRT Introduction Handout

 HRT is a proven behavioral technique for treating repetitive behaviors.

 It includes:
1. Awareness Training
2. Competing Response Training
3. Generalization of Skills
 The goal is to replace automatic habits with intentional, manageable alternatives.
2. Awareness Cues Worksheet

Category Examples Your Triggers

Emotional Anxiety, boredom, frustration
Sensory Itch, tingling, bump
Environmental Mirror, being alone, lying in bed
Behavioral Hand on face, scanning for bumps

3. Self-Monitoring Log

Urge Felt? Behavior What Was Emotion or Did I Notice

Date/Time
(Y/N) Occurred? Happening Before? Sensation Before Picking?

4. Homework Checklist – Session 6

 Begin using the Self-Monitoring Log.

 Focus only on increasing awareness — not changing behavior yet.
 Fill out Awareness Cues Worksheet (optional reflection).
 Bring both worksheets to Session 7.

Would you like to continue with Session 7: HRT – Competing Response Training?

4o

You said:

yes
ChatGPT said:

Great — here’s the full content for Session 7: HRT – Competing Response Training, the next
step in Habit Reversal Training for excoriation disorder:

Session 7: HRT – Competing Response Training

Therapeutic Objectives

 Teach the client how to interrupt picking urges with a physically incompatible behavior.
  Practice developing individualized competing responses based on common picking
contexts.
 Reinforce increased self-awareness as a cue to initiate response substitution.
 Promote consistency in applying the response to strengthen habit reversal.

Rationale

Once a client can notice urges or triggers, they are in a position to take action. A competing
response is a simple, intentional physical behavior that blocks the picking action and redirects
the urge. Practicing these responses helps rewire habitual pathways and reduces picking
frequency over time.

Session Structure

1. Check-in & Review Homework (5–7 mins)

o Review entries from the Self-Monitoring Log.
o Validate moments of awareness: “That’s a great catch — even noticing the urge is
progress.”
o Ask: “What situations or body sensations came up most often?”
2. Introduce Competing Responses (10–12 mins)
o Define a competing response:
 A behavior that is physically incompatible with picking.
 Simple, portable, and can be maintained for 1+ minutes.
o Examples:
 Clenching fists or sitting on hands
 Holding a textured object (e.g., stone, stress ball)
 Rubbing fingers on jeans or a fabric
 Stretching hands or playing with putty
3. Personalize Competing Responses (10–12 mins)
o Identify specific triggers or scenarios from the log (e.g., in bed, watching TV,
looking in the mirror).
o Match a tailored competing response to each one.
o Role-play or simulate common picking contexts and practice response use.
4. Set Use Guidelines (5–7 mins)
o Apply the response immediately when the urge is noticed.
o Continue the response for at least 1 minute or until the urge subsides.
o Keep objects (if used) in visible/easy-to-access locations.
o Pair response with a self-talk cue like: “This is how I break the cycle.”
5. Assign Homework (3–5 mins)
o Complete the Competing Response Log at least once per day (or more, as urges
arise).
o Use the Self-Monitoring Log to track when and where urges occur.
 o Optional: practice the competing response at set times, even without an urge, to
build the habit.

Therapist Reminders

 Reinforce the idea that this is a practice, not a test of willpower.

 Encourage trying several responses — not every one works the same for each person.
 Model curiosity: “Let’s see which ones work best in which moments.”

Materials Needed

 Competing Response Ideas Sheet

 Competing Response Log
 Updated Self-Monitoring Log
 Homework Instruction Sheet

Session 7: Worksheets & Handouts

1. Competing Response Ideas Sheet

Situation Urge Suggested Response

Lying in bed Hand to face Clench fists under pillow
Watching TV Bored hands Hold fidget object or knitting needle
Looking in mirror Scan for flaws Rub fingers on textured surface
After stress Need relief Deep breathing + squeezing stress ball

2. Competing Response Log

Date/Time Urge Felt? Response Used Duration (min) Effectiveness (1–5) Notes

3. Updated Self-Monitoring Log

(Same format as in Session 6, with optional column added: “Was a Competing Response
Used?”)
4. Homework Checklist – Session 7

 Identify 2–3 common urge situations and assign a response to each.

 Practice using the response whenever an urge arises (and at least once per day).
 Log your responses and rate their effectiveness.
 Bring logs and reflections to Session 8.

Would you like to continue with Session 8: Stimulus Control Strategies?

4o

You said:

yes
ChatGPT said:

Great — here’s the full content for Session 8: Stimulus Control Strategies, which builds on
awareness and competing responses to modify the environment:

Session 8: Stimulus Control Strategies

Therapeutic Objectives

 Identify environmental and situational triggers that contribute to skin-picking.

 Introduce practical stimulus control techniques to reduce exposure to cues.
 Empower the client to design a skin-friendly environment that supports recovery.
 Combine physical changes with behavioral awareness for long-term habit interruption.

Rationale

Stimulus control involves modifying the environment to reduce triggers and increase
behavioral alternatives. By addressing external factors (like mirrors, lighting, idle time, or tactile
triggers), clients can reduce opportunities for picking and improve self-regulation.

Session Structure

1. Check-in & Review Homework (5–7 mins)

 o Discuss use of competing responses.
o Ask:
 “Which situations were easier or harder to respond to?”
 “What seemed to make a difference in the moment?”
o Reinforce that partial use or effort still counts as progress.
2. Define Stimulus Control (5–7 mins)
o Explain that just as certain environments increase the urge to pick, others can
reduce it.
o Examples of triggers:
 Bright mirrors
 Idle alone time
 Textures (e.g., scabs or rough skin)
 Grooming rituals
o “We’re not avoiding life — we’re reducing unnecessary traps.”
3. Identify Client’s Triggering Contexts (10–12 mins)
o Use Stimulus Inventory Worksheet to explore personal triggers.
o Ask:
 “Where and when do picking episodes mostly occur?”
 “What are your hands doing when you’re not aware of them?”
o Consider sensory, emotional, and visual stimuli.
4. Brainstorm & Apply Control Strategies (10–12 mins)
o Examples:
 Covering or removing high-risk mirrors.
 Wearing gloves or Band-Aids during idle time.
 Keeping hands busy while watching TV.
 Using lotion to reduce skin texture triggers.
 Setting timers to break mirror-checking habits.
o Encourage small, doable changes rather than perfection.
5. Assign Homework (3–5 mins)
o Choose 2–3 stimulus control strategies to implement this week.
o Record in the Stimulus Control Log.
o Continue using competing responses and self-monitoring.

Therapist Reminders

 Avoid making the client feel like they must avoid all triggers — the goal is management,
not control.
 Normalize that adjusting the environment is a healthy act of support, not weakness.
 Encourage creativity and flexibility.

Materials Needed
  Stimulus Inventory Worksheet
 Stimulus Control Strategies Handout
 Stimulus Control Log
 Updated Self-Monitoring Log
 Homework Instruction Sheet

Session 8: Worksheets & Handouts

1. Stimulus Inventory Worksheet

Trigger Type Examples Your Triggers

Visual Bathroom mirror, magnifying mirror, strong lighting
Tactile Rough skin, scabs, bumps
Situational Being alone, lying in bed, scrolling phone
Emotional Anxiety, boredom, perfectionism

2. Stimulus Control Strategies Handout

Trigger Strategy
Mirror-checking Cover mirror, use dimmer light, set a time limit
Hands idle at night Wear gloves, hold a soft object, rub lotion
Rough skin Moisturize regularly, apply barrier creams
Alone time Set a picking-free goal, call a friend, keep a fidget nearby
Phone use Keep hands occupied while scrolling (e.g., doodle, knit)

3. Stimulus Control Log

Date Triggering Situation Strategy Used Was It Helpful? Notes

Yes / No

4. Homework Checklist – Session 8

 Complete the Stimulus Inventory Worksheet.

 Choose and apply 2–3 Stimulus Control Strategies.
 Fill out the Stimulus Control Log throughout the week.
 Continue using Competing Response and Self-Monitoring Logs.
Would you like to move on to Session 9: Exposure and Emotional Tolerance next?

4o

You said:

yes
ChatGPT said:

Excellent — here’s the full content for Session 9: Exposure and Emotional Tolerance, which
introduces skills for managing the emotions that drive or follow skin-picking:

Session 9: Exposure and Emotional Tolerance

Therapeutic Objectives

 Help the client build emotional resilience and reduce avoidance of distressing sensations
or thoughts.
 Practice exposure to emotional or sensory triggers without engaging in picking.
 Teach distress tolerance strategies to handle urges without acting on them.
 Reinforce that uncomfortable feelings can pass without harmful behavior.

Rationale

Many picking episodes are fueled by the desire to escape or reduce distress. Emotional
avoidance strengthens the picking habit. This session introduces exposure and response
prevention (ERP) principles, where clients gradually face urges or emotional discomfort
without picking. This builds emotional flexibility and reduces compulsive behavior over time.

Session Structure

1. Check-in & Homework Review (5–7 mins)

o Review stimulus control strategies.
o Ask:
 “Which changes helped the most?”
 “What was hard about managing your environment?”
o Acknowledge effort and perseverance.
2. Introduce Emotional Exposure (10–12 mins)
 o Explain that exposure is about facing what we usually avoid — like tension,
anxiety, or the urge to pick.
o Normalize that discomfort is a part of healing, and it can be survived without
picking.
o Discuss:
 “What emotions or sensations feel intolerable before you pick?”
 “What do you usually hope picking will fix in that moment?”
3. Teach Emotional Tolerance Skills (10–12 mins)
o Introduce distress tolerance strategies, such as:
 Grounding (e.g., 5-4-3-2-1 senses technique)
 Cold temperature (holding an ice cube)
 Breath work (box breathing)
 Delaying the urge: “I’ll wait 3 minutes before deciding to pick.”
 Surfing the urge: observing it rise and fall like a wave
o Practice one together during session.
4. Create a Mini Exposure Plan (10–12 mins)
o Identify 1–2 triggers the client is willing to face without picking.
o Example exposures:
 Looking in the mirror for 1 minute without picking
 Touching a rough skin patch and noting the urge without acting
 Sitting with anxiety or boredom and delaying response
o Pair with emotional tolerance skill for support.
5. Assign Homework (3–5 mins)
o Choose one exposure task to practice daily (or several times this week).
o Use the Emotional Exposure Log to record attempts.
o Continue stimulus control and competing response use.

Therapist Reminders

 This session may stir vulnerability — validate and support.

 Normalize discomfort: “This is challenging because it’s new, not because you’re failing.”
 Reinforce the idea that urges pass on their own when not acted on.

Materials Needed

 Emotional Exposure Planning Worksheet

 Emotional Exposure Log
 Distress Tolerance Skill Cards
 Homework Instruction Sheet
Session 9: Worksheets & Handouts
1. Emotional Exposure Planning Worksheet

Confidence (0–
Trigger Emotion or Urge Exposure Task Support Skill
100%)
Anxiety, Look in mirror for 1 min, no 5-4-3-2-1
Mirror 65%
compulsion picking grounding
Rough Touch skin for 30 sec, no
Tension, disgust Ice cube in hand 50%
skin picking

2. Emotional Exposure Log

Trigger Did I Support Strategy Urge Intensity How Long Did It

Date Reflection
Faced Pick? Used (0–10) Last?

3. Distress Tolerance Skills (Handout)

 5-4-3-2-1 Grounding: Name 5 things you see, 4 you feel, 3 you hear, 2 you smell, 1 you
taste.
 Box Breathing: Inhale 4 seconds → Hold 4 → Exhale 4 → Hold 4.
 Delay Strategy: Set a timer for 2–5 minutes before acting on any urge.
 Cold Intervention: Hold an ice cube or splash cold water on your face.
 Urge Surfing: Picture the urge like a wave—notice it rise, peak, and fade.

4. Homework Checklist – Session 9

 Choose one exposure task and practice it regularly.

 Use the Emotional Exposure Log to reflect on the experience.
 Practice at least one distress tolerance skill when facing an urge.
 Bring logs and reflections to Session 10.

Would you like to continue with Session 10: Mindfulness and Urge Surfing next?

4o

You said:

yes
ChatGPT said:

Great — here is the full content for Session 10: Mindfulness and Urge Surfing, a crucial step
in increasing awareness and detachment from automatic picking behavior.

Session 10: Mindfulness and Urge Surfing

Therapeutic Objectives

 Introduce mindfulness as a tool for increasing awareness without judgment.

 Teach urge surfing as a strategy to respond to urges without acting on them.
 Strengthen the client’s ability to observe thoughts, feelings, and urges without reacting.
 Reinforce that urges are temporary and manageable.

Rationale

Skin-picking often happens either automatically (without awareness) or in response to

emotional discomfort. Mindfulness teaches clients to pause, observe, and choose, rather than
react impulsively. Urge surfing builds confidence that intense sensations and urges will pass if
not acted upon — reducing compulsive behavior.

Session Structure

1. Check-in & Homework Review (5–7 mins)

o Discuss emotional exposure attempts and what helped.
o Reflect:
 “What was hardest about sitting with discomfort?”
 “Were there moments where the urge passed without picking?”
2. Introduce Mindfulness (8–10 mins)
o Define: “Mindfulness means paying attention on purpose, in the present moment,
without judgment.”
o Explain benefits:
 Detecting early signs of urges
 Increasing choice in behavior
 Reducing shame and reactivity
o Emphasize: Not a relaxation method, but a skill of awareness.
3. Guided Mindfulness Practice (8–10 mins)
o Lead a short exercise (2–5 minutes) such as:
 Mindful breathing
 Body scan
 Observing thoughts like clouds passing in the sky

o Reflect together: “What did you notice?”
4. Teach Urge Surfing (10–12 mins)
o Describe the concept: “Imagine your urge is a wave — it rises, peaks, and falls.”
o Steps:

1. Notice the urge (label it).

2. Breathe and observe body sensations.
3. Stay with it, using breath as a surfboard.
4. Let the wave pass without reacting.
o Normalize that the wave may return — that’s okay.
5. Practice Mini Urge Surfing (3–5 mins)
o Invite client to recall a recent urge and “replay” it in their mind while urge
surfing.
o Coach through observing and breathing.
o Ask: “What did you notice about the wave?”
6. Assign Homework (3–5 mins)
o Practice mindfulness for 5 minutes daily using the Mindfulness Practice Log.
o Use Urge Surfing Log during actual picking urges.
o Continue emotional exposure and stimulus control.

Therapist Reminders

 Praise effort even if urges led to picking — the goal is building awareness and curiosity,
not perfection.
 Emphasize repetition over mastery — mindfulness is a practice, not a quick fix.
 Reframe “failure” as part of the learning curve.

Materials Needed

 Mindfulness Instructions Handout

 Urge Surfing Diagram
 Mindfulness Practice Log
 Urge Surfing Log
 Optional: Audio link or app recommendations for mindfulness exercises

Session 10: Worksheets & Handouts

1. Mindfulness Instructions Handout
  Choose a 5-minute practice:
o Mindful Breathing: Focus on breath entering and leaving.
o Body Scan: Bring attention to each part of the body.
o Thought Watching: Imagine thoughts as clouds or leaves on a stream.
 Tips:
o Don’t try to “clear your mind.”
o Gently bring attention back when it wanders.
o No right or wrong experience — just noticing.

2. Urge Surfing Diagram

markdown
CopyEdit
URGE SURFING
🌊
/ \
/ \
Peak — Craving — Action Point
\ /
\ /
Calm

Key Message: “Ride the wave without falling into it.”

3. Urge Surfing Log

Date Trigger Urge Level (0–10) Strategy Used Did Urge Pass? Did I Pick? Reflections

4. Mindfulness Practice Log

Date Type of Practice Duration What I Noticed

5. Homework Checklist – Session 10

 Practice daily mindfulness (5 minutes) and note reflections.

 Use Urge Surfing Log during real-life urges.
 Continue using stimulus control and exposure strategies.
 Bring logs and insights to Session 11.
Would you like to proceed with Session 11: Self-Compassion and Relapse Preparation?

4o

You said:

yes
ChatGPT said:

Perfect — here’s the full content for Session 11: Self-Compassion and Relapse Preparation,
which helps the client foster kindness toward themselves and prepare for long-term recovery.

Session 11: Self-Compassion and Relapse Preparation

Therapeutic Objectives

 Introduce the concept of self-compassion and its role in recovery.

 Reduce shame and harsh self-criticism after lapses.
 Reframe setbacks as learning opportunities.
 Begin planning for possible future relapses and how to respond skillfully.

Rationale

Clients with excoriation disorder often experience intense shame and self-blame after picking
episodes, which can trigger more picking. Cultivating self-compassion interrupts this cycle,
allowing the client to approach lapses with understanding and recommit to recovery. Relapse
prevention planning builds confidence and reduces fear of future setbacks.

Session Structure

1. Check-in & Homework Review (5–7 mins)

o Discuss mindfulness and urge surfing logs.
o Reflect on what was difficult or surprising.
o Praise any effort to stay present and observe without reacting.
2. Introduce Self-Compassion (10–12 mins)
o Define: Treating yourself with the same kindness you would offer a struggling
friend.
o Explain components:
1. Self-kindness: Being gentle with yourself.
 2. Common humanity: Recognizing that struggle is part of being human.
3. Mindfulness: Noticing pain without exaggeration or avoidance.
o Discuss why self-criticism increases distress and picking urges.
3. Guided Self-Compassion Exercise (8–10 mins)
o Example prompt: “Think of a recent lapse or difficult moment. What would you
say to a friend in the same situation? Can you offer yourself those words now?”
o Encourage a compassionate letter or journaling if the client is open.
4. Discuss Relapse vs. Lapse (5–7 mins)
o Lapse = brief return to old behavior
o Relapse = falling back into patterns without interruption
o Normalize both: “Recovery is a process, not perfection.”
o Emphasize the importance of response after a lapse — that’s the real skill.
5. Begin Relapse Preparation Plan (8–10 mins)
o Identify high-risk situations or triggers.
o Develop responses to early warning signs:

 “What will I do if I catch myself picking again?”

 “How can I interrupt a slip before it grows?”
o Include self-compassion and supports in the plan.
6. Assign Homework (3–5 mins)
o Write a Self-Compassion Letter to yourself about your journey.
o Complete the Relapse Preparation Worksheet.
o Continue mindfulness and urge surfing.

Therapist Reminders

 Be gentle and encouraging; validate any fear or shame.

 Reinforce: Setbacks don’t undo progress.
 Model self-compassion in your tone and language.

Materials Needed

 Self-Compassion Handout
 Self-Compassion Letter Prompt
 Relapse Preparation Worksheet
 Homework Instruction Sheet

Session 11: Worksheets & Handouts

1. Self-Compassion Handout

 Remind yourself:
o “It’s okay to struggle. That doesn’t mean I’m weak.”
o “I can respond to this moment with kindness.”
o “I’m learning, not failing.”
 Tips:
o Replace “What’s wrong with me?” with “What do I need right now?”
o Practice compassion daily — especially when things go wrong.

2. Self-Compassion Letter Prompt

Instructions:

 Write a letter to yourself as if you were a kind, wise friend.

 Include:
o What you’ve gone through
o What you’re proud of
o How you want to respond to yourself going forward
 Keep the tone warm and encouraging.

3. Relapse Preparation Worksheet

Risk Support Self-Compassion

Early Sign Helpful Response
Factor System Reminder
Stress at Feeling “I’m doing my best — this
Use grounding + delay Text a friend
work overwhelmed is hard.”
Prioritize rest, use urge Talk to “This is a setback, not the
Poor sleep Urge increase
surfing therapist end.”

4. Homework Checklist – Session 11

 Write and bring a Self-Compassion Letter.

 Complete the Relapse Preparation Worksheet.
 Continue mindfulness and urge surfing practices.
 Reflect on how your relationship with yourself is changing.

Would you like to continue to the final Session 12: Relapse Prevention and Future Resilience?
4o

You said:

yes
ChatGPT said:

Here is the final session content for Session 12: Relapse Prevention and Future Resilience,
which focuses on creating long-term maintenance strategies and reinforcing the client’s ability to
stay resilient in their recovery.

Session 12: Relapse Prevention and Future Resilience

Therapeutic Objectives

 Solidify relapse prevention strategies.

 Strengthen the client’s sense of resilience and empowerment.
 Discuss how to maintain progress long-term.
 Ensure the client has tools for managing challenges that may arise in the future.

Rationale

Relapse prevention planning and building resilience are critical components of long-term
recovery. Even after completing therapy, clients need to feel empowered to manage triggers and
maintain progress. The goal of this session is to ensure the client feels equipped to face future
challenges without reverting to old behaviors.

Session Structure

1. Check-in & Homework Review (5–7 mins)

o Review the Self-Compassion Letter and Relapse Preparation Worksheet.
o Reflect:
 “What did you learn about yourself through these exercises?”
 “What steps do you feel most confident in?”
2. Review of Key Learnings (10–12 mins)
o Recap core concepts of the therapy:
 Skin-picking cycle and triggers
 Cognitive restructuring and emotional tolerance
 Mindfulness and urge surfing
  Self-compassion and relapse prevention
o Reinforce that progress is a journey, not a destination.
3. Strengthening Future Resilience (10–12 mins)
o Discuss how to stay connected to support systems (friends, family, or therapist).
o Create a plan for maintaining self-care routines (sleep, exercise, stress
management).
o Revisit the Relapse Preparation Plan — how will they continue to adapt it?
o Ask: “What will you do when life throws new challenges your way?”
4. Building a Long-Term Maintenance Strategy (8–10 mins)
o Plan a check-in strategy (e.g., weekly self-reflection, monthly therapy check-ins if
needed).
o Discuss self-monitoring: using logs or reflections periodically.
o Introduce the concept of recovery milestones: celebrate small victories and
recognize when things are getting easier.
5. Final Reflection & Closure (3–5 mins)
o Reflect on progress: “What are you most proud of in your journey?”
o Encourage confidence in continued growth: “You have developed a toolbox of
skills that you can use at any time.”
o Celebrate the work done together and acknowledge the client’s dedication.
6. Assign Final Homework (3–5 mins)
o Continue practicing the mindfulness and urge surfing tools regularly.
o Check-in log: A final reflection on their progress over the past 12 weeks.
o Continue using the Relapse Prevention Plan and keep it updated as needed.

Therapist Reminders

 Emphasize that the client has the skills to continue making progress.
 Celebrate their growth throughout the process.
 Validate any feelings of uncertainty about the future, but reassure the client that they are
equipped with lifelong tools for self-management.

Materials Needed

 Relapse Prevention Plan Template

 Final Reflection Log
 Maintenance Strategy Handout
 Homework Instructions Sheet

Session 12: Worksheets & Handouts

1. Relapse Prevention Plan Template

Trigger Response Plan Alternative Behavior Support Person/Resource

Use mindfulness and Go for a walk or do a
Stress Therapist or close friend
breathing grounding exercise
Rest or relax before engaging Read a book or do a calming Support group or family
Fatigue
in behavior activity member

2. Final Reflection Log

Date Key Achievement Key Learning Challenge Faced How I Responded

3. Maintenance Strategy Handout

 Weekly Review: Every week, take a few minutes to reflect on:

o What went well?
o What was challenging?
o Did I use my coping strategies effectively?
 Monthly Milestones: Celebrate successes each month. For example:
o 1 month without significant picking
o Successfully using urge surfing during a stressful event

4. Homework Checklist – Session 12

 Complete the Final Reflection Log.

 Reflect on the Relapse Prevention Plan and update if needed.
 Continue to check in with your self-care and support systems.
 Continue using mindfulness and urge surfing regularly.

Final Thoughts

 Remind the client that recovery is a lifelong journey, and that they are now better
equipped to handle future challenges.
 Encourage the client to reach out for support if needed, and reassure them that progress is
ongoing, not linear.