courage that lets us feel more of our pain allows us to feel more of the joy of life.
Increasing our ability to feel more of the pleasure, warmth, and fullness of life is as
much a goal as reducing the pain.
Sometimes, insight and change occur dramatically. A man may be screaming
furiously at his wife – a repeated scenario of their marriage – when she tells him:
"Right now, you sound exactly like your father. I can imagine how you used to feel
when he screamed at you." Struck by her perception, he doesn't simply see the
resemblance, he feels it; he remembers yesterday's pain in today's outburst. He can
still scream at his wife but never again with the same tormented fury. Knowing
where feelings come from robs them of despotic power and puts you in a position to
change how you act as well as feel.
Such sudden flashes of insight are the exception and usually come only after a
period of behind-the-scenes preparation. This man had been preoccupied with the
problems posed by his anger for some time and was ready to see the truth when it
was presented to him. He had found the courage to once again be the little boy
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terrified by his father's temper, and this relieved him of the need to repeatedly
"rewrite history" by taking the role of his angry father. He can now begin the
adventure of really knowing his wife, unshackled from history.
A similar process may help you free yourself from the grip of your symptom.
Recognizing how the emotional task of "seeking love and affection" is involved in
your allergies, for example, may foster a quest to understand its roots in a childhood
that didn't provide the love you needed. From insight comes the courage to
experience directly those childhood emotions that express themselves in adult
problems.
It's not a matter of rewriting your history – no one can do that – but of changing
your relationship to it, allowing it to fall back into the past. Dr. Alfred Adler, a great
pioneer of psychiatry, called the process of psychotherapy "spitting in the soup of
neurosis: you can still drink it, but it never tastes the same." Once you've experienced
the painful emotions that generate today's rash, uncontrollable temper, or series of
doomed relationships, you can continue to live the same way but you no longer have
to. Your past has lost its old power over you.
Change is part of life, and we often achieve liberating insight spontaneously as
we grow and mature. Supportive friends who care about you can be helpful, but a
professional psychotherapist is trained to help you get there. To know that you're not
alone in your struggle – that someone understands and appreciates what you're
going through – lightens any burden. A good therapist will be a constant reminder
that there's nothing weird, exaggerated, or unnecessary about your reaction to your
symptom: you're dealing with old as well as new problems. When you're working
with a therapist, you needn't worry about being self-absorbed or a burden, which is
natural when your troubles dominate conversations with friends. In fact, many say
that therapy improves friendships by taking some of the heat off them.
A therapist can be supportive in a special way. Change requires giving up safe,
tested ways of living and trying to do things differently while somewhere within you
remains the fear of the child you were: if you get angry, retribution will follow; if you
feel your sexuality, everyone around you will be appalled and accusatory. In therapy,
you have a safe testing ground where you can try out your emerging self with a
trustworthy support at your side and see for yourself that nothing unthinkable
actually happens. It is common for a patient to express anger at a therapist; this
doesn't mean therapy has failed but that it is working. It is providing a precious
opportunity to test the experience of anger – to feel it, to gain insight into where it
comes from, to see that no dreadful retribution follows.
But does psychotherapy actually work for skin problems? This is not a simple
question, and research in the field in inconsistent. Some psychotherapists consider
skin patients poor candidates for therapy, but case histories and controlled
experiments have documented substantial benefits for many people. Perhaps the
only reasonable answer is: sometimes, for some people. Just like medicine. Let's look
at some of the research results to help you gauge if it may help you.
At the University Medical Center in Indianapolis, for example, twenty-five
patients with various skin irritations, including dermatitis and neurotic excoriation,
were given short-term psychotherapy in twelve weekly sessions. Therapy is usually
tailored to the individual patient, but this focused on issues the doctors expected to
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be most relevant: unexpressed rage and unexpressed wishes for love. During the
twelve sessions, doctors encouraged patients to put their anger into words without
guilt; to see links between their early lives and their current relationships; and to
deal more directly with their feelings.
The results were striking. As angry feelings came to the surface, patients felt
understandably more upset – and their skin often got briefly worse. Then, as they
learned to express these angry feelings directly, their skin began to improve. Among
the thirteen patients who stuck with the therapy program all the way through, twelve
enjoyed substantial gains in their skin problem, gains that remained long after the
experiment was over.
In this sense, the experiment was a success. On the other hand, the dropout rate
was extremely high: nearly half the patients didn't make it through the program.lxii
This underscores an essential point: to be effective, therapy must be tailored to the
individual. The short-term, intense, and demanding therapy used here simply wasn't
right for half the participants. They were right in leaving. They might have done
better with a slower, less intensive type of therapy. It could be, too, that they weren't
ready for therapy at that time; they were not yet able to look at their anger and their
needs directly enough to make changes.
That therapy works only for those who need and are ready for it was implied by
another study, this one from England. Here, one group of eczema patients was given
the standard dermatological treatment; another group received dermatology plus up
to four months of psychotherapy. This therapy was more individualized. It aimed to
help patients deal with conflicts and frustrations and make them more aware of their
hostility and other disturbing emotions.
Results were not dramatically impressive overall. The psychotherapy group
experienced only slightly greater skin improvements than the control group, but a
look at individual participants was far more encouraging. Those people who had
psychological or physical symptoms before their eczema developed – who apparently
had some prior emotional problems – got better twice as fast as controls, and they
were the ones who hadn't improved at all with earlier dermatological treatment
alone.lxiii
This study suggests a simple conclusion: If there is an emotional dimension to
your skin problem, psychotherapy is essential; if not, it will have little impact.
However, don't overlook the fact that any skin problem, even if its origins are more
physical, will cause its own emotional turmoil, and many sufferers will gain
substantially from the support of a knowledgeable, sympathetic therapist, though
they will most likely feel the gains in their hearts, not their skins.
The support function of therapy was clear in a study at the University of
Pennsylvania, in which ten patients with severe, recurrent oral herpes – cold sores –
were given a series of psychoanalytically oriented therapy sessions. For all these
patients, physical treatments of all sorts had proved ineffective, and it had been
established that specific emotional events could trigger outbreaks.
Improvement in the severity of the symptom and in the patients' state of mind
was noted as early as the second session. Clearly, no major personality change or
profound insight had taken place. What was involved here was probably just the
presence of a caring, concerned, reassuring individual. Several patients, in fact,
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suffered recurrences when the therapist was unexpectedly absent.lxiv
The importance of the relationship with the therapist reflects the fact that
relationships are central in many skin problems. I think of them as diseases of two or
more people, although only one has the symptoms. Often the disorder involves
mother and child first and is later duplicated in marriage.
Many skin problems improve with therapy or counseling that focuses on
relationships rather than individuals. In one clinical study, a group of fifty-three
children with chronic eczema received medical care plus mother-and-child
counseling in which a psychologist explained how the child's emotional needs could
best be met. A control group received medical care alone. The children who had
counseling did significantly better than those who did not.lxv
Whether you've been getting good or not-so-good results with this book, you
might want to consider working with a psychotherapist. Many people find the
process of insight and change goes more quickly with the aid of a trained
professional. Even if you're ready to do the work yourself, a therapist can help you as
a coach helps an athlete, with encouragement and advice on your technique and
timing.
Don't be deterred by the mistaken notion that therapy is only for weak
individuals who can't make it through life on their own. Virtually anyone can, at some
point, gain from the professional help a good therapist can offer. Don't let the
profusion of therapies that have developed in recent decades overwhelm you with
the tasks of choosing the one that's just right for you. Studies have found that
experienced therapists, whatever their original training, actually do pretty much the
same things in therapy. If you feel ready for this kind of assistance, you'll find
practical suggestions of getting it in Appendix II.
lxii
P.F.D. Seitz, "Dynamically Oriented Brief Psychotherapy: Psychocutaneous Excoriation Syndromes,"
Psychosomatic Medicine 15(1953):200-242.
lxiii
Brown and Bettley, "Psychiatric Treatment of Eczema."
lxiv
H. Blank and M.W. Brody, "Recurrent Herpes Simplex," Psychosomatic Medicine 12 (1950):254-260.
lxv
D.H. Williams, "Management of Atopic Dermatitis in Children: Control of the Maternal Rejection
Factor," Archives of Dermatology 63 (1951):545-560.
13. Breaking The Itch-Scratch Cycle
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13 Breaking the Itch-Scratch Cycle
ONE YOUNG WOMAN'S STORY
Until recently, I'd never heard the word "excoriation," but now I know it was my
primary symptom: "scratching so severe as to tear the flesh." That's what I did every
night, clawing until blood flowed. I was shocked to read that neurotic excoriation is
caused by emotional difficulties 98 percent of the time. I was taken to doctor after
doctor from 1957 to 1971, but this was never mentioned; no one acknowledged that I
had emotional problems. Perhaps my parents thought the problems would go away if
they pretended they weren't there. Maybe they were ashamed to admit their daughter
might have such problems.
Nighttime was the hardest time. Without the day's distractions, it was just me and
my itching, me and my skin. Kids with severe eczema have an early self-awareness that
comes from confronting themselves in the dark every night. The nightmare is your own
body; the monster is you. This is emotionally devastating to a child because it breeds
self-hatred; when you feel so bad, you think you must be very bad – what did you do that
you're being punished for? Parents' reassurances are dwarfed by the power of the itch,
like an evil spirit. It was basically a solitary struggle.
At age eight I was fascinated by Houdini because he had been able to escape any
physical confinement handcuffs, straitjackets, chains. I myself was put into straitjackets,
handcuffs, chains, and gloves to keep me from ripping my skin to shreds every night. I
would spend my nights figuring ways out of confinement; I'd wriggle my skinned and
bleeding wrists out of the cuffs and tear at my flesh with a sense of triumph.
Eventually, I learned to stop myself from scratching by concentration: I tucked my
hands under my butt and pretended they were paralyzed. But whether I struggled to
free myself to scratch or to stop myself from scratching, I would only strive for a harsh
physical control over my body. For three years, I was a wild animal with myself as prey.
I was a secretive child, always ashamed of my skin. Trying to hide, to pretend I was
normal, to fool everyone by remaining mysterious, I lived in a fantasy world. I hated to
explain my allergies: I told all sorts of lies, believing no one would go near me if they
knew the truth. I became cynical at a very young age, hardening myself after so many
disappointments: the doctors promising miracle cures, my parents promising miracles
from God.
Looking back, I can see the sexual side of my eczema. I was able to touch and play
with my body more openly than most children; strangers were always peering at and
touching my naked body. I needed to have oils and lotions rubbed all over me, a task I
particularly enjoyed when performed by my father. He gave me a good workout with his
big, muscular hands.
Scratching was like ecstasy to me: digging my nails in and running them up and
down my body was orgasmic; I moaned and grunted as I scratched and clawed myself.
I can remember the advantages. Everyone gave me and my skin attention; it made
me important, although in a negative way. I got sympathy and affection that other kids
didn't get. It was a way to miss school, sleep late, be lazy and spoiled, feel special and
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unique, spend time alone and in fantasy, avoid social confrontations.
My situation was painful, but it was safe and familiar, keeping me dependent and
afraid of risks. I always had an excuse to avoid an unwanted task – I was the exception
to every rule.
Before age eleven, I believed a fierce vigilance the only defense against the all-
powerful itch. The only relaxation I remember from those years was exhausted collapse
after scratching myself into a frenzy, but then I learned to relax consciously.
This came about through my attempts to overcome my insomnia. Left to
themselves, my hands would scratch automatically, and it was scratching that kept me
awake. To keep my hands otherwise occupied, I held them up in front of me and touched
the fingertips together one by one, watching them slowly move and lightly touch, thumb
to thumb, forefinger to forefinger, down the row and back again. In this way, I
hypnotized myself to sleep.
After a while, I realized that this not only helped me sleep, it lessened my desire to
scratch. I wasn't forcing myself not to scratch; I just didn't need to. I was overjoyed with
this new feeling: for once, I would let go of my vigilance and still feel safe. I then
observed that my slow, deep breathing during this little exercise was in itself enough to
relax me; soon, whenever I sensed a wave of fitful scratching approach, I'd close my eyes
and breathe deeply to break the chain reaction.
I learned to defuse triggering situations. For example, if I exercised or got nervous
to the point of sweating, I'd start scratching wildly. I believed I was allergic to my own
sweat, and I convinced the doctors that I should be excused from gym class for this
reason.
Then I developed an alternative. When I started to sweat, I'd relax by deep
breathing and tell myself: "You don't feel any itch. Your skin is fine. Sweating is okay.
You don't have to scratch when you sweat. Just relax, sit quietly until you stop sweating,
and you'll be fine." With my relaxing and soothing self-talk, not only didn't I itch, but the
redness, welts, and hives that often accompanied sweating no longer appeared.
I learned to ignore the itch and my ravaged skin, leaving it to heal in peace. After
years of ripping scabs off partially healed gashes and clawing them open to bleed and
deepen, I finally learned to enjoy watching wounds heal.
I became able to limit my scratching to circumscribed areas. I'd allow myself to
scratch my for example, as long as I left the rest of my body alone. Then I gradually
reduced the permissible area until there was no place left to scratch, or I'd first let
myself scratch my arms, narrow that down to the hands, then to one finger. For some
time, I had my scratching narrowed down to my lower legs, which I continued to use as
a battleground. Since last year, however, I've been totally free of rashes, wounds, and
itching. I've let the hair grow on my legs to seal that "tomb" forever.
Before, my hands had been the enemy, inflicting rape and torture on my innocent
body. I hated them. Once I learned to relax, I made peace with my hands, treating them
with the same tenderness and respect I wanted them to show my body. I learned to use
them for healing. Saying, "What do you really want, skin?" I'd stroke the damaged, itchy
areas, kissing them and rocking as I hugged myself.
I learned to communicate with myself, talking out loud. At first, I told myself
stories to distract myself from scratching. Then I learned how to tell myself what I
needed to hear. I would pretend I was my mother telling me that she loved me; then I'd
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speak in my own voice, saying how afraid I was that I'd never get better. And on and on,
taking turns with voices until I'd said all I needed to say and hear. As I hugged and
stroked myself, I'd cry and assure myself, "Don't worry, I'll take care of you," creating
my own support system for changing my life.
I began to tell myself – and believe – that I was doing my best at every moment: if I
couldn't control myself this time, I'd do better next time. "Can I stop scratching now?"
I'd say. "If I can, that would be good. If not, that's okay too – I'll give myself five more
minutes to scratch and then stop, but next time I won't have to scratch at all." I gave
myself high praise when I didn't scratch. The praise, I knew, had to come from myself
since I no longer believed anyone else. I congratulated myself for keeping clear what
areas of skin I could.
When I decided that I, not my parents or my doctors, was my own savior, I stopped
worrying about other people's infuriating questions, their warnings about scars, and
their promises of miracles. I stopped worrying about looking ugly or causing a public
scene by scratching when I needed to scratch. No longer ashamed of my uninhibited self,
I started answering questions frankly and addressing people's fears of contagion
matter-of-factly.
I saw that I had a right to handle my disease in my own way, whether or not it was
offensive to others. I claimed my right to be treated with respect, not like a leper or an
uncontrollable child. I developed the confidence to go out in public, whether or not my
skin was beautiful. I finally realized that no one was scrutinizing every pore of my skin –
and that even if they were, it was none of their business and I was not obligated to look
good for them.
I learned not to fear my emotions, gradually understanding how to deal with them
calmly instead of falling, in an overwhelmed panic, into a chain reaction of scratching.
Listening to my deepest instincts, developing a relationship with myself based on love,
respect, and communication, I experienced a rebirth.
My strongest memories are of crying myself to sleep every night. My mother would
come in and rock me and reassure me that she loved me and that maybe tomorrow
there would be a miracle and I would be all better. I prayed for that miracle and waited
for that miracle for a long time. Then I just stopped believing in God.
This young woman's description of the itching that twisted and constricted her
childhood sounds extreme, but anyone who has been caught in the itch-scratch cycle
will recognize her torment.
It can have many causes. This woman's diagnosis was atopic dermatitis –
eczema. Some medical illnesses produce itching: diabetes, liver disease, kidney
problems, or reactions to medications. So do simple insect bites. Itching can
accompany eruptions of eczema, psoriasis, and hives or torment skin that looks
perfectly healthy.lxvi
Is your itch medical or psychological? You and your doctors could pursue this
fruitless question for years and you'll be itching all the while. So get