The British Skin Foundation sat down with Clinical Psychologist Dr Eleanor Chatburn to gain some insight in to the link between skin and mental health, what it means to be a Clinical Psychologist and what you might be able to expect from an appointment. 

Dr Eleanor Chatburn, Clinical Psychologist 

What does a clinical psychologist do, how do you become one, what does it allow you to do?

A clinical psychologist is a highly trained mental health professional who is registered with the Health and Care Professions Council (HCPC). The training route takes at least seven years and includes a three-year professional doctoral degree that combines clinical training, academic study, and completion of a doctoral level research thesis. After qualification, we are required to maintain regular clinical supervision and ongoing continuing professional development, and many of us choose to develop a special area of expertise.

Clinical psychologists are trained in at least two therapeutic modalities (which often includes cognitive behavioural therapy) which means that we can offer a bespoke approach depending on each person’s needs and goals. The foundation of clinical psychology practice is developing an in-depth understanding of a person and their difficulties (drawing on biological, psychological, and social factors) which then informs the design of psychological treatment (a process that is called “psychological formulation”). 

Clinical psychologists work with people of all ages and in a wide range of settings, including mental health and learning disability services, councils, schools, and prisons. In the last decade or so, more clinical psychologists have been employed in physical health settings, both in the community and in hospitals. This area is also sometimes called clinical health psychology, and a number of clinical psychologists now work in dermatology services as part of a multi-disciplinary team of clinicians who support people with impact of living with a chronic skin condition.

What is the difference between psychologist, psychiatrist, therapist etc?

This is a great question! The number of different names used for different people who work within the mental health sector can be really confusing. What a lot of people don’t realise is that anyone can call themselves a “psychologist”, “therapist”, or “coach” as these terms are not regulated. This is very worrying as it can mean that people in a lot of distress who are desperate for help end up paying to see someone who does not have the right professional training or expertise, and is not regulated by a professional body, which is risky and can lead to bad outcomes.

Clinical Psychologist is a protected title, which means that anyone wanting to use this title has to complete a stringent training process and pass accreditation checks with our professional body, the HCPC. Other protected titles for practitioner psychologists include Educational Psychologist, Counselling Psychologist, Forensic Psychologist, and Health Psychologist.

Sometimes people get confused between a clinical psychologist and a psychiatrist. Briefly, a psychiatrist is a GMC-registered medical doctor who has gone on to complete specialist training in psychiatry. They are licensed to prescribe medication, which a clinical psychologist is not able to do. Some psychiatrists are also trained in psychotherapy, although this is less common in the UK than it is in the USA.

What is “Psychodermatology”?

Psychodermatology is a rapidly growing area of practice that brings together the disciplines of psychology, psychiatry, and dermatology to assess and treat the mind and the skin together. It is based on the latest scientific research which shows how our physical bodies (including our skin health), our mental health, and wider wellbeing are all intrinsically linked.

Is there a link between skin and mental health?

The scientific research evidence is absolutely clear on this: skin disease can have a devastating effect on a person’s psychological wellbeing.

Self-management of a skin condition (remembering to take medication, apply topical treatments, extensive cleansing routines, avoiding triggers, etc) is also very burdensome, and can be an additional stress. Sleep can be impacted, and some people have to live with a lot of pain or discomfort. Many people also find that their skin condition adversely impact their personal, sexual, and work relationships, and social isolation is sadly common. People also tend to reduce activities that they previously found enjoyable and may drop out of sports, and others may have to completely change their diet.

It is perhaps no wonder then that research studies have found that people with skin conditions have a poorer quality of life and a higher risk of developing mental health problems including depression,  suicidal ideation, low self-esteem, and anxiety, as well as body image problems.

These are serious issues and this is why it why government reports and best practice guidelines for dermatology now call for the provision of specialist psychological support for people with skin conditions (All Party Parliamentary Group on Skin. 2013).

Is the link between skin and mental health only one way?

Many dermatology patients will recognise the impact of their skin condition on their emotional state, mental health and overall wellbeing, but fewer people realise is that the link between our skin and our mental health is actually bi-directional. The latest scientific research indicates that there may be “brain-skin axis” through which stress (both psychological and environment) is translated from the brain to the skin, and back again. The impact of stress on skin health can be seen most clearly in inflammatory skin conditions that tend to “flare” such as psoriasis, rosacea, and eczema. This bi-directional link also explains the stress-flare-stress-flare cycle, which can hard to break out of without the right support.

What emotional impact can skin conditions have on people?

The emotional impact of living with a chronic skin condition can be considerable. Common themes that I hear include feeling upset, sad, stressed, anxious, frustrated, angry, hopeless, and lonely. For people who are unable to access proper medical treatment or whose skin condition is poorly managed, this distress can be more acute.

What can make the emotional burden of skin conditions so much worse is that skin conditions are often highly stigmatised. People can sometimes respond in thoughtless or unhelpful ways. Others may perhaps react with fear because they think that the skin condition is “contagious”. Or they may even minimise the condition by saying, “it’s just cosmetic” or “you are being too sensitive”.

What this means is that many people keep their distress about their skin condition to themselves, which can increase their distress, their social isolation, and feeling of not being understood by others. They may come to believe that there must be something “wrong”, “bad, “dirty”, or “flawed” about them, and essentially that they are “not acceptable” as a person. Negative thoughts and beliefs of this nature are likely to further trigger powerful feelings of shame and embarrassment, which can trap people in a downward spiral that put them at risk of developing mental health problems.

What is the evidence base for psychological therapy for people with skin conditions?

A scientific systematic literature review confirmed that psychological interventions are beneficial to people with skin conditions (Lavda, Webb, and Thompson 2012). One of the most effective forms of therapy is Cognitive Behavioural Therapy (CBT). We know that CBT works well for a range of mental health and body image problems as well as some physical health conditions which include skin disease and also having a visible difference. The core idea of CBT is that when we are distressed, we can fall into patterns of thinking and responding which may seem like they help in the moment, but in the longer term can actually keep the problem going. CBT works by helping people to notice when they are falling into these traps and to find ways of responding that support them to feel better in the longer term.

There is also emerging evidence for the benefit of other therapeutic approaches which include mindfulness-based therapy, acceptance and commitment therapy (ACT), and compassion-based interventions. For people with body-focussed repetitive behaviours (BFRBs) such as skin picking, nail biting or hair pulling – which can be common in people who either currently have or used to have a skin condition – a form of CBT that includes habit reversal therapy is also recommended. 

What are the common reasons why someone who is struggling with their mental health due to a skin condition comes to see you?

What I find so rewarding about working within a dermatology setting is the diversity of the problems that people come to me with. Common reasons for visiting a psychologist include: low self-esteem, low mood, stress, worry and anxiety problems, body image problems, and relationship difficulties.

I also help people with body-focussed repetitive behaviours such as skin-picking or hair-pulling. Whilst these behaviours are just ‘bad habits’ for many of us, for some people the impact and nature of these compulsive behaviours is so severe that it turns into a habit disorder (excoriation disorder or trichotillomania), which does require treatment from a mental health professional.

Is there a relationship between how ’severe’ or visible a skin condition is and how distressed people are by it?

Contrary to what some people may assume, research indicates that the visibility or severity of a skin condition is not associated with a person's level of distress about their skin. 

What matters is what the skin condition means to that individual. There are many things can influence how distressed someone is by their skin condition, which may include:

  • Psychological factors
  • Other life stressors
  • Cultural factors
  • What stage they are at on their skin condition journey
  • Current and past medical treatment including experiences of accessing timely help
  • Capacity to self-manage their condition
  • Financial and wider security
  • General health status
  • Support available from family, friends, colleagues, etc.

This is why two people with the same skin condition, and even the same type of skin condition, can have hugely different experiences. One person could be highly distressed and disabled by this condition, and the other person may not.

What this means is that we must never make assumptions about what someone may be going through on the basis of how noticeable their skin condition or facial differences may appear to others.

What can someone whose wellbeing is negatively impacted by their skin, expect from an appointment with you?

It can be a big step to decide that you would benefit from talking with a therapist about the impact of your skin condition, so if you are thinking about taking this step then well done, you have already made a big step forwards. For the people I see in my psychodermatology clinic, once they have booked in, I will get in touch to send them some psychological screening questionnaires that I will review before I meet them. I often recommend that people note down any key things that they are keen to share with me and any questions they have about the way that I work.

When we meet, we first talk about I can make sure that the appointment is a comfortable, safe space to talk about potentially upsetting things. I will ask what the person hopes to get out of our appointment, and their longer-term goals. Then I will do a detailed assessment, asking about different areas of the person’s life and their previous mental health history. As I am a clinical psychologist (and do not tend to diagnose psychiatric disorders), I will work with the person to develop a shared understanding of how their problem developed and what may be keeping it going (this is called a ‘psychological formulation’). This formulation will then guide the shape of any therapy that I may recommend and I will discuss treatment options with the person, which may include referring to a colleague if I feel that someone else could better meet their needs. I prefer to do a thorough consultation, so this can take one or two sessions, but I always check at the end of our appointment that the person feels that they are leaving with some clear options about the next steps.

How many sessions of therapy do people tend to need for their mental health to improve?

It can take a few sessions to notice some changes, so I always advise people to give the process some time and to not expect changes overnight. Depending on the nature of the therapy, some people may initially feel worse before they get better. This is because therapy involves confronting some difficult thoughts and emotions that as humans we often become very good at avoiding.

 That being said, I do try when I work with people to think together about where we can make some ‘early wins’ as this can be a tremendous boost for someone’s confidence and can motivate them to keep going with the rest of the treatment.

Do you have any advice for people whose skin is affecting their mental wellbeing?

I am going to quote an anonymous person with rosacea who recently responded to one of my Instagram posts where I was talking about the emotional and psychological burden of living with a skin condition. They said:

“If I had read something like this a little bit earlier, maybe I wouldn’t have felt like there was something wrong with me and I would have understood that it really is okay to get help.”

So this is my key message for anyone reading this who is distressed about their skin condition: that there is nothing wrong with you. Your feelings about you skin are valid, and you are not alone in feeling this way. And there is no shame in seeking some additional support for your wellbeing and mental health to help you live your live to the fullest.

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