Table 2. Rothbaum protocol sessions framework and adaptations for use with skin picking disorder.

	Summary content of Rothbaum protocol	Adaptations	Rothbaum protocol adapted to Skin Picking
1. Information gathering	- Psychoeducation about trichotillomania. - Describing the hair pulling habit. - Identifying trigger situations.- Self-monitoring of hair pulling. - Homework: self-monitoring and collecting pulled hairs.	- Substituting skin picking for trichotillomania as the targeted habit; no technique changes.	- Psychoeducation about Skin Picking Disorder. - Describing the skin touching habit. - Identifying of trigger situations. - Self-monitoring the skin touching habit. - Homework: self-monitoring and collecting scabs.
2. Habit change strategies	- Azrin and Nunn’s habit reversal techniques. - Channels for manifesting anxiety. - Trichotillomania self-monitoring inspection. - Competing response practice. - Listing the drawbacks of trichotillomania. - Homework: self-monitoring using habit-reversal techniques. Collecting pulled hair to show the therapist in the next session.	- Substituting skin picking for trichotillomania as the targeted habit, e.g. applying some product to the skin rather than the hair; simulating the impulse by keeping the hands above the wound rather than the hair. - Wearing rings to avoid skin picking. - Substituting collected scabs for collected hair.	- Azrin and Nunn’s habit reversal techniques targeting skin picking. - Wearing rings to avoid skin picking. - Channels for manifesting anxiety. - Skin picking self-monitoring inspection. - Competing response practice. - Listing the drawbacks of skin picking. - Homework: self-monitoring using habit reversal techniques and checking their efficacy. Collecting scabs to show the therapist in the next session.
3. Coping skills	- Diaphragmatic breathing (session 3). - Progressive muscle relaxation (session 4). - Homework: self-monitoring, reading the list of drawbacks, and coping skills practice.	- Merging sessions 3 and 4 of the Rothbaum protocol.	- Diaphragmatic breathing. - Progressive muscle relaxation. - Homework: self-monitoring, reading the list of drawbacks and coping skills practice.
4. Thought stopping	- Explaining the A-B-C cognitive model. - Thought stopping and distraction technique. - Homework: self-monitoring and thought stopping practice.	- No changes.	- Explaining the A-B-C cognitive model. - Thought stopping and distraction technique. - Homework: self-monitoring and thought stopping practice.
5. Cognitive restructuring	- Technique for analyzing evidence within the A-B-C cognitive model. - Homework: self-monitoring and cognitive restructuring practice.	- Adding the decatastrophization technique, using a Likert scale of severity and the reassignment technique (pie chart).*	- Technique for analyzing evidence within the A-B-C cognitive model. - Decatastrophization technique, using a Likert scale of severity.* - Reassignment technique (pie chart).Homework: self-monitoring and practice with these 3 cognitive restructuring techniques.
6. Targeted internal dialogue	- Internal dialogue guidance in preparation for a stressor, based on the work of Veronen and Kilpatrick. - Positive reinforcement practice. - Homework: self-monitoring and targeted internal dialogue practice.	- No changes.	- Internal dialogue guidance in preparation for a stressor, based on the work of Veronen and Kilpatrick. - Positive reinforcement practice. - Homework: self-monitoring and targeted internal dialogue practice.
7. Role-changing and role-playing	- Exchanging therapist/patient roles and CBT role-playing for trichotillomania. - Reviewing the studied techniques and points for improvement. - Homework: self-monitoring.	- Changing the targeted habit from trichotillomania to skin picking.	- Exchanging therapist/patient roles and CBT role-playing for skin picking. - Reviewing the studied techniques and points for improvement. - Homework: self-monitoring and reviewing the studied techniques and points for improvement.
8. Relapse prevention	- Assembling the Trichotillomania Relapse Prevention Guide.	- Changing the targeted habit from trichotillomania to skin picking.	- Assembling the Skin Picking Relapse Prevention Guide.

^*Adapted from Wright et al.32