Psychodermatology: Anna K. Folkman

A huge thank you to Anna Folkman for allowing me to interview her for the website. Skin disorders and problems may not always be solved with conventional medicine. We need to take a deeper look to find the root cause of suffering. I found her answers very enlightening and I truly believe anyone going through a tough ordeal with their skin can benefit from therapy.

akfAnna Kinnaird Folkman 


Private practice in London, United Kingdom
Diploma in Counselling and Psychotherapy from the Centre for Counselling and Psychotherapy Education, London 
Masters in Psychotherapy Research Methods from Northampton University 
Member of the British Association for Counselling & Psychotherapy (BACP) 

She has over 9 years experience of working with individuals in both short and long term work. Alongside her general practice, she has special interests in both psychodermatology and postnatal issues. As well as offering therapy, she has a keen interest in psychotherapy research and publication.

Outside of work, she is a mother, artist, avid runner and yoga enthusiast. 

1. Have you always wanted to be a therapist? No, I started out in a completely different career! I became interested in psychotherapy in my early twenties and knew it to be a very powerful way to help people and change lives. A decade later, I completed a 5 year training as a psychotherapist, followed by an additional 2 years for my masters degree. I have been in private practice for over 9 years and I love my work.
2. When did you decide to specialize in Pschodermatology? Did it stem from you having skin problems yourself? I have atopic eczema and have first hand experience of the emotional impact of, and impactors to, this very common inflammatory condition. I found myself getting increasingly frustrated at the acknowledgment within dermatology of the established link between skin and the psychological/emotional world -yet nothing was being offered in terms of addressing this. Although it is no longer an issue for me, I am highly attuned, and sympathetic to, the distress caused by skin complaints and how therapy can make a profound difference in improving lives for those with difficult skin.
3. How does Psychodermatology help skin conditions? What are some of the techniques utilized? Therapy is immensely powerful in the treatment of intractable and chronic skin complaints. All too often, dermatologists will throw everything in their medical bags at the patient in the hope of calming down the inflammation, the itching, the infection etc. Yet oftentimes, these treatments do not work. The skin continues to errupt and protest and the patient becomes increasingly miserable. Psychodermatology usually picks up where these attempts have become exhausted.
I’ll give you an example. A client once came into therapy with me for a severe and intractable rosacea-like presentation which she had suffered with for over a year. She had been to numerous dermatologists, taken various drugs, had undergone expensive laser treatment abroad, had every test imaginable to try and work out what was going on. She eventually ended up in the office of an allergy specialist who also happened to be a therapist and held a very holistic view of his patient’s health. Towards the end of the consultation he asked the magic question: ‘What was going on for you at the time this first started?’ Of course, the patient opened up for the first time about a very difficult relationship, her face flared up instantaneously and violently and suddenly something very important had become known about her ‘skin’ condition. The patient was referred to me and was able to work through her supressed feelings in much the same way as a ‘regular’ client would. She was able to acknowledge her bottled up anger and sadness of her failed relationship, and how it was triggering earlier, unacknowledged grief for her estranged father. From the beginning of weekly sessions, her symptoms began improving quickly and therapy was concluded after a year. The client was able to resume normal life activities again and has remained symptom free. I found this to be a profoundly powerful and not uncommon case of psychodermatology in action.
4. How does this work, what is involved? At the least, therapy can offer patients a way to come to terms with their troublesome skin and the associated anxiety and depressive feelings it causes. In many cases however, a deeper exploration of the client’s life-as-a-whole uncovers deeply held material which is directly contributing to the health of their skin. The skin is a highly sensitive organ and it often takes on the role of expressing feelings -this is why conditions such as eczema and psoriasis flare up during times of stress. It is also not uncommon for psoriasis for example, to first appear during a stressful life event such as a death, loss of job etc. The good news is that these feelings can be expressed, worked through, and ultimately, let go of. Sometimes, the skin symptoms themselves are telling us something about the client’s experience. How often do we hear descriptions such as my skin is ‘angry/aggravated/irritated’, its ‘weeping’, I’m having a ‘flare up’, my skin is really ‘sensitive’ or that something has ‘gotten under our skin’? In these examples, we start to get a feel for the emotional world below the surface. Most of the time, simply talking about the deeply held material is sufficient to calm the skin and this is because the skin no longer has the job of expressing feelings. Sometimes getting to the bottom of the troubles can be a tricky process, and therapists will often use techniques such as visualisation, dream analysis, free drawing, journalling etc alongside talking, to enable the client to access what is bothering them. Another useful technique I use is to have the client construct a time line of their skin -documenting when it was at its worst/best, significant life details (ie birth of a sibling, starting school, divorce of parents etc), periods of happiness/sadness and any other information that can help build up a bigger picture of the client’s life and experiences (Grossbart, 1992). This can be incredibly powerful at uncovering very important links regarding the skin and its role throughout life.
5. Do you feel doctors are so quick to offer pharmaceutical help instead of trying other avenues first? Why? Absolutely. I think there are several factors at play here. Firstly, there needs to be an acknowledgement that the mind and body are intrinsically linked and are one and the same system. This can be difficult for some doctors to accept -even in this day and age where there is bountiful mind/body research proving this to be true. Dermatology training teaches doctors about the skin -the structure of it, the ways in which is can become aggravated, how they might stop this happening. They are skin specialists, and just like many other medical specialisms, it can result in tunnel vision. Patients thus come into the doctor’s office as a skin presentation which can have the effect of excluding any holistic consideration from the onset. Secondly, dermatology is hugely underpinned by the pharmaceutical industry which inherently pushes an illness agenda. Unfortunately, this agenda does not take into account holistic views of health and wellness and has set up the expectation that the relief of suffering is only found in pills and preparations. Thirdly, the patients themselves are also part of this larger context whereby we have been trained to expect a prescription from a visit to the doctor. There is a huge power imbalance between patients and doctors and patients have become increasingly reliant on the doctor ‘doing something’ to them to ease their suffering. Many patients would be upset, offended, or disbelieving if a doctor suggested therapy. This is often because they think the doctor believes its ‘all in their heads’ or that they are a ‘head case’ and this has deeply intrenched connotations. ‘Psychosomatic’ is a term which is often misunderstood in this way as it suggests patients might be ‘making it up’. Problems of the body are more acceptable and preferable than problems of the mind (manifesting itself in the body). Finally, it is vastly cheaper to prescribe drugs than it is to prescribe therapy. Drugs are seemingly quantitative in their affects (this is despite most drugs perfoming on par or worse than a placebo in drug trials), whereas talking therapy is qualitative and difficult to attribute causes to effects.
6. Would you say this should be a treatment on it’s own or should it be paired with medication? It really does depend. Clearly I am not a medical doctor but it is my experiential opinion that therapy is profoundly effective, long lasting and safer than many of the standardised medical treatments available. My clinical experience supports this claim in the cases I have worked with. Put it this way, therapy works by uncovering what is at play -the feelings, beliefs, memories etc that are troublesome in the client’s life but have become suppressed. The skin is an exquisitely sensitive organ and will act out a multitude of troubles we are trying to ignore. Medical treatments such as corticosteroids, immuno-suppressants, antihistamines and antibiotics for example, work to try and dampen down this aggravated response and work much like the proverbial band aid. All these treatments have significant side effects and limitations. Therapy, on the other hand, works to resolve any latent psychological issues of which the skin erruption is the symptom. I will say this, undergoing psychodermatology requires that the client is a far more proactive participant in the process and ultimately their journey to wellness. It can be an incredibly painful and difficult journey. Oftentimes things will get worse before they get better. It requires a real commitment in the process above and beyond that which is required by a medical protocol. Being a co-creator of restoring one’s health can be a profoundly empowering experience for clients who undergo therapy for their skin.
7. What are some of the emotional stresses people with skin conditions face in your office? Depression, anxiety, stress, social isolation, relationship difficulties, poor self image, confidence issues, anger, work-related problems. There is a strong correlation between the severity of these issues/impactors and what parts of the body are affected. For example, individuals with troubled skin on their faces and hands generally have higher degrees of impact than those who can cover up their problematic skin. Our society associates ‘good’ skin with ideals of beauty, preference, success and power. Conversely, troubled skin is often associated with poor hygiene, fear of contamination, ignorance and poor self care. These false and damaging perceptions can be very difficult to live with.
8. Is suicide a topic that is brought up by patients? Would you say it’s common in severe skin cases? Suicidal thoughts are common in individuals struggling with feelings of deep despair, anger and isolation. For many, there is a sense that something needs to die or be exterminated in order for life to feel worth living again. Certainly, living with incredibly problematic skin disorder can have this depth of impact on sufferers and it is commonly reported that for many, it feels as if life will never get better. Therapy can be hugely supportive in this instance. For many clients such as the brief case I reported above, when all other avenues have become exhausted, simply hearing another person say ‘I think I have an idea of what might be happening here, can I help you?’ is profoundly reassuring and healing in and of itself. It is a shame that this often comes as a last resort after a long and frustrating struggle.
9. Do you feel there should be a merging together with dermatologists and physchodermatologists, particularly situated in the same office? It would be a marvelous thing. I would love to see therapists working alongside dermatologists and maybe other professionals such as nutritionists, to offer a complete care package for each patient. Having therapists associated with dermatology practices would further normalise and validate this as a viable treatment option in the minds of patients and it would probably increase the likelihood of a patient commencing psychotherapy in the first instance. Imagine how powerful this could be for dermatologists to witness first hand, improvements in their difficult cases?
10. What age range do you see in your office? I work with adults although many of them are seeking therapy for the trauma of their childhood experience of severe skin problems.
11. Is diet ever discussed during sessions? Not generally, its not really my expertise and would take us off on a tangent instead of attending to the feelings. 
12. How many times a week do you normally see a patient? And for how long overall (a few weeks, a few months…)? My clients attend weekly hour long sessions. Duration is incredibly variable depending on the case.
13. Does insurance cover the cost of each visit? Here in the UK, many private health insurers will pay for a number of therapy sessions per year. Once again, it is variable. Sadly, long term talking therapy is not offered by our national health service due to cost and the inability to quantify results.

14. In the next decade, how do you hope the dermatology field would be in the respect to how they treat skin conditions? I would hope that a broader, more holistic approach would be the norm. I would like to see a reduction in the reliance on drug therapies and to see psychotherapy as a preferred, first line treatment option for many of the common and chronically difficult skin conditions. I would like to see increased research in the area of mind/body approaches to health and importantly, increased dissemination of the findings to the front line. I would like to see a growing awareness among the patient community of the benefits and results of therapy for skin conditions, and that there are options in the treatment of their skin. It would be amazing to see greater participation by patients in their recovery.

Also, Anna recommends Skin Deep by Ted Grossbart if you’d like to read more about skin counseling.
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