Beyond Topical: Psychodermatology with Matt Traube

Welcome to Beyond Topical, a series of Q&A’s with various experts that goes beyond topically applied skincare products to shed light on the various indirect influencers of skin health. While supporting skin with well-formulated and strategic topicals such as the ones we make at Marie Veronique is imperative, these interviews approach personal health and wellness through a holistic lens, expanding our awareness of how our systems interact and affect each other. Our intent with this series is to uncover valuable insights and information you can apply to your own practices. This interview is focused on how the mind impacts skin health.

+++

At Marie Veronique we often think about the power of the mind in relation to the skin — while the mind-gut connection is pretty well established, the connection between skin health and mental health is much less so. However, as anyone who’s dealt with chronic breakouts or other daunting skin concerns can attest, the emotional aspects that accompany physical symptoms are their own challenge. Not only are they difficult to deal with, but they can actually be part of the problem.

This is one of the reasons we wanted to interview Matthew Traube, a psychotherapist who specializes in psychodermatology, a relatively new and growing field of treatment that addresses the interaction between the mind and the skin. Matt’s approach is informed by his father’s book, “Skin Deep,” in which he explores healing skin concerns from a therapist's point of view, as opposed to that of a dermatologist. 

We work with clients regularly who are able to clearly trace their symptoms to stressful periods of their life or instances where the correlation between skin health and mental health is undeniable. Matt’s approach is revelatory because it's not at all about finding the source of one's symptoms, but instead about discovering the mental component, or “triggers,” behind them. And despite his knowing very little about the skin, his approach has helped many people resolve chronic skin issues.

This interview underscores just how integral the mind is to healing. That healing isn’t just about doing all the “right” things and checking all the boxes, but instead in learning — and trusting — that both the body and the mind play essential parts in the healing process. 

+++ 

Please tell us about your practice, what got you into this area of work, who your typical client is, and your approach. 

I am a therapist in a regular sense of the word, but I'm also a therapist with a twist because a lot of my practice focuses on psychological aspects of skin conditions. And what that means is essentially the skin influences the mind, and your mind can influence your skin. Dealing with different skin conditions has a big impact psychologically on a lot of people.

Three people can have the exact same skin condition, let’s say eczema, and one person can say, "I don't mind it, it doesn't bother me much," and somebody else can say, "No, it's a huge deal, and when the eczema is flaring and things are bad, it's preventing me from finding love, it's preventing me from doing well in a career or in school, in work, in all of these areas that are vitally important." So, having the experience is subjective. 

My father was working in what we loosely termed psychodermatology, this intersection between skin and mind. He had a practice for about 45 years, and a number of years in Boston where that was a heavy focus. He wrote a book called “Skin Deep.” He was a psychologist and my mother was a psychologist, so that makes me pretty crazy myself (laughs).

Growing up there were always a lot of psychologists around. They're very interesting and fun, quirky people that are really open and want to talk about everything. So, at an early age I remember talking about skin stuff, and when I or my older brother or anyone had problems, my dad always had a bit of a psychological slant, like, "This is what we can do in this direction."

So I became aware of the impact of your mind on your skin at an age when I didn't even understand what I was witnessing. And later in life when I became a therapist, I thought I wanted nothing to do with this field, that I was going to go off in another direction. But eventually I realized that it's a pretty good fit and it's really meaningful work. I started seeing regular clients, and so many people had skin problems that I would talk endlessly to my father, who really got me going in all of this.

By talking with him I realized this is an area where resources are so limited. Skin issues impact millions and millions of people and there are just not a ton of resources for addressing them. If you've got some sort of physical issue like a problem with your heart, people say, "Go see a cardiologist." But when people say, “I feel really down, my skin's been bad and I haven't wanted to leave my house," people kind of go, “That's weird, have you seen a dermatologist?”

And they say, “I have, and it's been a little helpful but I haven't gotten all the answers. I don't know what to do and my dermatologist is telling me a lot of it is probably mental or psychological.” So then they think, "Huh. OK, where do I go from here?"

Interesting. 

Early on in my own personal work with people with different skin conditions, I'd get these people that would call and say, “I've gone to 10 specialists and nobody's given me a good answer. I don't think you can help me but I'm willing to talk and maybe you can at least guide me a bit.” 

When you help somebody who feels like there's no help out there, it's incredibly gratifying. And in some cases it can be life changing. That was when I thought, you know, this is interesting, this is something that is very helpful and it's hard. In my practice, there are some things I've got set, almost manualized approaches that I know work for people, but in other areas I have no idea.

So let’s say I get somebody that has a skin picking problem. There's this whole area they call BFRBs, body focused repetitive behaviors, where people can't stop picking their skin or pulling hair or chewing, things like that. There are some pretty basic methods that you can use to help people reduce it and, in a lot of cases, get rid of it. And these are people that have had it for five or 10 years. Sometimes I get people that have had it for 40 years and think, “I'm just going to die with it and nothing can help.”

Over time you teach them how to learn how to reduce it. That stuff is challenging, but at least I know what direction to go in. So sometimes people call and say, “I've got this undiagnosed rash and I don't know what's going on. People said it's most similar to eczema but it's not necessarily categorized in that area, there's an itch to it.” I get a lot of, “It's red here, and if you could just help me manage the itch, let alone the skin, I'd be happy, because the itch is driving me crazy.”

So stuff like that requires more detective work. What's behind it? When does it get triggered? When did it start? What was going on?

It's not unusual for somebody to say, “Everything was great with my skin and then I was getting married and I had this flare up.” From, presumably, pressure, stress, anxiety, or sometimes anger is a big trigger for some people. So then I do some emotional detective work and figure out what's behind it and how we can better manage that. And sometimes that makes the difference.

I've noticed with the skin, it's a very fine line between stuff flaring and not. Sometimes if you can give people even a little help, sort of a few inches in this or that direction, that's the difference between, "My skin was really bad," and, "Actually, this was a great summer, my skin really didn't act up and I used X-Y-Z to help manage the stress." Or, "I noticed my relationship with my partner was having an impact, and so we learned how to communicate, and then I could sort of apply that and make sure that I'm managing my skin better while doing the thing that we figured out was the trigger."

It’s hard because the other thing is there are a large variety of things that impact the skin. Rarely is there one thing. Some people will go, “OK, I think it's this food,” or, “I think it's this environment, it's hot, it's cold, it's whatever.” So, I tell people, look, we don't always have control over managing the skin, but one area that we do have tremendous control over is your relationship with it. Is it healthy, is it unhealthy, is it limiting you? Is it something where you feel like when your skin looks bad for whatever reason, life isn't moving forward? Or can you actually embrace what you have, learn how to take it with you and move forward? 

What you are saying is so interesting! There are so many people with adult acne or eczema, psoriasis, etc. that now see some sort of integrative specialist, acupuncturist, or functional MD for help, and that approach is really so much more geared towards finding the source. They know there is something going on with the internal body, some sort of imbalance within the gut, for example. But they are much more interested in finding out what is actually causing these symptoms. 

But in your work, you take a very different approach. It's as if it doesn't even matter what the source is necessarily, but instead saying “OK, there are these triggers that influence the symptoms. How do we deal with them?” It's an alternative avenue to get people to do the work for the skin, but in reality it's an opportunity to guide them to work they can be doing for their overall well being. 

I'm a big believer in more of a holistic approach, because I do think there's a wide variety of things that will impact your skin, but skin conditions come with a lot of variables. What I generally tell people is to see a dermatologist before you see me. See different types of medical doctors. If there are quick answers, get answers. Sometimes it's a dietician. Dermatologists have great, really quick, specialized interventions and sometimes that does it.

But I think where it gets tricky is when people have taken that approach and then they feel stuck. Whatever it is, they’re not getting much movement on it and then it's really impacting or deteriorating their mental health.

Absolutely. With the type of work that you're doing during the treatment sessions, is there a lot of discussion around why people are triggered by certain things, like what's at the root cause emotionally to this condition? Or do you give journaling prompts, or something like tapping? What kind of style do you use?

Certainly there is a lot of work around triggers — what did you notice, when did it start? What, where, when, and why? Who was around, when was it going on? You notice the first time it happened. There's definitely some of that work to figure out some of the underlying psychological aspects of it, but then to move forward and then do the work on it, there could be stuff like journaling. I use a lot of psych approaches.

If you're dealing with, say, stress — that is a big trigger for a lot of people. Let's say we've defined some of your flare ups occur because of stress related to school or work or, I don't know, your partner or family. Then we go, okay, let's get into stress management tools. Journaling can be a great one. Basic stuff helps a lot there, things like are you getting enough sleep, are you eating well, are you exercising, are you taking care of yourself, are you taking time during the day to actually sit, relax, let your nervous system calm down a little bit? And kind of reset a little bit.

I've got a guy that I talk to on a regular basis who travels a lot for work, and any time that he's gone for too long, it tends to trigger flare ups. He's burning himself out, he works a lot, loves to work. So we try to get to know what's happening there. Do we have to change what it looks like in order for you to help manage your skin better so you get relief?

In that case, in that specific example, did this person come to you and say, "Look, I've got this chronic skin condition. I know my lifestyle is intense, and I need psychological assistance to manage it?" Or did you start working with him for another reason and later discover the skin component?

That happens with some people. But at this point, most people who find me have looked me up in some way. They probably do an internet search to find out, “Who is this person, and what do I think about him?”

Most of the time they go, “I've got X-Y-Z going on, and it's skin related. I read something from you,” or “Somebody told me about you.” Or, “It seems like you're somebody that could be potentially helpful here, let's talk.” It's not uncommon for me to have somebody call and say, “I'm struggling and a primary component is my skin, but I'm a human so I've got other psychological issues going on too, because life is beautiful but challenging for all of us.”

It's fascinating because most clients end up working with me because they are presenting symptoms. They have something going on with their skin that they're really trying to heal. But I would say most of the time people are not aware at all that there's a mental component and that stress is impacting their skin. I do try to rely on a lot of theory and explain the correlation of skin health and stress, but I'm so curious how things might change in the future. How do you see this becoming more integrated? To be honest, my demographic are not the clients who are calling you yet.

I think we're far behind in the U.S. in a way. For instance, there are hospitals in the UK that are more integrated. In their medical model they have a dermatologist, an internist, a psychologist, and they're all collaborating on skin conditions and things of that nature. We're definitely ahead of some countries, but there are some places where they're already doing more of an integrated approach.

Anecdotally, most doctors that I talk to, especially dermatologists, go, "Of course there's a psychological component to the skin condition," but the model we have in this country is not as integrated as it is in some other places. But I think that'll change. 

What is really interesting to think about is how your line of work is seemingly so much more abstract in a sense. For example, in my work, I can say, “Use these products, your doctor is telling you to take these supplements,” and they'll come back in a month and say, "I do X-Y-Z to the T.” And I'll say, “Okay, did you do your journaling and your breath work, have you made time to relax?” And they'll say, “No.”

So it's that part that I find to be the trickiest. It's easier to take the supplements and apply the products than it is to do the journaling, as it's just not as tangible or immediate with the results.

Right. That's a big problem in psychology in general. It's very interesting when you know some things work really well for people and it's very hard to get them to do it. What I do is tell people, “Look, if you do 20% of what we're talking about, it'll be helpful. You're going to see some improvements.” So I always say, “Practice, not perfect.” You don't need to do these things perfectly; there is no judgment. You could come back to me the next week and go, “I'm going to be honest with you, I didn't do any of it,” and I would go, “Okay, well, let's talk about that.” No judgment.

I do a lot of exposure and response prevention, or ERP therapy, with people with anxiety. In very gentle, small ways, we get them to practice doing the things that cause anxiety. So it retrains your brain to know and learn through experience that it's safe here. And it's very interesting. In the beginning most people go, “I don't know if this is going to work. I've been dealing with this for 10 years, and what's to say you know anything about it?”

And I'll say, “You don't even actually have to believe in what I'm saying, I just need you to do 20%, or at least a small portion.” And once they start doing a little bit, they go, “Whoa.” Not that [their issue] is cured instantly, but even if something moves to even 5% or 10% better, at that point it's undeniable.

This is so very helpful.

The truth is there are plenty of people I can't get on board with all the suggestions. It could be what I'm doing or where they are in life, but it's a challenge for both of us. But often they can see firsthand at least a little progress. And hopefully at some point, not too far down the line, they think, “All right, maybe this could be helpful.” At that point people really go for it. 

But you're right, in the beginning it's challenging and I do my best to set expectations by not having expectations. I tell them, “I'm not sure if this is going to help or not but I've seen a lot of people with very similar things, and this is what we've done that has been helpful.”

So you gain their trust in that way.

Yes. Early on someone told me, “As a therapist, the best tool you're ever going to have is your relationship with people. If it feels comfortable and safe and you seem like a half decent, kind human being to talk to, the amount of people who get on board is going to be significantly higher than the number who don’t.” And that is probably the best thing I have, because I don't always have the right answers. There are some things I certainly don't know.

But there's something amazing about building that rapport. To have somebody who’s on your side, on your team, and is going to support you through things no matter how challenging they are, it's very healing. 

Absolutely. Skin issues can make you feel really alone and even more vulnerable and closed off. I'm curious, have you ever tried to explain to a patient that some of their skin symptoms might have to do with their mind and had them react negatively? What do you say to that?

Yes. What I generally do there is work with them to identify when it got worse, and what was the trigger. I'll ask, “What was going on then in your life?” And overwhelmingly it'll be some sort of challenging event. “I took on a new business,” “I got out of a serious relationship,” “I moved.” All these very basic examples of things that cause stress. A lot of the same stuff keeps coming up.

So I do less explaining upfront and more questioning. Like, “What makes sense here? You tell me, it's your story.”

That's wonderful advice.

What I'm realizing is, anecdotally, a lot of people are having very similar experiences with different skin conditions. I can say, “Are you experiencing a little of this, a little of that?” And when people feel heard and they feel like it's relatable and supported in a down to earth way, they're much more prone to being open.

I don't have one model for everybody. Sometimes it's one thing that works really well for one person and then another person goes, “I'm not sure how into that I am, what else can we try?”

I work in the field in a lot of ways. There are certainly a lot of things I don't know about the inner workings of how the mind impacts the skin and the skin impacts the mind.

I think what's cool about the skin is that there is still so much to discover, so much unknown. Even the microbial part of it, that is changing every single day with the research that's coming out, and then the connection between the microbiome of the skin and the brain. Our best approach, in line with what you have been explaining, is to experiment and troubleshoot together to find solutions. 

Yes, there's definitely some of that. I think it's in some ways just being strategic about offering up what you hope might be helpful, and then being open that you don’t know for sure whether it will work. There are so many variables that impact skin that it's hard. 

Let's say I get somebody who says, “My skin has been really bad because I'm pretty sure I've been really anxious for the last couple of months,” and you do a really good job of reducing their anxiety or managing that area, and then they find out actually it was some environmental factor or something.

Totally. Or it was a combination of both. 

Right. It's challenging. Because we know humans don't do well with not knowing the answers.

Well that is really the difficult part about the skincare industry! In reality it's all about trying to gain back that control. That's really what's behind years and years of formulation in this industry — trying to gain control over the skin that is so influenced, directly and indirectly, by many, many things. And what’s interesting now is there's a change happening in the topicals industry where we're realizing that all these years of trying to control the skin is kind of backfiring.

What do you mean by that?

For example: acne. What are the three main components of acne? Oil, bacteria, inflammation. So, what can we control to eliminate acne? We can kill all the bacteria, we can eliminate the oil, and we can suppress the immune response and get rid of the inflammation. But that doesn't work long term, right? We're seeing what that does to the skin system and all the problems that come after that, so now there are different approaches for treating acne where it's more about support and nourishment and balance and holistic healing, bringing in the mental component, etc. Learning to relinquish control. 

So the thought that healthcare can move away from us wanting to control our bodies is interesting. For example, moving away from the germ theory of disease, to now all of a sudden welcoming bacteria in the form of probiotics! There are a lot of these little slow shifts happening.

Yes, it's an interesting idea. You’re sort of creating your own theory and relationship, physically and mentally, with your skin, right? 

Right.

I'm a little removed from that in my own day-to-day practice even though I'm doing a version of that often mentally.

That's exactly what it sounds like you're doing. Hearing you talk it seems like this is kind of an essential component for anyone's healing journey. If you're going through any sort of disease, there is a mental component, there is an influence of stress or something emotional. 

So, what if you can't go to someone like yourself and you're on a tight budget between the dermatologist's visits and the products and everything? What would you recommend to people like that?

I think on a basic level, as you mentioned, skin is isolating. A lot of people have these thoughts and feelings and they keep them to themselves and are silently suffering. There's still a stigma attached to skin issues for a lot of people. So on a very basic level that doesn't cost any money, I’d recommend talking to friends, family, people you feel comfortable with. I'm not saying go divulge all of your personal stuff to everybody you know, but find a friend or two.

Or even these days there are a lot of great online forums and groups of people that are suffering from certain skin conditions, so you can get more support there. Social support, emotional support, things at that level, they are incredibly helpful for a lot of people. But I also think you can do some of your own detective work. If you know there are certain things that are making your condition worse, you can think, ‘OK, what did I notice, what's happening here, how do I reduce that a little bit and how do I make that a little easier?’

But again, speaking up and getting help, I think that's the tricky part. I think so many of us in general as human beings are not so open to discussing our human imperfections. But when you do that, when you reach out to people, when you get somebody else who goes, "Yes, I experience this," or, "That must be really hard, that doesn't sound fun," even that takes a lot of pressure off. It doesn’t necessarily resolve everything, but it makes things a lot better for a lot of people. And that doesn't cost anything.

I think for most people, creating a routine helps ground you. Everybody's got a phone with access to the internet in their pocket. So you have tons of information at your fingertips, but it's one thing to have the information, it's another thing to then use it, implement it, integrate it in a lifestyle that's actually healthier and makes you happier. So generally, I'm a big fan of small, small steps that ultimately equal really big gains. Start somewhere and just build on that.

I always tell people, try it for a week, and if it feels good, keep it up. If it doesn't feel like it's doing much for you, get rid of it, let's go somewhere else. You can just slowly build, and you'd be surprised how helpful that is for most people to ultimately be happier.

And it's interesting, with some conditions, sometimes we're not even talking directly about the condition, we're helping people improve their quality of life. A few months down the line they're like, “You know, my skin is a lot better.” It's wonderful, what happens.

That’s great. Clients will sometimes get frustrated because I always say, “OK, these first three months of working together, we're not going to do anything really that intense, we're just going to think about sleep and clean up your diet a little bit and get you to calm down or exercise.” And they're like, “No, no I want more! I want full resolution.” We are a society that wants really quick fixes, and instant gratification, so a slower approach is not always welcomed.

Yes, I get it. I'll say, “You know, you've had this for five, 10, 15 years, so the idea that it's just going to go away tomorrow I think is a little unrealistic. So, let's build.” But you're right. Half the work is definitely finding a way to have some consistency with something that you think is going to be helpful.

I remind people, find 10 things that work 10% of the time, because if you can find a couple of things that are really going to a small but meaningful percentage of improvement, and then do that in five different places, all of a sudden you add it all up and you go, "OK, this is a big difference." 

That's really helpful.

It's a very fine line between, “That day wasn't that good,” or, “That week wasn't that good,” versus, “It was pretty good.”

My mom, who’s a great psychologist, always reminds me that on a basic level, if you work on just appreciating what's in your life more, and doing a good job of not getting so upset or unhappy with what you don't have and focus instead on what you do have, well, that doesn't cure all skin conditions, but it makes the experience of having something difficult better.

*

Matt Traube is a licensed therapist who specializes in helping people deal with psychological aspects of skin conditions. He utilizes a mixture of cognitive behavioral therapy and skin-focused psychotherapy. Examples of conditions he treats are: acne, body dysmorphic disorder, eczema, hives, skin picking, psoriasis, rosacea, scratching, and trichotillomania. His father Dr. Ted Grossbart was an early pioneer in psychodermatology who helped him cope with his own skin issues and understand the crucial relationship between mind and body. Dr. Grossbart believed that, “You touch the world and the world touches you through your skin; it is here that you experience pleasure or pain.”