Brain Lock: Free Yourself From Obsessive-Compulsive Behavior (33 page)

C. Compulsions-Mental. Right Feeling—Need For. Negate. Replace with Positive. Ruminate. Counting. Compulsions-Visible. Confess. Seeking reassurance. Tapping.

2. REATTRIBUTE. Medical condition. Biochemical imbalance. Gating theory: stuck in gear (caudate nucleus/putamen/striatum). False message: Car alarm. Static. Ego-alien. Genetic illness.

IT’S NOT ME—IT’S MY OCD. OUT OF MY CONTROL DISORDER. BLAME IT ON THE BRAIN.

A. ANTICIPATE. Prepare. Shall not fear. Blame it on the brain.

B. ACCEPT. Serenity prayer. Stature. Not because of me, but
despite
me.

3. REFOCUS. Turn away (other cheek). Do another behavior. Just say
know
. Put on hold—delay compulsions. Ignore.

4. REVALUE. Devalue-false messages. Who cares if it doesn’t go away? It’s not real anyway. Apathy—indifference. Humor. Sarcasm. Don’t be polemical—it’s just a chemical.

PART III

Self-Treatment Manual for the Four-Step Method

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

The concept of self-treatment as part of a behavior-therapy approach is a major advance. In this manual, I will teach you how to become your own behavioral therapist. By learning some basic facts about OCD, and recognizing that it is a medical condition that responds to treatment, you will be able to overcome the urges to do compulsive behaviors 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 behavior therapy techniques. Research has shown that exposure and response prevention are very effective behavior 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 behaviors. We call our method “biobehavioral” 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 behavioral 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:

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. Let’s begin by learning the Four Steps.

STEP 1: RELABEL

The critical first step is to learn to recognize 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 recognize 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 compulsion 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 recognize 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 behavioral 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 behavior 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, demoralization, and stress. It will, in fact, tend to make the urges worse. Probably the most important thing to learn in this behavioral 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 behavioral responses to OCD symptoms.

STEP 2: REATTRIBUTE

The key to our self-directed behavioral therapy approach to treating OCD can be summed up in one sentence: “It’s not me—it’s my OCD.” That is our battle cry. It is a reminder that OCD thoughts and urges are not meaningful, that they are false messages from the brain. Self-directed behavior therapy lets you gain a deeper understanding of this truth.

You are working toward a deep understanding of why the urge to check that lock or why the thought that “my hands are dirty” can be so powerful and overwhelming. If you know the thought makes no sense, why do you respond to it? Understanding why the thought is so strong and why it won’t go away is the key to increasing your willpower and enabling you to fight off the urge to wash or check.

The goal is to learn to Reattribute the intensity of the thought or
urge to its real cause, to recognize that the feeling and the discomfort are due to a biochemical imbalance in the brain. It is OCD—a medical condition. Acknowledging it as such is the first step toward developing a deeper understanding that these symptoms are not what they seem to be. You learn not to take them at face value.

Deep inside the brain lies a structure called the
caudate nucleus
. Scientists worldwide have studied this structure and believe that, in people with OCD, the caudate nucleus may be malfunctioning. Think of the caudate nucleus as a processing center or filtering station for the very complicated messages generated by the front part of the brain, which is probably the part used in thinking, planning, and understanding. Together with its sister structure, the
putamen
, which lies next to it, the caudate nucleus functions like an automatic transmission in a car. The caudate nucleus and the putamen, which together are called the
striatum
, take in messages from very complicated parts of the brain—those that control body movement, physical feelings, and the thinking and planning that involve those movements and feelings. They function in unison like an automatic transmission, assuring the smooth transition from one behavior to another. Typically, when anyone decides to make a movement, intruding movements and misdirected feelings are filtered out automatically so that the desired movement can be performed rapidly and efficiently. There is a quick, smooth shifting of gears.

During a normal day, we make many rapid shifts of behavior, smoothly and easily and usually without thinking about them. It is the functioning of the caudate nucleus and the putamen that makes this possible. In OCD, the problem seems to be that the smooth, efficient filtering and the shifting of thoughts and behavior are disrupted by a glitch in the caudate nucleus.

As a result of this malfunction, the front of the brain becomes overactive and uses excessive energy. It’s like having your car stuck in a ditch. You spin and spin and spin your wheels, but without traction you can’t get out of that ditch. With OCD, too much energy is being used in a frontal part of the brain called the
orbital cortex
. It’s as if the orbital cortex, which has an error-detection circuit, becomes stuck in gear. This is probably why OCD causes people to get a “something is wrong” feeling that won’t go away. You have to do the
work to get it out of gear—to shift the gears. You have a manual, rather than an automatic, transmission. In fact, the person with OCD has a sticky manual transmission; he or she must shift the gears. This takes great effort because the brain tends to get “stuck in gear.” But, whereas an automobile transmission is made of metal and can’t fix itself, people with OCD can teach themselves how to shift gears through self-directed behavior therapy. In doing so, they can actually fix this broken gearshift in the brain. We now know that you can change your own brain biochemistry.

The key to the Reattribute step is to realize that the awful intrusiveness and ferocious intensity of OCD thoughts are due to a medical condition. Underlying problems in brain biochemistry are causing these thoughts and urges to be so intrusive. That is why they won’t go away. By doing this Four-Step Method of self-directed behavior therapy, you can change the brain’s biochemistry. This takes weeks or even months of hard work. In the meantime, understanding the role the brain plays in OCD thoughts and urges will help you to avoid one of the most demoralizing and destructive things people with OCD almost invariably do: the frustrating attempt to “get rid of” the thoughts and urges. There is nothing you can do to make them go away immediately. But remember: You don’t have to act on them. Don’t take them at face value. Don’t listen to them. You know what they are. They are false messages from the brain that are due to a medical condition called OCD. Use this knowledge to avoid acting on them. The most effective thing you can do—something that will help you change your brain for the better in the long run—is to learn to put these thoughts and feelings aside and go on to the next behavior. This is what we mean by shifting gears: Do another behavior. Trying to make them go away will only pile stress on stress—and stress just makes OCD thoughts and urges worse.