Life Hacks: Skin Picking

Excoriation Disorder refers to an obsessive-compulsive type disorder that involves picking at the skin, often until it bleeds. It can be damaging to the skin and embarrassing for those who struggle with the behavior. Evidence-based treatments for the disorder include Cognitive Behavioral Therapy, Habit Reversal Therapy, and antidepressant medication.

Photo by Chermiti Mohamed on Pexels.com

Whether someone meets the criteria and is diagnosed with Excoriation Disorder or they pick at their skin for another reason (for example, as a way to cope with other forms of anxiety, hyperactivity, or secondary to Autism), sometimes part of the reason that the behavior is difficult to stop is that the act of picking the skin produces a specific, pleasing sensation.

Have you ever watched a pimple popper video? If you are one of the many people who finds those videos “oddly satisfying,” you might have some understanding of why someone could find skin-picking gratifying.

The reason we want to curb this behavior is that it can be harmful. Skin picking can lead to scars or permanent damage to the skin, and open sores from this behavior can get infected. But for many, the dopamine output they get, that feeling of satisfaction, makes it difficult to stop.

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If you (or your child) is struggling with skin picking, one way to get the gratification that comes with picking without the bodily harm is to take putty (silly putty or thinking putty both work well for this) and mix it with grains of rice. Just a tablespoon or so of rice for a large jar of putty is enough – you can re-use the same rice for this activity several times. The sensation of picking grains of rice out of the putty is very similar to skin picking without the physical harm!

It’s easy to store and carry these items with you, or you can set aside time specifically for this activity. This way, you get the positive sensation in a healthier way!

Uno

Are you even a child therapist if you don’t play Uno at least once a day at your practice? It’s an excellent way to build relationship, it’s fun, there’s a combination of strategy and luck involved, and kids of all ages already know how to play.

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A couple of my clients have struggled to get the links working properly, so I actually have played Uno in telehealth with a physical deck of cards. If you and the client both have Uno, you can each deal your own hand and hold up the card you are playing to the camera. This requires a level of trust with the client, but it can be a lot of fun.

Uno Freak lets you create private games with your clients. When you open the link, you are greeted with a screen that prompts you to create a game:

You can choose what settings work best for you

Typically, I make the room name and password something simple like Amy1 and use the same name and password. You can start with anywhere from 1-50 cards, but if you start with 50 the game can glitch because you might run out of cards in the pile. I recommend “Random Player Order,” as this will make the game alternate who goes first. I never check “Registered Players,” as I don’t want clients to have to create an account, and I always “Hide from Lobby,” as this is an added security layer to keep random people from joining your game (although if you password protect the game, they shouldn’t be able to join without the direct link anyway).

Uno also has some flexibility that other online games don’t have: you can choose to draw rather than play if you want to “go easy” on your client.

Pros of Uno as a telehealth intervention:

  1. I’ve found that kids have been more cooperative and stay engaged in the game even if they are losing, simply because the game automatically draws for them rather than them having to draw cards themselves.
  2. You can choose to add “bots” to your game if the child wants the feeling of a larger group.
  3. The game keeps track of “points” in between several games, which can be added fun.
  4. No shuffling!

Cons:

  1. Again, you can’t change certain rules (like draw once and then pass versus drawing until you can go).
  2. Since you click “Uno” instead of saying it, some kids don’t verbalize they are almost out, which means I sometimes don’t realize they are about to go out.

Uno was one of the first telehealth websites I found because I knew, no matter what my practice looks like, I had to have Uno for my clients.

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I Don’t Want To Be Bad: Kindle Edition

When I first looked into self-publishing I Don’t Want To Be Bad, it was important to me to go the paperback route because I pictured it as something people could hold in their hands, dog-ear, and mark up as they desired. I also wasn’t sure how to best format this type of book for an e-reader.

The more I thought about it, though, the more I realized that this was my vision for my book but not necessarily the only vision of what it could be. It was pointed out to me that, although I made the paperback available in every country that Amazon would let me, many parents looking for this kind of resource can’t or don’t want to wait for shipping. They might also prefer the convenience of having the book on whatever device they carry with them. Not to mention, print books carry the added cost of paper.

So I set aside my idea of what my book ought to be and re-formatted it for Kindle. The price is lowered by approximately what it costs to create a paperback copy, and it can now fit in your pocket with the entire internet. I hope this can make it accessible and reach more people with its message.

Thank you for reading. If you enjoyed I Don’t Want To Be Bad, tell me what other resources you’d like to see and I can try to put them together!

The Case for Primary Care Therapists

Stigma continues to be a serious problem in mental health, and anxiety about what it means to have a therapist can be a huge barrier to someone seeking services. Although we all have different life experiences and many people do not experience mental illness as defined by the DSM-5, every single person alive has an experience that is the worst thing they have ever been through. We need to normalize asking for and receiving help.

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Over the past four years that I have practiced as a clinical psychologist, I have had a number of clients reach their treatment goals and “graduate” from therapy. A number of these have asked, instead of terminating therapy completely, to continue to touch base with me on occasion, ranging from once a month to a couple of times per year. These appointments typically consist of checking in on symptoms, getting updates on any big changes in their life, and seeing what their needs are. Occasionally, I get a call in between these appointments because the client is struggling and needs to come in sooner.

I would argue that everyone ought to have a “primary care therapist” in the same way that we have primary care physicians: you don’t necessarily make regular appointments, but you know who you would call if you experience symptoms, and you check in a few times a year whether you need to or not.

Of course, there is the ongoing issue of accessibility for people who are low-income, uninsured, or living in rural areas. Telehealth helps with accessibility to an extent but does not completely solve the problem. There is also the issue that, in many parts of the United States at least, there are not currently enough licensed mental health professionals to meet the need, which is something that was discussed at the American Psychological Association 2020 convention.

But imagine if the question, “Do you have a therapist?” had the same answer as, “Do you have a primary physician?” It would not be unfamiliar or strange to make an appointment with a therapist because everyone does it!

I understand that this is not something that could be rolled out tomorrow, but I think re-conceptualizing mental health as something that everyone seeks out and actively works on throughout their lifespan would be a huge step toward eliminating stigma.

Bubble Breathing

(Because you can’t feel angry when you say “bubbles”) Photo by Pixabay on Pexels.com

Breathing is probably one of the most basic things we do every day. We breathe constantly and without thinking about it, but when we get upset, our breathing changes. When someone feels scared, angry, or anxious, their breathing tends to get faster and more shallow, and we often don’t even realize this is happening! Fast breathing makes our bodies feel like we are not getting enough air, which causes us to breathe even faster and become more agitated. It’s a vicious cycle.

Just like breathing faster can cause anxiety and other negative feelings to go up, breathing slowly and deliberately can bring these feelings down. This activity helps kids visualize something non-threatening (bubbles) while bringing their attention to taking slow, calming breaths. I practice it in session before printing off a copy to bring home and practice later.

Connect Four

I. LOVE. Connect Four. It’s similar to chess in that you have to plan ahead and focus on two things at once (where I’m moving and where you’re moving), but it’s much less complicated and so can be used with younger clients.

Photo by Pixabay on Pexels.com (There are surprisingly limited options for stock photos of board games)

If you want to play Connect Four with your clients, this website will let you create a private game. It lets you choose a nickname, which has had the fun unintended consequence of a few kids telling me, “Dr. Amy, you shouldn’t use your real name online,” and we ended up talking about internet safety. Although you can leave the name blank, I do recommend putting something in, even if it’s not your real name. If both people leave their name blank, you are both called “Opponent,” which can be confusing.

Another challenge I’ve had with this game is that it generates a link that, for some reason, doesn’t become a hyperlink when you paste it into the Zoom chat box. This is pretty easy to fix by typing https://www. before pasting the link.

So what makes Connect Four a great telehealth intervention?

  1. The game tells you when you’ve won, so if you are like me and sometimes don’t realize someone got four in a row, this isn’t something you have to think about anymore.
  2. The pieces don’t fall when you are in the middle of a game because you didn’t put the slider in just right!
  3. There is a timed feature, so you can work on executive functioning or anxiety about timed tasks without having to impose this limit yourself. If the client does not take their turn, the game goes for them and usually doesn’t pick a very good spot (natural consequences, anyone?).
  4. The game changes who goes first, so it’s not always you or always the client.

There are some drawbacks also:

  1. You can’t turn off the timer, so you have to play with a time limit whether you want to or not.
  2. The game changes which color each person plays as between games, which can be confusing.
  3. As with most of these games, you can’t let the client tweak the rules based on their preferences.

Connect Four online is pretty different from traditional Connect Four as a therapy intervention, but I think this game balances pros and cons. There are things you can work on using the online game that aren’t as feasible in person, but there are also some components of the in-person game that do not translate well to the online game.

A Change for Better: Sustainable, Accessible Mental Health

First of all, thank you to everyone who checked out I Don’t Want To Be Bad. Amazon can’t tell me if I made any sales until they ship, which takes some time when you print on demand, but the outpouring of support has been amazing. I have some other book ideas that I’ve been wanting to pursue, and the feedback has given me so much confidence!

Today I want to share with you all a startup I’m going to be working with. As we know, psychology is undergoing a shift toward telehealth right now. I know there are still some clients who benefit more from in-person sessions, but some great new research I saw presented at APA 2020 showed that telehealth can be equally, if not more, effective than in-person for many populations. It makes the services accessible for those who can’t physically come to your office, which is huge for me in South Dakota, since the state is about 90% farm land.

I met Ashley through a Facebook group for therapists. She told me about a project she’s been working on called A Change for Better, a company that would provide telehealth options for therapists that allows the therapist to set their own rate but also creates support options for low-income or uninsured clients.

If that alone didn’t peak your interest, A Change for Better will also have a ton of other resources for both therapists and clients. The goal is to make mental health sustainable by making sure the providers can pay their bills, but also accessible to the countless people around the world who don’t have access right now. It will also uphold ethical and legal standards for practice.

Ashley is looking for therapists to beta test this project so that it can be the best resource possible. For their help, beta testers will get to use the final platform at a discount.

If you’re looking to start or expand your private practice, or just offer better resources or reach underserved clients, please let me know! Comment on this post or message me through the contact link above, and I’ll put you in touch with Ashley.

Let’s make a change for better!

I Don’t Want To Be Bad

On December 31, 2019, I resolved that 2020 would be the year that I became a published author, and today, it is a reality. I Don’t Want To Be Bad is now available in paperback through Kindle Direct Publishing. Granted, this was not the project I had in mind when I made my resolution, but I don’t think anyone can say that this year has gone according to plan.

I Don’t Want To Be Bad by Dr. Amy Marschall is available on Amazon

Working as a psychologist is both frustrating and rewarding. Nothing makes me happier than to hear that a tool, technique, or suggestion I made has helped someone. At the same time, though, my reach is limited. I practice in Sioux Falls, South Dakota, which is not considered an underserved area, and yet providers in the area are only able to serve 50% of the local mental health needs. It saddens me to think, for everyone who comes into my office, there is at least one other person who needs services but can’t get them.

While I maintain that empathy is a good quality, it’s the reason why so many people in my field burn out. I Don’t Want To Be Bad is my way of reaching more families and more children without expanding my hours.

I Don’t Want To Be Bad is for therapists who want to add techniques for children and families to their toolbox. It’s for counselors who want to teach kids how to feel and express their emotions in ways that don’t get them into trouble.

I Don’t Want To Be Bad is also a tool for parents. Although no book should be used as a substitute for therapy, parents who want to better connect with their children can use this book to build that relationship. Some kids struggle with self-regulation but do not necessarily meet the diagnostic criteria for a mental illness. Those kids can still use support and understanding from their parents, and they can find that in these pages.

If you find my book helpful, please hop on Amazon and give it a review! Also feel free to subscribe and follow my blog for more tips to help kids communicate and make good choices. After all, kids don’t want to be bad!

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Battleship

A popular therapy game is Battleship. It takes focus, it takes planning, it’s a combination of strategy and luck, and it’s a fun way to build rapport. I’ve also used Battleship with kids who are working on memory by keeping my ships in the same place a few games in a row so that they can try and remember where they were.

Photo by Marc Coenen on Pexels.com (There were no free stock photos of the game, but I think this communicates the same message)

I have heard of therapists using the original Battleship board game if both the client and therapist have access to it – similarly to how you would play in person, each person sets up their ships and guesses locations while sitting in front of the camera. This, of course, is dependent on whether your client has their own Battleship game. I’ve also heard of using a template on Excel or just with grid paper to play this way, but that can get confusing and complicated with younger kids.

This website lets you create a private Battleship game with a client. You can choose between two versions: “Classic” and “Russian,” with classic most closely mimicking the board game we all grew up with. As with all games, there are some differences between Battleship for telemental health and Battleship in a traditional session.

The pros of online Battleship, in my experience, include:

  1. Since there are two different versions, your client can choose how many ships they want on the board.
  2. There is a “randomize” option, so you can choose not to spend time placing your ships and spend more time on the game.
  3. If you are working on honesty and playing fair, the online game doesn’t allow the client to “cheat” by peeking at your ships.
  4. Since ships can’t touch each other, “hits” narrow down the remaining options quickly, so the game can go by fast.
  5. You click instead of stating your guesses, which makes for easier flow of conversation if you are talking while you play.
  6. You won’t constantly find those tiny pegs around your office.

The cons are:

  1. Whoever creates the game always goes first – I haven’t found a way to let my client take the first move unless they know how to set up the game. EDIT: I figured it out! It’s not whoever creates the game that goes first – it’s whoever clicks PLAY first. So just have the client tell you when they click PLAY and they can go first.
  2. You can’t place ships touching each other, which some kids like to do.
  3. As with most online games, the rules can’t be changed based on your or your client’s preference.

If you or your client is using wifi that blocks game sites, you can also play Battleship via telehealth using this free Google spreadsheet. It includes detailed play instructions and is super easy to use!

Is Battleship a game you use in your practice? How does it compare online versus in person for you?

Coming Soon: I Don’t Want to be Bad

Blueline copy of my manuscript

I am excited to announce that I’ve decided to self-publish my manuscript! I’ve been compiling worksheets and interventions that I use with kids and parents when the child has behavioral problems.

I Don’t Want to be Bad helps parents understand their role in the child’s behavior and help the child learn to express and cope with strong emotions appropriately.

Coming soon to Amazon, as soon as I finish the final run of line edits this weekend!