By Carissa Weber, MA, LPC, CSAC
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Have you ever substituted an ingredient in a recipe? You know, you start cooking and you realize you don’t have the necessary ingredients, so you make substitutions. Some substitutions work better than others (like chocolate chips if you don’t have raisins for oatmeal cookies). Your coping skills are the same way.
In therapy, there are a lot of different skills that we use to help people manage, and change, their mental health. Just like last week’s post, Become a Bad Ass by using Behavioral Activation! went over a crucial skill, this week is no different. This week, we are tackling my favorite skill, the 4 Rs!
What are the 4Rs?
The 4 Rs are something that have been a staple of obsessive-compulsive disorder (OCD) for many years. First introduced by Dr. Jeffrey Schwartz in 2011, the 4 Rs were designed from a neuroscience backing (a guy after my own brain nerdiness!) to help people cope and challenge distressing thoughts. This amazing acronym has been used to help with symptoms of anxiety, depression, and intrusive thoughts ever since.
The 4 Rs were designed to be a sort of “self-treatment,” using skills and information from cognitive behavioral therapy that a person could apply without the assistance of a therapist being there. When we break down the 4Rs, it is pretty clear how they help:
- Decrease anxiety by lowering activity in that darn amygdala
- Increase activity in both your prefrontal cortex and your hippocampus
- Improve your overall distress tolerance for stressful situations
As we start talking about this powerful acronym, let’s start with the first R: Relabel. Relabeling Takes us to the point where we can recognize any of the distressful thoughts that are happening. In the case of anxiety, were looking at things that increase our anxiety symptoms. Depression, we are looking at things that increase our feeling of hopelessness, worthlessness, and being alone.
Relabeling occurs AFTER we have identified the issue at heart. This means we know what is going on, not just the superficial feeling on the surface.
It is in this moment that we start calling the thought what it is: the actual symptom. Let’s go over an example, shall we?
Let’s say you’re having one of those days where nothing goes right. Your friends are leaving your messages unread, you have no motivation to be at work, and the world just seems to be falling apart. Rather than going down the road of saying “no one cares about me,” “I’m a loser,” or “I should have just stayed in bed,” we are going to label what is actually happening. In the place of the negative thoughts, we are going to simply say “I am experiencing symptoms of depression.”
This is going to help your brain in a few different ways. First, you are moving from your overactive darn amygdala (you know, where you feel powerless and overwhelmed by all the negative information it is seeing) to your proactive prefrontal cortex. By creating this shift, you are activating the problem-solving skills your prefrontal cortex is known for. I should note here: just relabeling your thoughts for what they are will not make them go away. They will still be there. What we are doing is creating a shift so you can better cope with the thoughts.
Honestly, this is one of my favorite parts of the 4Rs. Reattribution is the act of us using the skills we have to combat the source of our thoughts. This means we are challenging the anxiety, the depression, the OCD, not the feelings or thoughts themselves.
In this case, the depression, we are acknowledging that we have a medical condition that impacts how our brain is wired. Say that again, out loud: “I have a medical condition that impacts how my brain is wired.” I could be biased, but I think it feels so amazing to say that.
Another part of the reattribution stage is recognizing that we have a choice to make. We can choose to give in to the thoughts and continue down the rabbit-hole of mental health. Or we can choose to engage in a different behavior. This different behavior could be using a new and healthy coping skill, focus on something in your control, or even doing something you love. By doing this, we are placing the prefrontal cortex large and in charge. We are also preparing our brain to release the feel-good neurotransmitters, which decreases your darn amygdala’s activity (and creating new memories).
The third R of the 4Rs is the most important R of them all. Refocusing is where you are actually doing what you choose to do in the reattribution step. It’s true, this step in the 4 Rs is tough, but is necessary.
By refocusing, you are actively choosing your new option (versus focusing on the feeling or thought creating the negative thoughts) and PARTICIPATING in that choice. By doing this, even for 15 minutes, you are:
- Increasing the release of dopamine, oxytocin, and serotonin, naturally decreasing depression levels
- Moving to increase activity in your prefrontal cortex and insula as you are most likely engaging your body in some sort of activity
- Creating new pathways and memories for your hippocampus to know what to do if these thoughts pop up again
Refocusing can be the hardest step of the 4Rs because it requires consistent and persistent practice. The first couple of times you practice, you may only be able to practice it for a few minutes before the distressing thoughts come back in. When that happens, it is important to recognize the thought still exists. Say what?! It is true.
After you participate in a different activity, and the negative thought is still there, take time to recognize:
- How strong the thought is
- What changes have happened since the thought first started
- What changes your coping skill made to the thought
It is this action, the refocusing your energy on something in your control, that helps rewire your brain to have your prefrontal cortex in control. Remember, it takes 66 days to create a new habit, a new pathway in your brain. It will be tough, but do not give up!! There is light at the end of the tunnel!
The last R in the 4Rs, revalue is a very crucial step. It is in this step that you decrease how much real estate your negative thoughts take up in your brain.
You’ve done a lot of hard work with relabeling, reattributing, and refocusing, now that hard work starts to pay off. As your prefrontal cortex focuses on your new choice, your hippocampus starts to recognize the weight that your negative thought carries. This is because your brain, specifically your pineal gland, has decreased the production of cortisol. With less cortisol, it allows your brain to release glutamate.
Glutamate is the neurotransmitter responsible for forming memories. As your prefrontal cortex is giving energy to your new choice, the glutamate remembers this. It remembers the energy and feel-good neurotransmitter release versus the cortisol-releasing negative thought. Naturally, this means your hippocampus is going to remember how to feel good and comfortable, not uncomfortable.
After you complete your new choice, you can do several things to help your brain revalue your negative thoughts. How do you do that? By answering the following questions of course!
- How has my heart rate changed since starting the 4Rs?
- How long was I able to keep the negative thought away?
- Do I notice anything different about how I am physically feeling after using the 4Rs?
- What activity did I choose to be my new choice?
- How does it feel to be in control of my negative thoughts?
- Can I practice this for 66 days?
- What step of the 4Rs was the most useful to me?
Do you use the 4Rs?
The reason why I love this skill so much is that it can work with any sort of thought you are not enjoying having. Beating yourself up? The 4Rs are there! Struggling with cognitive distortions? The 4Rs have your back!!
I want to thank you for taking time to learn and letting me be part of that learning. The 4Rs is a skill I use, personally, when the self-doubt and thoughts of worthlessness creep in. I hope you find it as useful as I do!
- Gorbis, Eda (date unknown). Dr. Jeffrey Schwartz’s Four Steps for OCD: Principles from Brainlock Help Overcome OCD. Retrieved from Dr. Jeffrey Schwartz’s Four Steps | Beating OCD | Westwood Institute for Anxiety Disorders | OCD Treatment in LA (hope4ocd.com)
- Rigglo, Ronald (2018). The 4 R’s of Managing Anxiety. Retrieved from The 4 R’s of Managing Anxiety | Psychology Today