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Habit Reversal Tip #14. Scratching and atopic eczema: quantity v. quality
For adults and older children following the clinic-based protocol for The Combined Approach to atopic eczema there are particular points to consider at the 3rd visit. This is the same using the self-help version: see Chapter Six of "The Eczema Solution".
An example from a patient handbook log is shown above. Thus, after two weeks of following The Combined Approach, habit reversal can have had a major impact on scratching frequency: the continuing use of the hand tally counter is a measure of this progress. When an episode of scratching - we call it "a scratching" - is successfully replaced by habit reversal there is nothing then to register: daily scratching episode frequencies therefore gradually reduce as habit reversal is practised. By the third visit episode frequencies reported are often at least 50% of the initial base-line frequency, and sometimes down to 10%. Many report at the same time the % of scratching due to itch goes up - for example, from a initial 20% to 80% - but this varies considerably.
The third visit is a time to make sure all is "on track" - habit reversal can now be be given a special focus on those times and situations when most scratching is still occurring, to ensure the final stage of using habit reversal is completely successful.
It may be important to reconsider the use of the hand tally counter. It only measures the frequency of scratching, not its quality. The length of a scratching episode, and the energy put into the scratching, are not accounted for by registration.
When using habit reversal, as any scratching continues to occur (some always will, to begin with), the behaviour is counted as an episode of scratching and registered on the counter. This means conscious awareness is reinforced, both that scratching is happening, and when it is happening. But success can still be partially re-couped, if rather than continuing to scratch after clicking, immediately the behaviour is switched to the preferred safe behaviour - that is, habit reversal is implemented as soon as it is realised what is happening.
All contact with the skin "counts" as scratching for registration, including touching. As habit reversal is practised over two weeks, there can be gradually more touching and less rubbing, and less use of the nails, for example - the skin is therefore less damaged as a consequence, yet the frequency shown on the counter does not show this change in quality of the potentally damaging contact with the skin.
When assessing progress therefore it is important to consider also the quality, as well as the quantity, of the behaviour being counted as scratching. If the numbers are reducing at only a modest rate, it is often true that the skin is still being much less damaged after two or three weeks of habit reversal, as what is being counted is not going on for as long as before, and is also much less violent.
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