FOUR STEPS OF COGNITIVE BIOBEHAVIORAL THERAPY
BASED ON JEFFREY SCHWARTZ’S TREATMENT OF OCD
Interpreted and summarized by Barbara J Nichols, Ph.D.
“It’s not me—it’s my OCD”
“Mindful awareness and the impartial spectator will empower you”
Many people on the autism spectrum suffer with obsessive-compulsive-like symptoms. The symptoms of OCD are wide ranging and may include frequent hand washing, checking the stove, the door locks, or the faucets repeatedly, adhering to rigid rituals and routines that have no functional benefit like dressing in a certain order, repeating words and phrases, engaging in behavioral mannerisms (nail biting, picking at the skin, or pulling the hair) and hording books, magazines, or papers. These behaviors are accompanied by thoughts that repeat themselves over and over and are annoying and stubborn. Anxiety, guilt and remorse often plague people with OCD.
People who engage in OCD-like behaviors can spend an inordinate amount of time with the non-functional behaviors that interfere with job duties, relationships, and pursuing interests and hobbies. Depression and anxiety are often associated with OCD symptoms and low self-esteem, self-recrimination and self-deprecation can be socially crippling. Thoughts of suicide, as a way to escape from the insidious thoughts and behaviors that seem to control one’s life, are prevalent. However, there are very promising therapies for OCD and the outcomes are very hopeful.
Dr. Jeffrey Schwartz, after years of research and experience treating OCD patients, devised a treatment protocol that has been found to be highly effective in controlling OCD symptoms. The treatment grew out of Dr. Schwartz’s study of mindfulness practices and his brain scan studies. Studies of the brain before and after weeks of treatment by Dr. Schwartz showed that the brain responded as well as it would under prescription drug therapy for the same condtion. Below is a brief synopsis of the treatment .
*The four steps numbered below are Dr. Schwartz’s protocol. I have illuminated and separated out associated steps for clarity.
“The goal of the first three steps is to use your knowledge of OCD as a medical condition caused by a biochemical (and structural) imbalance in the brain to help you clarify that this feeling is not what it appears to be and to refuse to take the thoughts and urges at face value, to avoid performing compulsive rituals, and to refocus (your attention) on constructive behaviors.” (Dr. Jeffrey Schwartz)
FORCE OF WILL: Neuroplasticity is the brain’s ability to physically change in response to your efforts:
Because OCD patterns are rooted in overused neuropathways, it takes strong discipline to resist the old patterns and institute new ones. Placing your mental health at the top of your priority list by following the below-listed steps with discipline and determination will result in the emergence of new functional and healthy neuropathways that will become, with time and effort, the path of least resistance. Dr. Schwartz performed brain scans before and after treatment. He found that before treatment, the orbitofrontal cortex and the caudate neucleus are over active. After treatment both brain structures are returned to normal function and the difference is as significant as that seen in OCD patients who are administered drug therapy.
REJUVENATE: People with OCD and autism are vulnerable when under stress. Stress management is crucial to recovery. The following list suggests life style alterations that are known to lower stress levels and increase energy:
- Sleep – 7 to 8 hours, darkened and quiet room
- Nutrition –regular meals, whole nourishing foods, reduce caffeine, alcohol, and sweets
- Exercise–vigorous regular exercise 4-5 times a week for at least 20 minutes at a time
- Recreation–spend time with friends who renew you
- Meditation, yoga, prayer, contemplation, Tai Chi, Chi Cong at least 20 minutes per day
- Mindfulness practices such as walking meditation, meditation in action, watching the thoughts
- Breathing exercises: slow, deep, smooth breathing with attention to the details of the breath
- Energy psychology techniques such as EFT, TFT and FIT
Four Steps of Biobehavioral Therapy with Additional Mindfulness Practices
Preliminary Step 1. REVIEW AND KNOW YOUR PATTERNS:
- Make a complete list of your usual OCD behaviors and thoughts and display the list where you can readily access it for reference.
- Keep a journal of the frequency and duration of OCD behaviors and thoughts.
Preliminary Step 2. RECOGNIZE OBSESSIVE THOUGHTS AND COMPULSIVE URGES WITH MINDFUL AWARENESS AS THEY ARISE:
- Pay attention to the early signs that the pattern is about to commence: e.g., fear, anxiety, dread, rumination, guilt, remorse, an urge to find the right feeling by repeating the behavior.
- Develop the “impartial spectator” or the “witness” that observes without judgement.
- Mindful awareness is deep and precise, and achieved through focused effort.
- Be mindful of the lack of sensory data that supports your fear when the obsession begins. It is a thought not an experience that is fueling the fear.
STEP ONE: PART I: RELABEL:
- Use the labels obsession and compulsive, e.g., “I’m having an obsessive thought to perform the compulsion of washing my hands.”
- “This thought is an obsession; this urge is compulsive”.
- I am not washing my hands because they are contaminated. I am washing my hands because I have OCD.
STEP ONE: PART II: REFUSE TO ENGAGE IN THE COMPULSIVE BEHAVIOR:
- The goal is to resist the urges, not to stop the thoughts.
- Block any temptation to engage in the OCD behavior. Total response prevention over a period of three days has been shown to powerfully reduce subsequent urges.
- Just because the urge is there, does not mean you have to respond.
- Only by learning to resist OCD symptoms, can you change the brain.
- If you have rechecking behaviors, like rechecking locks, be mindful while you perform the duty the first time around. Resist all temptation to recheck.
- Maintain the witness mode until the urge has weakened or passed (at least 15 minutes).
STEP TWO: PART I: REATTRIBUTE – CHANGE THE MEANING OF THE PATTERN:
- “This is a biochemical imbalance in my brain”.
- “This is not real. It is just my OCD”.
- “This is the result of faulty wiring in my brain. It is not my personal self. “
- Understand and know the obitofrontal cortex (OFC) in the brain, responsible for decision making, is hyperactive. The caudate nucleus, lying close to the OFC which is the center for habit control and the traffic hub between the cerebral cortex (conscious thought) and the amygdala (center for fear), is also hyperactive. The hyperactivity of the OFC and the CN result in the repetition found in OCD symptoms.
STEP TWO: PART II: REMEMBER NEUROPLASTICITY:
- The brain constantly changes in response to your thoughts, actions, emotions, and attitudes.
- Change your thoughts and automatic responses and you will rewire your brain.
STEP THREE: REFOCUS: SWITCH TO ANOTHER BEHAVIOR/THOUGHT WITH EFFORT AND MINDFULNESS:
- Practice distracting yourself to prevent engaging in the OCD behaviors and thoughts: e.g., shift your attention to something pleasant, e.g., mindfulness exercises like deep, slow breathing, walking, exercising, playing music, singing, dancing, calling a friend, reading………….
- Keep a journal of the thoughts, feelings, behaviors with Labels and Reattributions
- Uncomfortable feelings will continue for a short while and then will recede. Wait it out.
- Goal of Refocusing: never again perform a compulsive behavior in response to an OCD thought, but, if the thought persists, impose a time delay (15 minutes) before performing any compulsion. You will find that you no longer feel compelled to respond.
STEP FOUR: REVALUE:
- “These OCD thoughts and behaviors are not worth my time and energy. They are trash.”
- The obsessions and compulsions are simply false messages coming from the brain and are not rooted in sensory data. They are just useless mindstuff.
- Brain Lock: Free Yourself from Obsessive-Compulsive Behavior Paperback by Jeffrey M. Schwartz
DEFINITIONS FROM WIKIPEDIA:
Caudate nucleus: innervated by dopamine neurons, highly involved in learning and memory. It has been found to be dysfunctional in persons with OCD in that it may be unable to properly regulate transmission of information regarding worrying events between the thalmus and the OFC. PET scans found that people with OCD have increased grey matter volumes extending to the caudate nuclei, versus the decreased grey matter in neighboring structures as in anxiety disorders. In OCD, smooth, efficient filtering and the shifting of thoughts and behaviors are disrupted by a glitch in the CN.
Orbitofrontal cortex (OFC) is a prefrontal cortex region in the frontal lobes in the brain which is involved in the cognitive processing of decision-making. It has been proposed that the OFC is involved in sensory integration, in representing the affective value of reinforcers, and in decision-making and expectation. In particular, the OFC seems to be important in signaling the expected rewards/punishments of an action given the particular details of a situation. In doing this, the brain is capable of comparing the expected reward/punishment with the actual delivery of reward/punishment, thus, making the OFC critical for adaptive learning.
When OFC connections are disrupted, varying cognitive, behavioral, and emotional consequences may arise. Disorders associated with dysregulated OFC connectivity/circuitry center around decision-making, emotion regulation, and reward expectation.