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Four Steps to Manage Obsessive-Compulsive Disorder

When I was a young girl, I struggled with obsessive-compulsive disorder. I believed that if I landed on a crack in the sidewalk, something terrible would happen to me, so I did my best to skip over them. I feared that if I had bad thoughts of any kind, I would go to hell.

To purify myself, I would go to confession and Mass over and over again, and spend hours praying the rosary. I felt if I didn’t compliment someone, like the waitress where we were eating dinner, I would bring on the end of the world.

What Is OCD?

The National Institute of Mental Health defines OCD as a “common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over.” OCD involves a painful, vicious cycle whereby you are tormented by thoughts and urges to do things, and yet when you do the very things that are supposed to bring you relief, you feel even worse and enslaved to your disorder.

The results of one study indicated that more than one quarter of the adults interviewed experienced obsession or compulsions at some point in their lives — that’s over 60 million people — even though only 2.3 percent of people met the criteria for a diagnosis of OCD at some point in their lives. The World Health Organization has ranked OCD as one of the top 20 causes of illness-related disability worldwide for individuals between 15 and 44 years of age.

Whenever I am under considerable stress, or when I hit a depressive episode, my obsessive-compulsive behavior returns. This is very common. OCD breeds on stress and depression. A resource that has been helpful to me is the book Brain Lock by Jeffrey M. Schwartz, M.D. He offers a four-step self-treatment for OCD that can free you from painful symptoms and even change your brain chemistry.

Distinguishing Form from Content of OCD

Before I go over the four steps, I wanted to go over two concepts he explains in the book that I found very helpful to understanding obsessive-compulsive behavior. The first is knowing the difference between the form of obsessive-compulsive disorder and its content.

The form consists of the thoughts and urges not making sense but constantly intruding into a person’s mind — the thought that won’t go away because the brain is not working properly. This is the nature of the beast. The content is the subject matter or genre of the thought. It’s why one person feels something is dirty, while another can’t stop worrying about the door being locked.

The OCD Brain

The second concept that is fascinating and beneficial to a person in the throes of OCD’s torture is to see a picture of the OCD brain. In order to help patients understand that OCD is, in fact, a medical condition resulting from a brain malfunction, Schwartz and his colleagues at UCLA used PET scanning to take pictures of brains besieged by obsessions and compulsive urges. The scans showed that in people with OCD, there was increased energy in the orbital cortex, the underside of the front of the brain. This part of the brain is working overtime.

According to Schwartz, by mastering the Four Steps of cognitive-biobehavioral self-treatment, it is possible to change the OCD brain chemistry so that the brain abnormalities no longer cause the intrusive thoughts and urges.

Step One: Relabel

Step one involves calling the intrusive thought or urge exactly what it is: an obsessive thought or a compulsive urge. In this step, you learn how to identify what’s OCD and what’s reality. You might repeat to yourself over and over again, “It’s not me — it’s OCD,” working constantly to separate the deceptive voice of OCD from your true voice. You constantly inform yourself that your brain is sending false messages that can’t be trusted.

Mindfulness can help here. By becoming an observer of our thoughts, rather than the author of them, we can take a step back in loving awareness and simply say, “Here comes an obsession. It’s okay … It will pass,” instead of getting wrapped up in it and investing our emotions into the content. We can ride the intensity much like a wave in the ocean, knowing that the discomfort won’t last if we can stick in there and not act on the urge.

Step Two: Reattribute

After you finish the first step, you might be left asking, “Why don’t these bothersome thoughts and urges go away?” The second step helps answer that question. Schwartz writes:

The answer is that they persist because they are symptoms of obsessive-compulsive disorder (OCD), a condition that has been scientifically demonstrated to be related to a biochemical imbalance in the brain that causes your brain to misfire. There is now strong scientific evidence that in OCD a part of your brain that works much like a gearshift in a car is not working properly. Therefore, your brain gets stuck in gear. As a result, it’s hard for you to shift behaviors. Your goal in the Reattribute step is to realize that the sticky thoughts and urges are due to your balky brain.

In the second step, we blame the brain, or in 12-step language, admit we are powerless and that our brain is sending false messages. We must repeat, “It’s not me — it’s just my brain.” Schwartz compares OCD to Parkinson’s disease — both interestingly are caused by disturbances in a brain structure called the striatum — in that it doesn’t help to lambast ourselves for our tremors (in Parkinson’s) or upsetting thoughts and urges (in OCD). By reattributing the pain to the medical condition, to the faulty brain wiring, we empower ourselves to respond with self-compassion.

Step Three: Refocus

In step three, we shift into action, our saving grace. “The key to the Refocus step is to do another behavior,” explains Schwartz. “When you do, you are repairing the broken gearshift in your brain.” The more we “work around” the nagging thoughts by refocusing our attention on some useful, constructive, enjoyable activity, the more our brain starts shifting to other behaviors and away from the obsessions and compulsions.

Step three requires a lot of practice, but the more we do it, the easier it becomes. Says Schwartz: “A key principle in self-directed cognitive behavioral therapy for OCD is this: It’s not how you feel, it’s what you do that counts.”

The secret of this step, and the hard part, is going on to another behavior even though the OCD thought or feeling is still there. At first, it’s extremely wearisome because you are expending a significant amount of energy processing the obsession or compulsion while trying to concentrate on something else. However, I completely agree with Schwartz when he says, “When you do the right things, feelings tend to improve as a matter of course. But spend too much time being overly concerned about uncomfortable feelings, and you may never get around to doing what it takes to improve.”

This step is really at the core of self-directed cognitive behavioral therapy because, according to Schwartz, we are fixing the broken filtering system in the brain and getting the automatic transmission in the caudate nucleus to start working again.

Step Four: Revalue

The fourth step can be understood as an accentuation of the first two steps, Relabeling and Reattributing. You are just doing them with more insight and wisdom now. With consistent practice of the first three steps, you can better acknowledge that the obsessions and urges are distractions to be ignored. “With this insight, you will be able to Revalue and devalue the pathological urges and fend them off until they begin to fade,” writes Schwartz.

Two ways of “actively revaluing,” he mentions are anticipating and accepting. It’s helpful to anticipate that obsessive thoughts will occur hundreds of times a day and not to be surprised by them. By anticipating them, we recognize them more quickly and can Relabel and Reattribute when they arise. Accepting that OCD is a treatable medical condition — a chronic one that makes surprise visits — allows us to respond with self-compassion when we are hit with upsetting thoughts and urges.

Four Steps to Manage Obsessive-Compulsive Disorder


Therese J. Borchard

Therese J. Borchard is a mental health writer and advocate. She is the founder of the online depression communities Project Hope & Beyond and Group Beyond Blue, and is the author of Beyond Blue: Surviving Depression & Anxiety and Making the Most of Bad Genes and The Pocket Therapist. You can reach her at thereseborchard.com or on Facebook, Twitter, Instagram, or LinkedIn.


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APA Reference
Borchard, T. (2019). Four Steps to Manage Obsessive-Compulsive Disorder. Psych Central. Retrieved on October 12, 2019, from https://psychcentral.com/blog/four-steps-to-manage-obsessive-compulsive-disorder/
Scientifically Reviewed
Last updated: 13 Apr 2019
Last reviewed: By a member of our scientific advisory board on 13 Apr 2019
Published on Psych Central.com. All rights reserved.