An essential part of treating OCD is distinguishing between mental processes that can and cannot be controlled. This can be especially confusing when it comes to attention. Confusion about this leads, in turn, to confusion about distraction, as well as to difficulty eliminating rumination.
The purposes of this article are:
(1) to explain what aspects of attention are and are not controllable
(2) to explain what forms of distraction are and are not helpful
(3) to explain how the above apply to eliminating rumination
Awareness Versus Directed Attention
The key to working with attention is differentiating between:
- Something being in your awareness
- Directing your attention toward it
You can’t control whether something is in your awareness, but you can control whether you direct your attention toward it.
As long as you direct your attention toward it, you guarantee that it will remain in your awareness.
However, if you stop directing your attention toward it, it will eventually leave your awareness on its own.
Thus, if you want something to leave your awareness, the best you can do is to:
(1) Not try to force it to leave, but
(2) Stop directing your attention toward it
This will allow it to eventually leave your awareness on its own.
Metaphorically, you can’t make it fly away, but if you let go, it will eventually fly away on its own.
To be clear, this does not mean actively keeping it in your awareness. It means letting go and doing nothing. If doing this feels effortful, something is wrong; you are probably directing your attention toward it in some way.
It bears noting that, inevitably, the thought will eventually enter your awareness again. Rather than seeing this as a failure, I invite you to see it as a success. The fact that it re-entered your awareness indicates that it left. This means you successfully stopped directing attention toward it and allowed it to leave, which is perfect. Now just do the same thing again: Refrain from directing attention toward it and it will eventually leave your awareness on its own.
In light of the above, distraction can be helpful or unhelpful depending on how it is done.
If distraction is aimed at forcing something out of awareness, that will not work, because you can’t force something out of your awareness. This is thought-suppression and will just keep you focused on the thing you’re trying to stop thinking about.
But if you allow something to remain in your awareness (again, not in any active sense), and distract yourself in the sense that you are directing your attention elsewhere, that can be helpful.
It bears noting, however, that even this helpful form of distraction is not necessary in order to stop directing your attention towards something. Directing attention towards something is controllable, and you can stop doing it even without directing your attention towards something else.
Distraction During Exposures
Notably, many if not all therapists who believe that exposure works through habituation discourage distraction during exposure exercises.
As someone who believes that exposure works through learning, not through habituation, I believe that distraction (the helpful kind) during an exposure is perfectly fine.
For example, I think it’s fine if someone watches television while they eat an avoided food or contaminate something.
Notably, I’m not advocating for doing an exposure exercise without being aware that you’re doing it. I’m arguing against the importance of mental engagement that goes beyond awareness. (In fact, I think it may be the case that, beyond awareness, less mental engagement means less rumination, which allows the person to see that without rumination, the exposure doesn’t make them that anxious.)
Is attention a form of rumination? Does distraction help with rumination?
People define rumination in many different ways. I define rumination as any type of mental engagement with the obsession, and this includes directing attention toward it.
The goal is not to engage with the obsession at all. When people direct their attention toward the obsession, they remain anxious, and they most often slip into trying to figure it out.
This is one reason I believe that approaches that encourage engagement (e.g., ‘bossing back the OCD’) are unhelpful, if not downright iatrogenic.
When people completely refrain from engaging with the obsession, without trying to force it out of awareness, the thought passes out of awareness quickly and with little to no distress.
This is what it means to not have OCD. It doesn’t mean you’re immune to uncomfortable, even distressing, thoughts and feelings. All humans experience those. It means you move right past them.
Consistent with what was said above about distraction, as long as a person isn’t trying to force the obsession out of their awareness, distraction is okay, and can even be helpful.
But distraction is never a replacement for the clear decision to stop ruminating. As long as the person is directing their attention toward the obsession, and especially if they are trying to figure it out, they guarantee that it will remain in their awareness, and that it will continue to cause them distress. In the simplest terms, no matter how hard you’re trying to stop thinking about something, it won’t work if you’re also still thinking about it.
In a Nutshell
Here’s what doesn’t work:
“I don’t want to think about that so I’m going to concentrate very intently on this other thing in order to force that out of my mind.”
Here’s another thing that doesn’t work:
“I’m trying to figure it out, and I haven’t made a clear decision to stop, but I’ll try doing something else to stop myself.”
Here’s an example of what does work:
“I know that that issue is still there. I can’t make it go away, but I am not going to engage with it at all. I am going to get engaged with other things, and eventually it will leave my mind. And when it comes back, that’s okay, I’ll just refrain from engaging with it again.”
Removing the Taboo Around Distraction
When we tell patients not to use distraction, they sometimes think they are supposed to focus on the obsession on purpose. This is probably not what anyone means, but that’s not always understood.
I propose we remove the taboo around the word ‘distraction,’ and get much more nuanced about what does and doesn’t work. Thought-suppression doesn’t work, but getting completely distracted by life is the ideal treatment outcome.