The Four Steps: Step 3 - Refocus

By Dr Jeffrey Schwartz

Watch our video introductory overview of the Four Steps treatment method for OCD. (Length - 34:47).

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 strong 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.

Step 1: Relabel

Step 2: Reattribute

Step 3: Refocus

Step 4: Revalue

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.

Source: Brain Lock by Dr Jeffrey Schwartz

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The Next Chapter: Step 4: Revalue

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