Dr Schwartz’s breakthrough in OCD provided the hard evidence that the mind can control the brain’s chemistry, and that it can do so through the classic Buddhist idea of mindfulness.

The Four Steps

By Dr Jeffrey Schwartz

If you have obsessive thoughts and compulsive behaviours, you will be relieved to learn of significant advances in the treatment of this condition. Over the past twenty years, behaviour therapy has been shown to be extremely effective in treating obsessive-compulsive disorder (OCD).

The concept of self-treatment as part of a behavioural therapy approach is a major advance. In this manual, I will teach you how to become your own behavioural therapist. By learning some basic facts about OCD, and recognising that it is a medical condition that responds to treatment, you will be able to overcome the urges to do compulsive behaviours and will master new ways to cope with bothersome, obsessive thoughts.

At UCLA, we call this approach “cognitive-biobehavioral self-treatment.” The word cognitive is from the Latin word “to know”; knowledge plays an important role in this approach to teaching basic behaviour therapy techniques. Research has shown that exposure and response prevention are very effective behaviour therapy techniques for treating OCD. In traditional exposure and response prevention, people with OCD learn–under the continuing guidance of a professional therapist–to expose themselves to stimuli that intensify their obsessive thoughts and compulsive urges and then learn how to resist responding to those thoughts and urges in a compulsive manner. For example, people who obsess irrationally about contamination from dirt may be instructed to hold something dirty in their hands and then not wash for at least three hours. We’ve made some modifications in this method to allow you to do it on your own.

The technique is called response prevention because you learn to prevent your habitual compulsive responses and to replace them with new, more constructive behaviours. We call our method “biobehavioural” because we use new knowledge about the biological basis of OCD to help you control your anxious responses and to increase your ability to resist the bothersome symptoms of OCD. Our treatment differs from classic exposure and response prevention in one important way: We have developed a four-step method that enhances your ability to do exposure and response prevention on your own without a therapist being present.

The basic principle is that by understanding what these thoughts and urges really are, you can learn to manage the fear and anxiety that OCD causes. Managing your fear, in turn, will allow you to control your behavioural responses much more effectively. You will use biological knowledge and cognitive awareness to help you perform exposure and response prevention on your own. This strategy has four basic steps:

The goal is to perform these steps daily. (The first three steps are especially important at the beginning of treatment.) Self-treatment is an essential part of this technique for learning to manage your responses to OCD on a day-to-day basis. Let’s begin by learning the Four Steps.

The Four Steps: Step 1 – Relabel

 By Dr Jeffrey Schwartz

The critical first step is to learn to recognise obsessive thoughts and compulsive urges. You don’t want to do this in a merely superficial way; rather, you must work to gain a deep understanding that the feeling that is so bothersome at the moment is an obsessive feeling or a compulsive urge. To do so, it is important to increase your mindful awareness that these intrusive thoughts and urges are symptoms of a medical disorder.

Whereas simple, everyday awareness is almost automatic and usually quite superficial, mindful awareness is deeper and more precise and is achieved only through focused effort. It requires the conscious recognition and mental registration of the obsessive or compulsive symptom. You should literally make mental notes, such as, ‘This thought is an obsession; this urge is a compulsive urge.” You must make the effort to manage the intense biologically mediated thoughts and urges that intrude so insistently into consciousness. This means expending the necessary effort to maintain your awareness of what we call the Impartial Spectator, the observing power within us that gives each person the capacity to recognise what’s real and what’s just a symptom and to fend off the pathological urge until it begins to fade and recede.

The goal of Step 1 is to learn to Relabel intrusive thoughts and urges in your own mind as obsessions and compulsions – and to do so assertively. Start calling them that; use the labels obsession and compulsion. For example, train yourself to say, “I don’t think or feel that my hands are dirty. I’m having an obsession that my hands are dirty.” Or, “I don’t feel that I have the need to wash my hands. I’m having a compulsive urge to perform the action of washing my hands.” (The technique is the same for other obsessions and compulsions, including compulsive checking of doors or appliances and needless counting.) You must learn to recognise the intrusive, obsessive thoughts and urges as OCD.

In the Relabeling step, the basic idea is: Call an obsessive thought or compulsive urge what it really is. Assertively Relabel it so you can begin to understand that the feeling is just a false alarm, with little or no basis in reality. As the result of much scientific research we now know that these urges are caused by biological imbalances in the brain. By calling them what they really are–obsessions and compulsions–you begin to understand that they do not really mean what they say. They are simply false messages coming from the brain.

It is important to remember that just Relabeling these thoughts and urges won’t make them go away. In fact, the worst thing you can do is to try to make them vanish. It won’t work because the thoughts and urges have a biological cause that is beyond your control. What you can control is your behavioural response to those urges. By Relabeling, you begin to understand that no matter how real they feel, what they are saying is not real. The goal: to learn to resist them.

Recent scientific research on OCD has found that by learning to resist obsessions and compulsions through behaviour therapy, you can actually change the biochemistry that is causing the OCD symptoms. But keep in mind that the process of changing the underlying biological problem, and by doing so changing the urge itself, may take weeks or even months. It requires patience and persistent effort. Trying to make these thoughts and urges go away in seconds or minutes will cause only frustration, demoralisation, and stress. It will, in fact, tend to make the urges worse. Probably the most important thing to learn in this behavioural treatment is that your responses to the thoughts and urges are within your control, no matter how strong and bothersome they may be. The goal is to control your responses to the thoughts and urges, not to control the thoughts and urges themselves.

The next two steps are designed to help you learn new ways to control your behavioural responses to OCD symptoms.

The Four Steps: Step 3 – Refocus

By Dr Jeffrey Schwartz

The Refocus step is where the real work is done. In the beginning, you may think of it as the “no pain, no gain” step. Mental exercise is like a physical workout. In Refocusing, you have work to do: You must shift the gears yourself. With effort and focused mindfulness, you are going to do what the caudate nucleus normally does easily and automatically, which is to let you know when to switch to another behaviour. Think of a surgeon scrubbing his hands before surgery: The surgeon doesn’t need to wait for a timer to go off to know when it’s time to stop scrubbing. After a while, the behaviour is simply automatic. After a while he gets a “feel” for when he’s scrubbed enough. But people with OCD can’t get the feeling that something is done once it’s done. The automatic pilot is broken. Fortunately, doing the Four Steps can usually fix it.

In Refocusing, the idea is to work around the OCD thoughts and urges by shifting attention to something else, if only for a few minutes. Early on, you may choose some specific behaviour to replace compulsive washing or checking. Any constructive, pleasant behaviour will do. Hobbies are particularly good. For example, you may decide to take a walk, exercise, listen to music, read, play a computer game, knit, or shoot a basketball (in the UK we would play football of course. OCD-UK Editor).

When the thought comes, you first Relabel it as an obsessive thought or a compulsive urge and then Reattribute it to the fact that you have OCD – a medical problem. Then Refocus your attention to this other behaviour that you have chosen. Start the process of Refocusing by refusing to take the obsessive-compulsive symptoms at face value. Say to yourself, “I’m experiencing a symptom of OCD. I need to do another behaviour”.

You must train yourself in a new method of responding to the thoughts and urges, redirecting your attention to something other than the OCD symptoms. The goal of treatment is to stop responding to the OCD symptoms while acknowledging that, for the short term, these uncomfortable feelings will continue to bother you. You begin to “work around” them by doing another behaviour. You learn that even though the OCD feeling is there, it doesn’t have to control what you do. You make the decision about what you’re going to do, rather than respond to OCD thoughts and urges as a robot would. By Refocusing, you reclaim your decision-making power. Those biochemical glitches in your brain are no longer running the show.

The Fifteen-Minute rule

Refocusing isn’t easy. It would be dishonest to say that dismissing the thoughts and urges and moving on does not take significant effort and even tolerance of some pain. But only by learning to resist OCD symptoms can you change the brain and, in time, decrease the pain. To help you manage this task, we have developed the fifteen-minute rule. The idea is to delay your response to an obsessive thought or to your urge to perform a compulsive behaviour by letting some time elapse–preferably at least fifteen minutes–before you even consider acting on the urge or thought. In the beginning or whenever the urges are very intense, you may need to set a shorter waiting time, say five minutes, as your goal. But the principle is always the same: Never perform the compulsion without some time delay. Remember, this is not a passive waiting period. It is a time to perform actively the Relabeling, Reattributing, and Refocusing steps. You should have mindful awareness that you are Relabeling those uncomfortable feelings as OCD and Reattributing them to a biochemical imbalance in the brain. These feelings are caused by OCD; they are not what they seem to be. They are faulty messages coming from the brain.

Then you must do another behaviour – any pleasant, constructive behaviour will do. After the set period has lapsed, reassess the urge. Ask yourself if there’s been any change in intensity and make note of any change. Even the smallest decrease may give you the courage to wait longer. You will be learning that the longer you wait, the more the urge will change. The goal will always be fifteen minutes or more. As you keep practicing, the same amount of effort will result in a greater decrease in intensity. So, in general, the more you practice the fifteen-minute rule, the easier it gets. Before long, you may make it twenty minutes or thirty minutes or more.

It’s what you do that counts

It is vitally important to Refocus attention away from the urge or thought and onto any other reasonable task or activity. Don’t wait for the thought or feeling to go away. Don’t expect it to go away right away. And, by all means, don’t do what your OCD is telling you to do. Rather, engage in any constructive activity of your choosing. You’ll see that instigating a time delay between the onset of the urge and even considering acting on it will make the urge fade and change. What is more important, even if the urge changes hardly at all, as sometimes happens, you learn that you can have some control over your response to this faulty message from the brain.

This application of mindful awareness and the Impartial Spectator will be empowering to you, especially after years of feeling at the mercy of a bizarre and seemingly inexplicable force. The long-range goal of the Refocus step is, of course, never again to perform a compulsive behaviour in response to an OCD thought or urge. But the intermediate goal is to impose a time delay before performing any compulsion. You’re learning not to allow OCD feelings to determine what you do.

Sometimes the urge will be too b, and you will perform the compulsion. This is not an invitation to beat yourself up. Keep in mind: As you do the Four Steps and your behaviour changes, your thoughts and feelings will also change. If you give in and perform a compulsion after a time delay and an attempt to Refocus, make a special effort to continue to Relabel the behaviour and to acknowledge that this time the OCD overwhelmed you. Remind yourself “I’m not washing my hands because they are dirty, but because of my OCD. The OCD won this round, but next time I’ll wait longer.” In this way, even performing a compulsive behaviour can contain an element of behaviour therapy. This is very important to realize: Relabeling a compulsive behaviour as a compulsive behaviour is a form of behaviour therapy and is much better than doing a compulsion without making a clear mental note about what it is.

A tip for those who are fighting checking behaviours – checking locks, stoves, and other appliances: If your problem is, say, checking the door lock, try to lock the door with extra attention and mindful awareness the first time. This way, you’ll have a good mental picture to refer to when the compulsive urge arises. Anticipating that the urge to check is going to arise in you, you should lock the door the first time in a slow and deliberate manner, making mental notes, such as “The door is now locked. I can see that the door is locked.” You want a clear mental image of that locked door; so when the urge to check the door seizes you, you will be able to Relabel it immediately and say, “That’s an obsessive idea. It is OCD.” You will Reattribute the intensity and intrusiveness of the urge to check again to your OCD. You will remember, “It’s not me–it’s just my brain.”

You will Refocus and begin to “work around” the OCD urges by doing another behaviour, with a ready mental picture of having locked that door because you did it so carefully and attentively the first time. You can use that knowledge to help you Refocus actively on doing another behaviour, even as you Relabel and Reattribute the urge to check that has arisen, as you anticipated it would.

Keeping a Journal

It is important to keep a behaviour-therapy journal as a record of your successful Refocusing efforts. It need not be anything fancy. The idea is simply to have a written record to remind you of your successes in self-directed behaviour therapy. The journal is important because you can refer back to it to see which behaviours most helped you to Refocus. But–and this is equally important–it helps you to build confidence as you see your list of achievements grow. In the heat of battle against a compulsive urge, it isn’t always easy to remember which behaviour to Refocus on. Keeping a journal will help you to shift gears when the going gets tough, when the obsessive thought or compulsive urge heats up, and will train your mind to remember what has worked in the past. As your list of successes gets longer, it will be inspirational.

Record only your successes. There is no need to record your failures. You have to learn to give yourself a pat on the back. This is something people with OCD need to learn to do more of. Make sure to give yourself encouragement by consciously acknowledging your successful use of Refocusing behaviours as a job well done. Reinforce that success by recording it in your behaviours-therapy journal and giving yourself a little reward, even if it’s only to tell yourself how terrific you are for working so hard to help yourself.

The Four Steps: Step 4 – Revalue

by  Dr Jeffrey Schwartz

The goal of the first three steps is to use your knowledge of OCD as a medical condition caused by a biochemical imbalance in the brain to help you clarify that this feeling is not what it appears to be and to refuse to take the thoughts and urges at face value, to avoid performing compulsive rituals, and to Refocus on constructive behaviours. You can think of the Relabel and Reattribute steps as a team effort, working together with the Refocusing step. The combined effect of these three steps is much greater than the sum of their individual parts. The process of Relabeling and Reattributing intensifies the learning that takes place during the hard work of Refocusing. As a result, you begin to Revalue those thoughts and urges that, before behaviour therapy, would invariably lead you to perform compulsive behaviours. After adequate training in the first three steps, you are able in time to place a much lower value on the OCD thoughts and urges.

We have used the concept of the “Impartial Spectator,” developed by 18th-century philosopher Adam Smith, to help you understand more clearly what you are actually achieving while performing the Four Steps of cognitive biobehavioral therapy. Smith described the Impartial Spectator as being like a person inside us who we carry around at all times, a person aware of all our feelings, states, and circumstances. Once we make the effort to strengthen the Impartial Spectator’s perspective, we can call up our own Impartial Spectator at any time and literally watch ourselves in action. In other words, we can witness our own actions and feelings as someone not involved would, as a disinterested observer. As Smith described it, “We suppose ourselves the spectators of our own behaviour” He understood that keeping the perspective of the Impartial Spectator clearly in mind, which is essentially the same as using mindful awareness, is hard work, especially under painful circumstances, and requires the “utmost and most fatiguing exertions.”. The hard work of which he wrote seems closely related to the intense efforts you must make in performing the Four Steps.

People with OCD must work hard to manage the biologically induced urges that intrude into conscious awareness. You must strive to maintain awareness of the Impartial Spectator, the observing power within that gives you the capacity to fend off pathological urges until they begin to fade. You must use your knowledge that OCD symptoms are just meaningless signals, false messages from the brain, so you can Refocus and shift gears. You must gather your mental resources, always keeping in mind, “It’s not me–it’s my OCD. It’s not me–it’s just my brain.” Although in the short run, you can’t change your feelings, you can change your behaviour By changing your behaviour, you find that your feelings also change in time. The tug-of-war comes down to this: Who’s in charge here, you or OCD? Even when the OCD overwhelms you, and you give in and perform the compulsion, you must realize that it’s just OCD and vow to fight harder the next time.

With compulsive behaviours, simply observing the fifteen-minute rule with consistency and Refocusing on another behaviour will usually cause the Revalue step to kick in, which means realising that the feeling is not worth paying attention to and not taking it at face value, remembering that it’s OCD and that it is caused by a medical problem. The result is that you place a much lower value on–devalue–the OCD feeling. For obsessive thoughts, you must try to enhance this process by Revaluing in an even more active way. Two substeps – the two A’s – aid you in Step 2: Reattribute: Anticipate and Accept. When you use these two A’s, you are doing Active Revaluing. Anticipate means “be prepared,” know the feeling is coming, so be ready for it; don’t be taken by surprise. Accept means don’t waste energy beating yourself up because you have these bad feelings. You know what’s causing them and that you have to work around them. Whatever the content of your obsession–whether it is violent or sexual or is manifested in one of dozens of other ways–you know that it can occur hundreds of times a day. You want to stop reacting each time as though it were a new thought, something unexpected. Refuse to let it shock you; refuse to let it get you down on yourself. By anticipating your particular obsessive thought, you can recognize it the instant it occurs and Relabel it immediately. You will simultaneously, and actively, Revalue it. When the obsession occurs, you will be prepared. You will know, “That’s just my stupid obsession. It has no meaning. That’s just my brain. There’s no need to pay attention to it.” Remember: You can’t make the thought go away, but neither do you need to pay attention to it. You can learn to go on to the next behaviour There is no need to dwell on the thought. Move ahead. This is where the second A–Accept–comes in. Think of the screaming car alarm that disturbs and distracts you. Don’t dwell on it. Don’t say, “I can’t do another thing until that blankety-blank car alarm shuts off.” Simply try to ignore it and get on with things.

You learned in Step 2 that the bothersome obsessive thought is caused by OCD and is related to a biochemical imbalance in the brain. In the Acceptance substep of Reattributing, you realise that truth in a very deep, perhaps even spiritual, way. Do not get down on yourself. it makes no sense to criticize your inner motives just because of an imbalance in the brain. By accepting that the obsessive thought is there despite you, not because of you, you can decrease the terrible stress that repetitive obsessive thoughts usually cause. Always keep in mind, “It’s not me–it’s the OCD. It’s not me–it’s just my brain.” Don’t beat yourself up trying to make the thought go away because in the short run, it will not. Most important, don’t ruminate and don’t fantasize about the consequences of acting out a terrible obsessive thought. You won’t act it out because you don’t really want to. Let go of all the negative, demeaning judgments about “the kinds of people who get thoughts like this.” For obsessions, the fifteen-minute rule can be shortened to a one minute rule, even a fifteen-second rule. There is no need to dwell on that thought, even though it lingers in your mind. You can still go on–indeed, you must go on–to the next thought and the next behaviour In this way, Refocusing is like a martial art. An obsessive thought or compulsive urge is very b, but also quite stupid. If you stand right in front of it and take the full brunt of its power, trying to drive it from your mind, it will defeat you every time. You have to step aside, work around it, and go on to the next behaviour You are learning to keep your wits about you in the face of a powerful opponent. The lesson here goes far beyond overcoming OCD By taking charge of your actions, you take charge of your mind–and of your life.

Conclusions

We who have OCD must learn to train our minds not to take intruding feelings at face value. We have to learn that these feelings mislead us. In a gradual but tempered way, we’re going to change our responses to the feelings and resist them. We have a new view of the truth. In this way, we gain new insights into the truth. We learn that even persistent, intrusive feelings are transient and impermanent and will recede if not acted on. And, of course, we always remember that these feelings tend to intensify and overwhelm us when we give in to them. We must learn to recognise the urge for what it is–and to resist it. In the course of performing this Four-Step Method of behavioural self-treatment, we are laying the foundation for building true personal mastery and the art of self-command. Through constructive resistance to OCD feelings and urges, we increase our self-esteem and experience a sense of freedom. Our ability to make conscious, self-directed choices is enhanced.

By understanding this process by which we empower ourselves to fight OCD and by clearly appreciating the interest.

Four Steps Summary

Step 1: Relabel Recognise that the intrusive obsessive thoughts and urges are the RESULT OF OCD.

Step 2: Reattribute Realise that the intensity and intrusiveness of the thought or urge is CAUSED BY OCD; it is probably related to a biochemical imbalance in the brain.

Step 3: Refocus Work around the OCD thoughts by focusing your attention on something else, at least for a few minutes: DO ANOTHER BEHAVIOUR.

Step 4: Revalue Do not take the OCD thought at face value. It Is not significant in itself.

You may now wish to read the full book, Brain Lock and review the Four Steps introduction video (34 minutes).control one gains by training the mind to overcome compulsive or automatic responses to intrusive thoughts or feelings, we gain a deepening insight into how to take back our lives. Changing our brain chemistry is a happy consequence of this life-affirming action. True freedom lies along this path of a clarified perception of genuine self-hood.