The Four Steps: New Developments.  ** Lectures on Progressive Mindfulness **/ by J.M. Schwartz, M.D.

This is the brief series of lectures leading up to the OC Foundation meeting 2001 in Denver, lecture on progressive mindfulness.  These will be a brief series of lectures done before a live audience, the OCD group on Thursdays: so it's May 17, 2001.

So, the first thing that we want to review is Step 1: Relabel.  And when we talk about progressive mindfulness, what that really is going to mean in practice is this distinction between the so-called superficial Relabeling and the deep Relabeling.  But what do we mean by Relabeling. Well in the box at the beginning of Chapter 1 of Brain Lock it says "Relabel answers the question, 'what are these bothersome intrusive thoughts.'  The important point to keep in mind is that you must Relabel these unwanted thoughts, urges and behaviors.  You must call them what they really are:   they are obsessions and compulsions; you must make a conscious effort to keep firmly grounded in reality.  You must strive to avoid being tricked into thinking that the feeling that you need to check or count or wash, for example, is a real need.  It is not."  And how mindfulness comes into that is mindfulness is the function of your mind that tells you that this feeling is OCD.  So when we say Relabel, we're answering the question, "what is this that is bothering me?.  What are these bothersome, intrusive thoughts?"  And these bothersome, intrusive thoughts are obsessive thoughts and compulsive urges.

Now, when a person cannot do that, and there are definitely people in the beginning who cannot do that, in other words, the intensity of the bothersome thought and urge is so much -- the feeling of fear, the feeling of discomfort, the feeling of anxiety, the feeling that something is wrong, is so strong that they really can't answer the question, "what are these?" by saying, "this is OCD"; they literally keep saying to themselves "Something really is going to happen wrong," and when you can't answer the question, "what is this?"  by really saying to yourself, at least superficially, this is OCD, or at least at a level of belief that you really believe that it's OCD, even though you're worried that it's really real, if you can't answer the question, "what are these thoughts?" clearly enough by Relabeling, "this is OCD," then you need to use some combination of just regular behavior therapy  -- because in regular classical behavior therapy -- you don't have to Relabel  -- you don't have to answer the question, "what are these thoughts?"  -- and/or medication.  And obviously if it is that severe, you'll always need medication, in a case like that.

But, if you happen to be fortunate enough that your symptoms are not so severe and you really can answer the question, "what is this feeling that is bothering me, what is this thought that is bothering me, what is this urge that is bothering me?" and you can answer that question really with some level of confidence -- not complete certainty because, you know,  its still the beginning of treatment -- but at least with some level of confidence, "this is caused by OCD", then that is what we call Relabeling.  And the reason why, it involves what we call mindfulness or the Impartial Spectator  -- which I'll speak a little bit more about next week in the next lecture is because mindfulness and the Impartial Spectator is the part of your mind that allows you to view the thought with an impartial objective perspective literally as if it was someone else who was having the thought.  So you're calm and you see reality clearly and you actually see your own thoughts objectively from an impartial perspective as if, we sometimes say, you were literally standing outside yourself reading your own mind; and the more that you can do that, the more that you can see the thought as an obsessive thought and the urge as a compulsive urge, and the goal of the first step is to literally tell yourself, "this is an obsessive thought; this is a compulsive urge".  If you can't do that, classical behaviorism will help you by exposing you to the things that are causing you to have those symptoms and exposing you until the anxiety goes down.  But even under those circumstances, the goal to remember is that when the anxiety does come down, you should use the relief to be able to remember, that feeling was caused by OCD.   And in the end, the goal, even of a classical behaviorist approach -- the way we do it here, integrating it with the Four Steps --  we want to be able to use your exposures to get a control on your anxiety and when you get that control on your anxiety, you use the clarity of mind that comes with decreased anxiety to Relabel and realize the feeling itself is obsessive-compulsive disorder.

And then I'll just finish for today by saying superficial Relabeling is when this is done in a fairly automatic way, sort of the way a person with a moderate case of OCD goes into the doctor's office and says, "I know this is OCD, what can we do to make it better?"   But deeper Relabeling, which is when we get to the end of this series we are going to really get into this in more detail, but the goal of treatment in many ways is to get to the deeper Relabeling which as we are going to see is really the same as Step 4, Revalue.  And deeper Relabeling is when you actually come to feel the feeling as an OCD feeling; so as you do this with practice and couple it with behavior therapy and exposures so that you learn that you can tolerate this anxiety and the anxiety comes down, you literally will get to the point  -- and this is really the core of what we call progressive mindfulness -- when you come to actually feel the feeling itself as OCD; and, of course, we're going to elaborate more on that in the future lectures.

Brief Lecture number 2:  It is May 24, 2001 in front of the OCD group:

So we're finishing up with Step 1.  So I am going to just go over the key points to remember at the end of Chapter 1 quickly: So this is Step 1.  Key points to remember.

Step 1 is the Relabel step.  Relabel means calling the intrusive, unwanted thoughts and behaviors what they really are: obsessions and compulsions.  So that is the key point about Relabeling.  We're trying to go for reality.  We're trying to call this feeling that we're having what it really is -- namely, an obsession or a compulsion.  And of course the rule of thumb is if you think it might be an obsession or a compulsion, then it is an obsession or compulsion.  But for sure when you know it is an obsession or compulsion we want to actually work at getting a firm grasp of that reality.  This thought is an obsession; this feeling is a compulsive urge.  And when we get to the deeper Relabeling -- which is when we get to Revaluing it will really become obvious -- the deeper Relabeling is really learning to identify the actual painful feeling itself, that grinding, grabbing feeling, that uncomfortable sense that you really want to wash it, maybe it's dirty, maybe it's left unlocked but you know it's an obsession; and when you get into the more superficial level of Relabeling, you're saying this is an obsession.  But when you get into the deeper level of Relabeling, you're literally observing the feeling as an obsession.  So you're literally feeling the feeling as an obsessive feeling -- and you're literally saying to yourself, this feeling is the disease state.  And that's really what we're aiming for -- that's real mindfulness.  Feeling the feeling as the disease state, OCD.

Relabeling won't make unwanted thoughts and urges go away immediately, but it will prepare you to change your behavioral responses.  Now that's a very important point right in the box there -- key point to remember -- that Relabeling won't make unwanted thoughts and urges go away immediately, but it will prepare you to change your behavioral responses. When you change your behavior, you change your brain.

So the biggest thing that gets in the way of Relabeling is this desire, this very understandable desire, coupled with, perhaps because of the anxiety and the severity of the symptoms, for many people in the beginning, the actual anxiety itself and the painful feeling itself, gets in our way of seeing things as they really are.  And one of the things that really makes that even worse is this fantasy -- very understandable -- that if we just say it's an obsession, it'll stop bothering us.   And of course, all these experienced people are nodding.  But because we all know this and you learn this from very, very hard experience.  But when you're early in your treatment, you know you so much want it to go away that you just can't help but believe that if you just follow this instruction, it'll stop bothering you.  But unfortunately, it's more difficult than that.  And, of course, this is also where the behavioral exposures come in. 

The behavioral exposures come in exactly at the point where you just can't get the traction on your own to call it an obsession and compulsion and especially to act on that true awareness that it's an obsession and a compulsion and if you just don't have the insight, the knowledge or, what is more common, that the anxiety is so strong that you just can't think clearly yet about what this really is, and you feel confused or too unsure, then it really helps to have a therapist assisted exposure because when you do a therapist assisted exposure, then automatically, just because of the effect of exposure on the lower autonomic nervous system, just that exposure itself when done properly with response prevention will make the anxiety come down. 

So that's why exposure and response prevention can be very helpful for getting you to learn how to use the Four Steps more effectively because if you can't do the Relabeling effectively enough to just be able to not do compulsions based on the awareness that this is an obsession, this feeling is a compulsion, then the exposure and response prevention treatment which is of course very difficult to tolerate and takes a lot of, you know, tolerance which is why a therapist's assistance is really needed in the beginning to do it, but because it doesn't require insight to work, it will then bring down the anxiety just based on the effects of exposure and response prevention on the vegetative, on the autonomic nervous system, on basically the animal nervous system; but then what we want is to not just let that decrease in anxiety be the treatment because that's how the old behavior therapists used to do it.  That's the old behavior therapy. 

We're now taking this to a new level because in the new approach, we take advantage of this decrease in anxiety to stress; now we can Relabel.  So as the anxiety comes down we can start using the Four Steps more aggressively -- more assertively.  And the key to success is to strengthen your Impartial Spectator, your ability to stand outside yourself and observe your actions with mindful awareness. And of course since this whole series is called "progressive mindfulness" -- you know, that's obviously very, very important.  That the key is to be able to strengthen your Impartial Spectator -- the part of your mind that just can observe impartially, objectively, can really see what's actually going on -- stand outside yourself and watch, and that really, that act of standing outside yourself and watching really is the same thing as mindful awareness.  When we use the term "mindfulness" or "mindful awareness", that is really what we mean; taking that Impartial Spectator perspective and, of course, the deeper you do that, the more you can actually be with the feeling just knowing what it is and not really having an uncontrollable desire either to make it go away or to certainly, to act on it.  And that really would be deep mindfulness.

So I'll just finish today by reading a little bit out of the box for Step 2 -- Reattribute, and then next time we'll get into more detail on Reattribute.  Reattribute answers the question, "Why doesn't this bothersome thought, urge and behavior go away?  Why do they keep bothering me?   Why do these bothersome thoughts, urges and behaviors keep bothering me?  Why?  What should I attribute them to?"  And the answer to that question, of course, is that they persist because they are symptoms of obsessive-compulsive disorder, a condition that has been scientifically demonstrated to be related to a bio-chemical imbalance in the brain that causes your brain to misfire.

And next week we'll get into a little bit more detail about how understanding that this is your brain sending you a false message will help you be more mindful.  This is where biological knowledge actually helps to increase your mindfulness to help you Relabel on a deeper level.

This is brief lecture number 3 on May 31, 2001.

So we're going to answer the question that came up after we turned the tape off last week -- how exactly do you know the difference between Relabel and Reattribute -- I mean, how should you think of it so that you don't feel, what's the difference, you know, how do I know which is which?

So, as we say, it really does boil down to remembering the difference between answering the question, "what is this that's bothering me?" 'cause Relabeling is answering the question, "what is this that's bothering me?"  And of course the answer is this feeling that's bothering me, this thought that's bothering me, this urge that's bothering me, this tension that's bothering me, this anxiety that's bothering me, all of these things that, all these bothersome thoughts and feelings, what they are is OCD; they're symptoms of OCD.  So the whole idea of Relabeling is to answer the question, "what is it that's bothering me?" Because if you don't specifically make that effort of Relabeling it, you're gonna automatically get caught up in taking it at face value thinking that "I feel like I need to wash, I feel like it might be dirty" and since the biology of the condition, which is exactly what the Reattribute step is designed to remind you about, the biology of the condition is really pushing you towards this "what if" kind of thinking, this repeated worrying, you know, what if something is wrong, what if it's dirty, what if something really bad is going to happen, and when you recognize that these "what ifs", disease of doubt, all of these kinds of, ways of describing it -- but let's face it, in the end it so frequently does come down to this deep, gut level deep fear anxiety, "what if it's dirty, what if it's open, what if it's turned on, what if I don't do this compulsion even though I feel like its foolish, maybe something will really go wrong."

So when you Relabel it and say, "okay it's an obsession and a compulsion," you're at least beginning to remind yourself that all these "what ifs" are false.  But it's in the second step that you really do start to understand and work at really remembering and forming a very real understanding as it were a picture in your mind so that you're really understanding why you're feeling the way you are to answer the question, "why doesn't this feeling of what if something goes wrong, go away -- why does it keep on bothering me?"  And if it wasn't a brain condition what more or less would happen is once you Relabeled it and said "okay, it's just a compulsion, okay it's just an obsession", if it wasn't for the actual OCD disease process, Relabeling it really would be largely enough; or it would be a much bigger, direct benefit to making the feeling more controllable than it is.  But the fact is that Relabeling the feeling, this is an obsession, this is a compulsion, although it is crucial because if you don't do that you'll have no chance at all of resisting and not giving in, but the fact is you're still left with this extremely bothersome feeling.  And so you have to really know that, and, as we're going to see in a moment, Anticipate and Accept become extremely important when, especially when its primarily an obsession, just the thought itself that you're dealing with; but you have to plan ahead, Anticipate, not be taken by surprise that this feeling is still bothering you. And then when you really want to understand why doesn't it go away; because if you can begin to really understand why doesn't it go away, and as we know, even when you get into very advanced stages of treatment and development where you're not even doing any compulsions anymore, it's very easy, or very few, it's very easy to forget why this feeling doesn't go away and believe or allow yourself to get conned into thinking that there's something directly that you could do to make it go away.  But the fact is that because it's a medical condition, there's nothing directly you can do to make this bad feeling go away and that is where the Step 2, Reattribute comes in, because Reattribute means answering the questions, "Why do these thoughts and urges keep bothering me?" -- "Why don't they go away?"  The answer is, because of a medical condition called OCD.  And this is right from the box at the end of Chapter 2, the key points to remember:

OCD is related to a biochemical imbalance in the brain that results in a malfunction of the brain's gear shift:  The brain gets "stuck in gear".  Because the brain is stuck in gear, it's "error-detection circuit" keeps firing inappropriately.  This causes very uncomfortable feelings.

Changing your behavioral responses to the uncomfortable feelings and shifting to useful and constructive behaviors will, over time, make the broken gearshift come unstuck, at least to some degree it will come unstuck.  As the brain starts to shift gears properly, the uncomfortable feelings begin to fade and become easier to control. 

So that's kind of the big message.  Now in the actual chapter in the book we go into some detail about it's the caudate nucleus and which is part of what's called the basal ganglia which is the caudate nucleus and the putamen together and what that all really just means, all the names of these brain regions, is really knowing that these brain regions are involved in having behaviors, as well as thoughts, shift under natural circumstances.  That's why so much of what we do in day to day life, including things as simple as getting up and out of a chair or sitting down.  It's actually a very complex physical movement if you really are very mindful when you do it.  If you actually pay close attention to what you're doing when you stand up or sit down in a chair, you'll realize there are a lot of different movements going on and, when that area of the brain in the basal ganglia does not work properly, like it doesn't in people with Parkinson's Disease, which is the most well known disease where the basal ganglia really isn't working right, and if you've ever seen a person with Parkinson's Disease try to get up or sit down in a chair, you will know that it's not so simple for them to do because they have to actually think about every movement and actually think it through and use a lot of conscious effort to get up and sit down because the automatic movement is not happening for them because this basal ganglia is broken.  And so if you remember the physical situation of Parkinson's Disease where people's bodies literally get stuck in gear and then we can understand that Obsessive Compulsive Disorder, in a very significant way, has a similar type of mental symptom to the kind of bodily symptom that Parkinson's Disease has and its because basically the same area of the brain -- the basal ganglia -- is not working right.

So that is one way to really remember just how medical the problem is.  Because, the reason why the feeling doesn't go away and the reason why it literally gets stuck is literally your mind and the feeling is getting stuck just the way a person's body gets stuck when they have Parkinson's Disease and it is because of the same type of brain problem: namely, a basal ganglia deficiency, a basal ganglia malfunction which impairs the brain's ability to make easy automatic shifts in situations where you would normally be able to shift from this to that.

Now, the other key point to remember about the brain -- and then we'll finish up for the Reattribute step for today and next week we'll go onto the Refocus step -- is a big difference between Obsessive Compulsive Disorder and a more physical, a more bodily, condition, Parkinson's Disease.  In Parkinson's Disease, in fact their thinking also does slow down a lot of the time.  But in Obsessive Compulsive Disorder, there's a particular part of the thinking part of the brain that gets stuck in gear and that part of the brain is the so-called orbital frontal cortex which is the picture on the back of the book showing that the orbital frontal cortex is overactive and stuck in gear in people with Obsessive Compulsive Disorder.  And what the orbital frontal cortex does to a very significant degree is cause this error feeling.  It notices things, it processes information and when it sees that something isn't the way you would expect it to be, it fires and takes notice of that and doesn't let it go.  You can literally think of it as holding on to it and saying, "what is this?"  Well under a normal brain circumstance, once you answer that question reasonably you could automatically shift to the next thing.  But what's going on in Obsessive Compulsive Disorder is that this part of the brain, this error detection part of the brain that is giving you this bad compulsive urge or this bad obsessive thought literally is stuck in gear and will not let go.  And so once you really remember that, you'll have the answer to the question, why this feeling doesn't go away, why this feeling keeps bothering me.

Now, if you can't understand that clearly, which even if you can understand it clearly in an intellectual way, a lot of the time in, I would say most of the time in people at the beginning of treatment, the feelings are so intense and the bothersome urges are so intrusive, they keep coming in again and again and again and they bother you to such a degree, that just knowing what they are isn't quite enough yet to actually be able to resist them a lot of the time.  So one of the things, of course, that you do is take medication to make the gear shift work better and to make the feeling go down.  But this is also the place where the more classical type of behavior therapy can in fact be very helpful because in the classical type of behavior therapy where you're just doing the exposure and the response prevention and working on your fear structure and hierarchy, then without having to get an excessive amount of understanding, without having to get that really deep understanding that allows you to create a mental distance from the feeling, which is what, when we get into the steps of Refocus and Revalue, we're really going to be working on -- and that really is progressive mindfulness.  But what do you do before you're up to progressive mindfulness?   Well, you take medication to make the feeling go down and/or you do exposure and response prevention to allow that anxiety to decrease in intensity, because what classical behavioral therapy will do is allow you to be exposed to the kinds of situations that cause the OCD to really flare up and give you very bad feelings but after doing the very difficult job of exposure and response prevention which generally often requires a therapist's assistance in the serious severe symptoms, doing that though causes a decrease in the bothersome urge, causes some decrease in the anxiety and the fear.  And so the big shift we're trying to make now in our approach to treating OCD is that we are not just trying to use medication and classical behavior therapy just to make the feeling go down and we are not calling just a decrease in anxiety and a decrease in fear and even a decrease in compulsions per se the complete treatment.  But in fact what we want to do is use that decrease in fear and that decrease in anxiety to allow us to understand more clearly what is going on.  And with a decrease in anxiety and decrease in fear, more mindfulness power can come into play because when you're less distracted and less uncomfortable, you can think more clearly, and when you can think more clearly, you can really begin to understand, in a deeper way, "this is just my OCD bothering me and this is something I don't have to listen to". 

And next week we're going to talk about what do you do then, which is of course Refocus on a functional adaptive behavior, but the big picture now becomes that we're using medication and we're using classical behavior techniques, exposure and response prevention, not just to relieve anxiety and not even just to make obsessions and compulsions become less, but rather we're now using the two classical approaches of medication and classical behavior therapy as a means to a larger end; as a means to getting a decrease in anxiety and then using that decrease in anxiety so that we can have more mindfulness, more awareness of what's going on and the advantage of that, as we're going to see in the next couple of lectures, is that once you have accomplished that state and gotten to that point where you can think more clearly, be more mindful and understand that "this is just OCD, I'm in no real danger, nothing really bad is going to happen"; all these "what ifs" are nonsense, I don't have to listen to them because there's no "what if" that makes any real difference,  once you begin to actually see that clearly, with this mindfulness and decreased anxiety, it increases your options tremendously, so then you don't have to only do medication, or don't have to only do exposure -- of course, you can always do that, that's fine, but it raises the opportunity to do other types of Refocusing, kind of just adaptive behaviors, and that's where we really see a broadening out of this whole notion of self treatment, where you can even expose yourself by yourself because of the decrease in anxiety, that's fine, expose yourself to the things that make you frightened, do self-directed exposure and response prevention, or you can just realize this is OCD and just do something adaptive.  And over the next couple of weeks, we're going to really begin to fill in the details of how you make the decisions about whether you should do something adaptive, whether you should do self exposure right now, and this whole issue of how much exposure, how much positive Refocusing onto adaptive behaviors and how to fit these all together.  And we'll continue with that next week when we begin to get into the in-depth look at the Refocus step.

So this is lecture number 4, brief lecture number 4 on June the 7th, 2001.

And we are now going to begin our discussion of the Refocus step and also this, this new concept that we have recently come up with called "Refocus With A Star" and Refocus With A Star refers specifically to the notion that if there are things that, stimuli, in your environment or situations that happen to you on a day to day basis that cause you to have OCD symptoms, a particularly good way to Refocus, but not for beginners, but when you get into a bit of a more advanced stage or to do with a therapist earlier on in the treatment, is to actually Refocus your activities on the very thing that is causing you to get OCD symptoms. So, and of course, another name for that is self-exposure.  And so we're going to make that a, sort of a higher level Refocusing which we're going to call Refocus With A Star.

So the question comes up, and what we're going to talk about today and next week and get into some real detail on here is the answer to the question which has been, the question that has caused the most confusion over the years since people have been working on the Four Steps, you know sort of the book being published and people that you know I don't know work on it and people come and ask me questions, which is always very nice, but one of the controversial questions that I get, especially from classical behavior therapists and also sometimes from the patients of classical behavior therapists is: what is the difference between what is called 'avoidance' in all kinds of cognitive behavioral therapy, but especially in classical behavior therapy, there is a particularly nasty thing that people with OCD do called "avoidance" which really makes symptoms much, much worse and avoidance means that you literally avoid places and situations, things, people, anything that causes you to get an OCD symptom; you will avoid that situation and that, that is something that will make OCD much, much worse.  So that is called an avoidance and sometimes, I think possibly because people didn't really read the method very, very closely or didn't really think about it so deeply but when a method gets popular, you know you just have to know that's going to happen so, you know, that's understandable.

But people say, "what is the difference between Refocus and avoidance?" because in a superficial way if you don't think about it, you know, very clearly or very deeply, it sounds like, you know, Refocus might mean the same thing as get away from the situation that's making you anxious.  But that's a terrible misunderstanding.  Refocus never means, never means, get away from the situation that's causing you anxiety just because it's the situation that's causing you anxiety.  And, in fact I noticed, which I had actually forgotten when I was looking through the Refocus chapter three in the book, that the subtitle of the chapter is actually called "Wishing Won't Make It So", and that was done, in fact, to stress this very point that, that we're making here, because I knew very early on that there was a real risk that people would try to use the Four Steps, in a very understandable way, to help the feeling go away; and that is really a misapplication of the Four Step method and the one line that really sums up how much of a mistake that is, is the line that says "It's not how you feel, it's what you do that counts."  So everything that is in the Four Step method is directed towards getting you to do healthy things, do wholesome things and learn not to be so affected by the feelings that you have, obviously especially the OCD feelings. And it's in, it's in understanding that critical point that you can begin to really see clearly why Refocusing properly understood will never be avoidance because that subtitle "Wishing Won't Make It So" is directly addressed to the problem of people saying, well if I just Refocus and hope this stops bothering me, it will stop bothering me. But we want to make very clear right at the beginning that wishing won't make it so; there is nothing you can do or hope to make the OCD feeling just go away.  That's where the whole concept of "working around it" comes from.  "Working around it" means that with the OCD feeling still there, with the OCD symptom still bothering you, you actually work around that feeling, meaning that the feeling is still there, but even though the feeling is still there, you still do some wholesome adaptive healthy behavior.  And therein lies the critical difference between avoidance and Refocusing.

Because in avoidance what you're doing is avoiding a situation that's making you anxious because it's causing OCD symptoms.  So you see something, you know, the color red makes a person feel like maybe there's blood on that and makes them get irrational, obsessive thoughts and fears and so then they start staying away from things that are red.  And sometimes they'll even tell themselves, if they have a very superficial notion of the Four Steps and don't really understand it properly, they'll say, "well, I'll just Refocus away from, from red."  And that's exactly how this misunderstanding really started is because people started to misunderstand that perhaps you could Refocus away from things that were causing your OCD symptom.  And that is not the proper understanding of what Refocus means.  Because Refocus actually means is not that you Refocus away from something that's causing you to have an OCD symptom, but rather it means that instead of doing a compulsion, you do a good behavior.  So you're not Refocusing away from the thing that's causing you to have an OCD symptom, you're not Refocusing away from the stimulus or the situation that's causing you to have the OCD symptom, rather what you're doing is Refocusing away from the actual act of doing a compulsion or even the act of thinking about an obsession over and over and over again.

So what you want to do during the Refocus step is actually change from doing a compulsion to doing a healthy behavior.  And so to finish up for today, the key point becomes:   In an avoidance, you are actually trying to avoid getting a certain feeling by doing some behavior.  And so avoidance itself is a compulsion. That's one of the most important points to remember for doing cognitive behavioral self-treatment.  Because that's one of the places where you're going to really run into a rut if you forget.  If you do things that are avoiding situations that cause you to get OCD symptoms, that itself is a compulsion.  So that's a symptom.  Avoidance is a compulsion. Refocus, on the other hand, is never that you are just avoiding something that causes an OCD situation, rather, Refocus means that instead of fixing your mind on the OCD feeling itself and trying to make it go away by doing compulsions, you actually "work around" the bad feeling and do wholesome behaviors.

So with Refocus then, you're always doing a good behavior and you're always doing a good behavior instead of doing a compulsion.  So with Refocus of course, you're never doing a compulsion, you'realways doing a wholesome behavior.  With avoidance, on the other hand, it's always a compulsion. Because anything that you do, if the reason why you're doing it is just to stay away from something in the environment that's causing you to get an OCD symptom, that itself is a compulsion.  Avoidances are compulsions.

So there, just by definition, by a proper understanding of the words, you'll know that avoidance can never be the same as Refocusing, because avoidance, which means doing something that avoids a situation or a stimulus that causes an OCD symptom, avoidance is itself a compulsion.  But Refocusing, on the other hand, means that instead of doing a compulsion, you do a wholesome adaptive behavior.  And, of course, Refocus With A Star would mean the best Refocus you can actually do is to literally go and handle, Refocus on the very situation that is causing you to get the OCD feeling.  So, a Refocus With A Star would be, if you're afraid of the color red, you actually Refocus on something that's the color red and handle it and then work around the anxiety that that will cause.  Now that's a self-exposure and, again, it's not for everyone all the time; and there are other Refocuses that you can also do instead of just straight self-exposure.  But Refocus With A Star is always correct.  So if you Refocus on the thing that's causing you to get an OCD symptom, that will always be good.  And, of course, in the classical method, that's the only correct thing to do.

What we're going to do in the following two lectures is go over the fact that with the Four Steps, although self-exposure is always a good thing to do, with mindfulness, there are also other things you can do as well as just self-exposure and that's why the Four Step method, while not negating or disagreeing with anything classical behaviorism says, says there are other things that we can do besides just self-exposure.

So in that way we're trying to clarify why classical behavior sometimes disagrees with Four Steps; but Four Steps in principle never disagrees with the advice that classical behaviorism gives.

Brief Lecture number 5 on June 14th, 2001.

So last week we had completed reviewing the difference between avoidance, which means you're avoiding something that causes you to have a feeling of obsessive thoughts or compulsive urges, in other words, you're avoiding a stimulus in the environment that you know causes you to get uncomfortable feelings; and that is always bad and so the summary was, avoidance is a type of compulsion.  So avoidance means that you are avoiding something because it makes you feel uncomfortable with OCD feelings and you should always know that itself, the avoidance, is a compulsion.  That is, avoiding something that makes you uncomfortable, is itself a compulsion because it will make the avoidances get worse and worse and worse and will lead to more symptoms.

Refocusing, on the other hand, is not avoidance because Refocusing is when you are doing a compulsion or are about to do a compulsion.  So with Refocusing, you are not avoiding a stimulus.  With Refocusing, you are not avoiding something that causes you to get a feeling of OCD.  And in fact with of course the new step, Refocus With A Star, you are on purpose exposing yourself and confronting a stimulus that causes you to get OCD symptoms and then working around it by not doing the compulsion. So that's Refocus With A Star, an especially powerful form of Refocusing.

But even with standard Refocusing, it is never Refocusing away from something that causes you to get OCD symptoms.  When we talk about Refocusing, we're talking about not Refocusing away from a stimulus in the environment that causes you to get OCD symptoms, we're talking about Refocusing away from the actual performance of a compulsion.  So, say you were exposed to something, we've been using the example red so let's keep using it, so you're exposed to something red and you happen to be one of those people who have the symptom that the thought red makes you feel like you might be contaminated, maybe there was blood on that, or something like that.  So you go and start washing your hands.  Well, Refocusing would be to not wash your hands.  So at the point when you were going to go wash your hands, then you would do something, preferably involving the color red.  Ideally, the best would be Refocusing on something that actually was a stimulus that caused you to get OCD symptoms.  But of course you might not always be able to do that, especially on your own.  But in a therapist assisted situation, especially if a classical behavioral exposure and response prevention technique was being used, then you would, in that case, essentially always expose yourself to some stimulus that was red in that case, if red was the thing that was causing the symptom. 

But if you were just working on your own and you were just out there in the, in a more self-treatment situation without a therapist available, then any wholesome, good thing that you could Refocus on, and we always use gardening as a perfect example, because gardening, you put your hands in the dirt and of course anyone who has concern about dirt, I mean that's good because that, if they do have a concern about dirt, that would in fact be Refocus With A Star because that would be a self-exposure.  But it could be playing a musical instrument and then, you know, people would say, "but then my musical instrument will feel contaminated" and that in fact is a good thing because you'll realize, "hey this is just OCD and I will not avoid using my musical instrument just because I'm getting these obsessive thoughts that it's contaminated."  So it's good to use a musical instrument as the thing to Refocus on.  But it could be, you know we always talk about knitting, crocheting, it could be, it could be almost any useful activity and, of course, if you're at work, I'm now going to correct the one big thing that I left out of the book, so now it will be recorded on the tape, if you are at work, of course you Refocus on your work, because people have incredibly frequently said to me, "what if I'm at work, how can I Refocus?  I can't go listen to music or work in the garden if I'm at work."   And that's very true, but when you're at work you can always do your work, and of course that's the best Refocus of all in many ways because we always say that when you have a job when you have OCD, that's really the best because then you have two things at once, your job is your therapy.  So that when you're at work and you're doing something for work, you're not only doing your thing for work, which is very helpful, but you're also doing exposure and behavior therapy and certainly Refocusing right at work.

Now, what's new?   Okay, the thing that is new here, because there's one thing that I'm now going to be bringing up for the first time in the series, which is genuinely new.  Because everything I've been saying so far has been saying, everything that the Four Steps says -- "be mindful, Relabel, Reattribute, call it what it really is, Relabel, know it's just the medical condition, your brain sending you a false message, Reattribute, Refocus on some useful thing and then we're going to get to Revalue in the next time or two, you know, no, don't take it at face value," all of those things are consistent with what is done in a classical behavior exposure and response prevention treatment.  There's nothing in classical exposure and response prevention treatment, per se, that the Four Steps has any controversy about.  But, but it does go the other way because there have been things in classical behaviorism that, things about classical behaviorism have disagreed with principles in the Four Steps and that's what we really want to clarify and resolve in, in this lecture series.

And the main thing that was, has been a point of controversy is that because, in classical behavior theory, the notion is to expose the person until the anxiety comes down to the baseline.  So you expose the person to something that causes them a lot of anxiety; the anxiety goes up to a high level and then you want the anxiety to come down to the baseline or even below the baseline which usually takes a fair amount of waiting period, which is called the response prevention period.  And this is a classical paradigm derived from animal research, also effective in humans, but because the classical behavioral approach never really dealt with the inner life of an individual because it just so happens that the history of behaviorism never really wanted to deal with inner thoughts and feelings and put a major stress on what you can observe with your five senses, they got into the habit, the method of telling the people that you can't really remind yourself or the person shouldn't be reminded that this is not really dangerous; that this exposure will not cause you any harm. 

Now, if you're in a therapist assisted situation, I think that it is very reasonable to just trust the method and especially if it's an acute intensive treatment and especially if it's in the beginning of therapy when the insight, the person doesn't have a deep awareness, a deep understanding, "this is just my OCD."    If you're in a therapist assisted situation, I think that it is quite reasonable to just put the accent on tolerating the anxiety and knowing that the anxiety is going to come down.  As I've said a number of times, I mean one of those little things that the behaviorists do without really admitting it is they allow you to Refocus on them when, when you're doing the exposure and response prevention, you can talk, you can get distracted in conversation with the therapist  That they don't really consider not allowable, but technically that really is just Refocusing as well and all I'm really trying to do is generalize that principle and saying anything wholesome that you Refocus on during the response prevention period is actually okay. 

And then on top of that, I am making a somewhat stronger statement than that.  Because in this Four Step method, the accent is on mindfulness.  The accent is not just on getting the symptoms to go down.  I mean, of course, we want the symptoms to go down, I mean there's no question about that.  But what we're really, we have a, but we have a bigger goal in mind than just having the symptoms go down and, that, what that bigger goal is is having a, as a goal of the actually therapy itself, a goal of the Four Steps, is getting people to be more mindful, which means getting people to understand this symptom, this feeling, this bothersome fear, this feeling of contamination, this feeling of incompleteness, this worry, this bad thought, all of it is just OCD, none of it is really dangerous, it's just my brain sending me a false message, it's not me, it's just the OCD.  And because that really is the big goal of the treatment, especially once you're past the most acute, short term, intensive, therapist assisted part of the treatment or if you happen to not to be fortunate enough to ever have a therapist to do that with and you're doing the entire treatment on your own, then it is reasonable, at any point in the therapy, to always use mindfulness.  And what mindfulness is always going to tell you is, "this is just OCD".   And so any time you're exposing yourself to something that causes you to get OCD, or in the just regular environment of day to day life, something happens that makes you feel like you better do a compulsion, like some of us in here have the symptom, they better say something good, they better have a good thought, they better say, you know, "I love my wife", all of those things, which if they're done to avoid a bad feeling, are compulsions.  You Refocus away and don't do that while telling yourself "I don't need to do that, that is just a compulsion and the only reason why I feel like I need to do it is because of OCD."

And so when mindfulness is the goal, then it always is appropriate to remind yourself, "this is just OCD; I'm in no danger" and then you can do your self-exposures with a lot more confidence.  And I think one of the basic advantages of the Four Steps and one of the reasons why it is an advance in cognitive behavior treatment is because it's so consistent with and such an encouragement for doing exposure and response prevention totally on your own in a self-directed manner without the assistance of a therapist. You can always expose yourself to something that's causing you OCD and then do what we call Refocus With A Star which means Refocus on good thoughts, good wholesome thoughts, not compulsive good thoughts but genuine good thoughts -- things that are not related to doing compulsions, not trying to negate the feeling, not trying to make the feeling go away but just what we call "working around" the bad feeling. 

And so we'll finish, we're going to definitely get into more detail on that next time, but we'll finish for today by saying this is exactly why we can now, I think clearly see coming into a clearer focus if you will, why avoidance is always bad and why the Four Steps, and especially Refocusing, is never avoidance, because avoidance, remember, means you avoid something in the environment that causes you to have OCD or get an OCD symptom.  But in Refocus, you never do that.  In Refocus in fact, what you do is allow yourself to come into contact with the things that cause you to get OCD feelings and then use mindfulness to realize just that "this is just my OCD," and so when you use the Four Steps properly and have Relabeling and more mindfulness at your disposal, you will realize when you're starting to do an avoidance.  In other words, you won't do avoidances mindlessly and get into this unconscious habit of just avoiding things that cause you to get OCD symptoms.  In fact what you'll do is Relabel and say "I'm doing an avoidance now".  An avoidance is a compulsion.  That is one of the things that we're really adding as a one line message in this whole series.  An avoidance is a compulsion.

And when you have mindfulness, you will realize, "I'm doing an avoidance, an avoidance is a compulsion".  And so the Four Steps will help you realize when you're avoiding things in the environment that you know you should be doing, because if it's an avoidance, it's something that you know you should be doing.  So as soon as you realize "this is an avoidance, this is something I should be doing, the only reason I'm staying away from it is because of my fear of OCD," then you'll say, "that's just OCD, Relabel, it's just caused by the medical problem ,OCD, it's a false message coming from my brain, Reattribute" and then you'll Refocus on some healthy thing and if it's in the case of an avoidance, you'll actually do the thing that you're avoiding which would be Refocus With A Star.  When we do that regularly, we'll come to Revalue and as soon as we see our self avoiding something, we'll go, "let's do that because I don't want to do an avoidance."

And, and so, to sum up for today, the real value of mindfulness and the reason why Refocusing is never avoidance is because mindfulness in the Relabel and Reattribute steps will help us realize when we're doing an avoidance and will help us not avoid things in the environment that cause OCD but actually willfully and purposefully confront and expose ourselves to the very things that we used to be avoiding which is what we're now calling Refocus With A Star.  And we'll finish for today.

This is brief lecture number 6 on June 21st, 2001.

So today we're going to basically finish up the Refocus step and go over in a little bit more detail, some of these details on Refocusing and then I'm going to start the Revalue step or at least next time we will do the Revalue step and then we'll be finished up with the series.

So I'm just going to start off by reading a few points, the points from, the key points to remember at the end of the Refocus chapter of the book, "Brain Lock".

Step 3 is the Refocus step.

Refocus means to change your behavioral responses to unwanted thoughts and urges and focus your attention on something useful and constructive.  DO ANOTHER BEHAVIOR.

This is the no pain, no gain step.  You must be ACTIVE.  You can not be passive.

Use the fifteen minute rule.  Work around your symptoms by doing something wholesome and enjoyable for at least fifteen minutes and after fifteen minutes, make mental notes of how your symptoms have changed and try to Refocus for another fifteen minutes.

Use your Impartial Spectator.  It will strengthen your mind.

When you change your behavior, you change your brain.

Now, the big, the big point that we're trying to stress for this, for this series of lectures, that's making this new, is this whole issue of not doing avoidances.  And so when we do the Refocusing, I think especially in the beginning, it's important to remember that you want to mainly Refocus on a behavior or an activity, because Refocusing on a thought, especially for obsessive symptoms is really, really tricky.  So, so the really good rule of thumb, especially when you're really learning these Four Steps, is that when we speak about Refocus, we want to be Refocusing on doing something basically physical -- a behavior, an activity, and especially an activity that number one, you find reasonably enjoyable, and an activity that is basically something you already know how to do, that's why we frequently talk about a hobby, the reason for that is because then you'll have that habit mechanism in the basal ganglia focusing in on a good thought or a good activity I should say, not a good thought but a good activity, a good behavior, and then you're going to get that automatic transmission to start wiring, getting wired in to doing a wholesome behavior, a wholesome activity when you get that feeling of wanting to do a bad compulsive activity.  So that's why we want it to be enjoyable and we want it to be something that is basically a hobby-like activity, something that you're familiar with doing so that the actual doing of the activity is something you know how to do and that way you can be focusing your attention on doing it while having, cause we know you're going to have the distraction in the back of your mind, I mean we're planning on that.

That's the whole concept of "working around."  You're doing this new behavior, this new wholesome activity knowing, Anticipating, Accepting, which are the two A's, that you're going to have the bad thought in the back of your mind.  So you accept the fact that the bad thought's going to be there and the urge too, but you don't listen to that urge, you know it's just OCD, and then you Refocus your attention on a new wholesome activity which happens to be a wholesome activity like a hobby -- that's why we say gardening, playing a musical instrument -- something that you basically know and enjoy and are familiar with.

Now I do want to make the special point about why the thing about thinking a good thought is really not a good idea at all for Refocusing, and especially in the beginning and in general it's a bad Refocus to say, "I'm going to think a good thought instead of the bad thought" -- that is not a good idea for Refocusing. And, and the reason why -- let's just use the classic kind of example that actually came up in the questions after last lecture , after last week's lecture  -- you're getting these thoughts about dying and so then you try to sort of respond to that by thinking quote, unquote, a good thought such as "I'm healthy". The reason why that that is not a good idea, and that that is not a good Refocusing practice, is because it is so easy for a thought like that to actually become an avoidance.  Because if you're thinking "I'm healthy" when you're getting this intrusive, bothersome obsessive thought about death, then in essence what you're trying to do, especially early on, is that you're avoiding the stimulus that's associated with the OCD symptom, namely the thought about death.

So the reason why you don't want to think "I'm healthy" as a way of Refocusing if you're getting a thought about death  -- and I'm just using this as a specific example to make the general point, is because that basically is very close to avoiding the stimulus that is causing you to get the OCD fear, namely the thought of, of death, and because of the fact that it's avoiding the stimulus, then it is in fact, becoming an attempt to neutralize the bad thought.  And any attempt to neutralize a bad thought is an avoidance, which means it is a compulsion.

So anything that you're doing to try to neutralize a bad obsessive thought is a compulsion.  So it would never be a good Refocus, because of course, a Refocus is never a compulsion, and so you want to be very careful not to be doing things that have an attempt to neutralize the bad thought or to make the bad thought go away.  You never want to try to make a bad obsessive thought go away, you want to work around it, which means that you accept that it's there and then try to do another behavior.

However, the thing that is new here, in this series, is that I am telling you that it is okay, acceptable, part of being mindful to remind yourself, "this is just an obsessive thought" so that when you're getting this thought about death, you don't want to be saying "I'm healthy" because that is really too much like trying to neutralize the bad thought and that's why it's not a good Refocus, because it's in essence trying to avoid the stimulus which is the bad obsessive thought about death and you never want to avoid the bad -- the thought that's causing the OCD stimulus.  You never want to just try to avoid or neutralize a bad obsessive thought.  What you want to do is accept that it's there and work around it by focusing attention on a good behavior.  However, because mindfulness is always good and that's a basic thing you can always remember -- mindfulness is always beneficial, mindfulness is always good -- mindfulness, the Impartial Spectator, will tell you that this thought, "I'm going to die," this thought about death, is just an obsessive thought.  So you don't try to neutralize it and you don't try to avoid it and you don't try to make it go away.

However, it's just pure mindfulness to be aware of what it really is and so you certainly can remind yourself that this is, this thought about death, to use that example, is just an obsessive thought, it's an obsessive thought, nothing more, nothing less.  And what we're trying to do is accept that we have this thought about death in our minds or whatever the obsessive thought is and then work around it by focusing on not a thought but a behavior, a wholesome behavior.

So the key is not to try to make the bad feeling go away.  You're not supposed to be trying to neutralize it or make the bad feeling go away  -- you're supposed to be working around it which means accepting that the bad thought is there but not focusing on it.  Focusing your attention on some adaptive behavior or activity.

So that's really what we mean by "working around it" and that, of course, is the key to the Refocus step -- working around it  -- not trying to make it go away but mindfully Refocusing, but because it's mindful Refocusing, we are certainly allowed to realize the reason why we're Refocusing away from this painful, bad thought is just because it's an obsessive thought and because it's an obsessive thought, it's not true.  So that is acceptable, genuinely acceptable; mindfulness is always good and mindfulness tells us "this is an obsessive thought".  We accept that it's there, we don't try to make it go away, but then we Refocus on another behavior.  And that behavior should be a familiar behavior more or less, and one that is enjoyable and you really want to focus your attention on it, working around the fact that the bad thought will still be there, and of course, that's what we mean "working around," accepting that the bad thought is there, not trying to make it go away, not trying to just make the urge go away, not trying to neutralize it, but accepting that it's there and not focusing attention on it, focusing attention on something else.  And so it's like working around it as if it was an obstacle.

Refocus With A Star, on the other hand, the next higher level, we might say, the more intensified level of Refocusing which you start to do either with therapist assistance in the beginning, or, as you really get more of a mastery with Refocusing if you're working on your own, with Refocus With A Star you would actually focus attention on the bad thought, focus attention on the stimulus that's causing the OCD to happen, all the while knowing this bad feeling is just OCD.

And next week, we're going to talk about Revalue, which is a deeper understanding.  Revalue is deepRelabeling and in Revalue, which will be the final lecture, we will come to see how it's understanding that this feeling itself, seeing the feeling as OCD and starting to do that in an automatic way.  And that will be all for today.

This is very brief lecture, the final lecture of the series, number 7 on June the 28th, 2001.

So we finished last time talking about Revaluing being deep Relabeling and what you really want to do is come to see the actual feeling of obsessional thought, that bad feeling of compulsive urge; Revaluing really  is understanding the feeling itself, the bad feeling as being an OCD symptom, as being an OCD experience.  And so I just want to read the box at the end of the Revalue chapter -- the key points to remember.

Step 4 is the Revalue step:

Revalue means don't take your symptoms at "face value" -- they don't mean what they say.  See them for what they are.

Work to Revalue in an active way, by seeing the reality of the situation as quickly and clearly as possible.  Strengthen the clarity of your observation with assertive mental notes, such as "It's not me -- it's just OCD."  So make those assertive mental notes.  "This feeling is OCD."  That is really what we mean by progressive mindfulness, because the deep mindfulness, the progress of mindfulness is really understanding the feeling, the bad feeling, as OCD.  So you want to separate away -- that's what the Impartial Spectator will do; so you're not going "I feel like I'm nervous"; you're going "this nervous feeling is OCD".  When you Revalue and devalue unwanted thoughts and urges you are strengthening your Impartial Spectator and building a powerful mind.  It's the Revaluing and devaluing of the unwanted thoughts and urges that strengthens the Impartial Spectator.

A mind that can take note of subtle changes and understand the implications of those changes is a powerful mind; a powerful mind can change the brain by altering responses to the messages the brain sends.  This is true self-command; it results in real self esteem.

So the point, the big point there is that as you see that feeling as being just OCD, it strengthens your, your Impartial Spectator and when that Impartial Spectator gets strengthened -- which is just what we mean by progressive mindfulness -- progressive mindfulness means making the Impartial Spectator stronger -- and when that happens, you actually create this mental distance that allows you to experience the nervous feeling, experience the unwanted urge, experience the bad thought as not being me and just actually feel it as obsessive compulsive disorder.

That really is the goal of the entire Four Steps because when you do that, then you get into an automatic Refocusing mode -- because you say "hey, this is not worth paying attention to" and you can see that clearly.  That's why we say that Revaluing is just deep Relabeling.  Because in the beginning you need to actually remind yourself, "this is just OCD."  Then you say, it's caused by the condition, the brain is sending the false message -- you Refocus on something good.

But when you get to the fourth step -- Revalue -- you are actually now at the point -- the reason why it's deep Relabeling, is because it's not just saying to yourself, "this is OCD" -- it's not just a verbal message in your mind, it's actually feeling the feeling, observing the experience -- that's where the Impartial Spectator comes in -- actually having the sense of discomfort be understood as OCD.

And so in the end what you want to do is not be saying, "I feel bad -- what do I do to make myself feel good -- how do I get rid of this bad feeling".  The goal of progressive mindfulness, and the goal of deep Relabeling and Revaluing, is to strengthen the Impartial Spectator so that you experience that urge, you experience those bad thoughts as being OCD -- and then the experience itself is understood by your mind as OCD and when that happens you will then automatically start doing the Refocusing and the whole notion of "keep on going".

And that finishes our series of lectures.  Thank you very much.

AN EPILOGUE

Thanks to the magic of digital editing as performed by Maestro Bryan Clark, we have a few minutes left to sum up on August 5th, 2001.

My good friend, Dr. John Teasdale, of Cambridge University in England, has develop a method called "Mindfulness-Based Cognitive Therapy" which is very similar to the Four Steps.  And in summarizing that method, he writes, "Participants are helped to cultivate an open and acceptant mode of response, in which they intentionally face and move into difficulties and discomfort, and develop a de-centered perspective on thoughts and feelings in which these are viewed as passing events in the mind."  This is an extremely helpful perspective and very relevant to Obsessive Compulsive Disorder, this notion of moving into difficulties and viewing them as passing events in the mind.

Another thing that's very helpful came up in discussions with Dr. Eda Gorbis, my long-time colleague, and Dr. Nili Benazon.  We have decided to call the original Refocus as presented in "Brain Lock", Refocus Classic, and this new method, Refocus With A Star.  Dr. Benazon writes in email to me, "It is a good idea to work hard on mindfulness and on Refocus Classic for most of the time, but I would suggest that patients take two to three 10-minute periods per day to do exposure therapy for the sole purpose of befriending the enemy, whether it be germs or anything else.  I explain to them that the more familiarity you have with something, the easier it is to be friends with it, and to be mindful of its benign properties.  That means that most of the time they are encouraged to get on with their day, but they must stop periodically throughout the day for some brief exercises in exposure that are complementary to the mindfulness training."

And so we will conclude by saying, yes definitely use the new Refocus With A Star and focus on stimuli that cause you to get OCD symptoms.  But remember, the big goal is developing mindfulness itself and having a friendly attitude towards the things that cause you to get obsessive thoughts and compulsive urges is a very good way of remembering how to enter in, not be afraid; as John Teasdale says, "learn to move into the difficulties and discomfort," but do it with mindfulness, with the Impartial Spectator operating so that you can remember, this is just OCD -- feel it as OCD -- feel the uncomfortable feelings as OCD itself.  Strengthen your Impartial Spectator in that way and you will be on the way towards progressive mindfulness and strengthening the power of your mind.

Thanks a lot; keep working; keep your spirits up; be mindful.  May you be well.

Transcription by Bonnie Janofsky and Janie Wechter.  Reviewed and revised by JMS.