Fig 4.20 The Undesirable Behaviour Sequence
Fig 4.21 The Desirable Behavioural Sequence
The established sequence needs interruption to allow a different consequence; with no further damage, healing occurs. Thus new behaviour is needed after the antecedent (itch), such that when it is performed the behaviour : Scratch is no longer possible. Hence the new consequence (healing) will be achieved (Fig 4.21). Specific instructions Scratching is divided into two behavioural stages: (a) 'going to' the area to be scratched, and (b) scratching. This is described in the handbook, and should be demonstrated to the patient. Scratching is old, undesirable behaviour, to be replaced be new, desirable behaviour desirable because the consequence will be healing. Stage (a) of the new behaviour is clenching the fists gently for 30 seconds, fixing the arms in a comfortable position at the sides of the body. Stage (b) is gentle pinching or pressing of a finger nail against the area of skin that would otherwise have been scratched, until the impulse to scratch has gone. The new behaviour should be demonstrated, doing it together with the patient. The handbook sets out a sequence for the patient to practice (p. 127), a few times over the next two days. Otherwise from now on all scratching is to be replaced by the new sequence. If the relevant antecedents to scratching are referred to as impulses, the point that it is not only itching that provokes scratching is emphasised again. The patient is advised that if the impulse to scratch goes during the 30 seconds of fist clenching, there is no need to go on to the new stage (b), skin pinching or pressing with a finger nail. In designing this particular new behavioural sequence 'habit-scratching' is seen as being countered by fist clenching, and the 'itch-scratching' is seen as being replaced by skin pinching or finger nail pressing. If this is explained, some patients will remember learning as children how the itch of an insect bite can be relieved by briefly pressing a finger nail into the wheal caused by the bite (p. 45). General strategies The handbook goes on to explain how to alter behaviour how to limit, and eliminate damage more generally caused by scratching using more general measures. Thus when the circumstances during which scratching seems