The Mind and the Brain (11 page)

Relabeling and Reattributing reinforce each other. Together, they put the difficult experience of an OCD symptom into a workable context: Relabeling clarifies what is happening, and Reattributing affirms why it’s happening, with the result that patients more accurately assess their pathological thoughts and urges. The accentuation of Relabeling by Reattributing also tends to amplify mindfulness. Through mindfulness, the patient distances himself (that is, his locus of conscious awareness) from his OCD (an intrusive experience entirely determined by material forces). This puts mental space between his will and the unwanted urges that would otherwise overpower the will.

Besides Relabeling and Reattributing their OCD symptoms, I realized, patients needed to turn their attention to something else, performing an activity other than the one being urged on them by their stuck-in-gear brain. It seemed a good idea to make it a systematic part of the treatment, akin to the practice of methodically directing attention “back to the breath” when the mind wanders during meditation. So I gave it a name: Refocusing. It evolved to become the core step of the whole therapy, because this is where patients actually implement the willful change of behavior. The essence of applying mindful awareness during a bout of OCD is thus to recognize obsessive thoughts and urges as soon as they arise and willfully Refocus attention onto some adaptive behavior.

Directed mental focusing of attention becomes the mind’s key action during treatment. The goal of this step is not to banish or obliterate the thought, but rather to initiate an adaptive behavior unrelated to the disturbing feeling even while the feeling is very much present. Refocusing on such a behavior, and thus resisting the false message to carry out the OCD compulsion, requires significant willpower, for the feeling that something must be washed or checked is still very much a part of the inner experience. Although the patient has Relabeled and Reattributed the obsessions and compulsions to brain pathology, the anxiety and dread still feel frighteningly real. Early in treatment, I therefore suggested to patients that they Refocus on a pleasant, familiar “good habit” kind of behavior. This is when biological reasoning became crucial: I specifically wanted patients to substitute a “good” circuit for a “bad” one. The diversion can be almost anything, although patients began telling me that physical activity—gardening, needlepoint, shooting baskets, playing computer or video games, cooking, walking—was especially effective. That is not to say it was easy. To the contrary: Refocusing attention away from the intrusive thought rather than waiting passively for the feeling to go away is the hardest aspect of treatment, requiring will and courage.

Soon after I explained the Refocus step to one patient, Jeremy, he
began carrying around a small notebook in which he wrote ways to Refocus whenever a compulsive urge arose. On its cover, he had written “caudate nucleus.” In what he called his “refocus diary,” Jeremy told me, he recorded how he prevented himself from responding to an OCD urge and which alternative behavior he used. The diary, it turned out, not only increases a patient’s repertoire of Refocus behaviors, but also boosts confidence by highlighting achievements: see, yesterday when I had a seemingly irresistible urge to count cans I did some needlepoint instead. Many patients were helped by selecting one Refocus task daily as the “play of the day,” to remember and review as a form of positive feedback and self-empowerment. Over the course of treatment, patients slowly developed the sense that they could control their response to the OCD intrusions and that well-directed effort really does make a difference.

Early on, I developed a “fifteen-minute rule.” The patient had to use an “active delay” of at least fifteen minutes before performing any compulsive act. Setting a finite length of time to resist giving in seems to help patients (for the same reason, probably, that devout Catholics find it easier to give up drinking or smoking for the forty days of Lent than they do to give up bad habits for an open-ended period). The fifteen minutes should not be just a passive waiting period, however. Rather, it must be a period of mindful adaptive activity intended to activate new brain circuitry, with the goal of pursuing the alternative activity for a minimum of another fifteen minutes. This seems to be the length of time generally needed for most patients’ OCD urges to diminish noticeably. When a patient’s mind is invaded by obsessive thoughts, even brief periods of Refocusing help, for they demonstrate that it is not essential to squelch intrusive thoughts entirely in order to engage in healthier behaviors.

Refocusing also alleviates the overwhelming sense of being “stuck in gear.” This is where Relabeling and Reattributing come in: both help keep patients’ minds clear about who they are and what the disease process is. This mental clarity has tremendous therapeutic power, for it keeps the Refocusing process moving forward. It
also reinforces the insight that active will is separable from passive brain processes—an awareness that forms the core of the quantum perspective on the mind-brain interface, as we shall explore later.

At the neurological level, the rationale for Refocusing is straightforward. Our PET scans had shown that the orbital frontal cortex, the caudate nucleus, and the thalamus operate in lockstep in the brain of an OCD sufferer. This brain lock in the OCD circuit is undoubtedly the source of a persistent error-detection signal that makes the patient feel that something is dreadfully wrong. By actively changing behaviors, Refocusing changes which brain circuits become activated, and thus also changes the gating through the striatum. The striatum has two output pathways, as noted earlier: direct and indirect. The direct pathway tends to activate the thalamus, increasing cortical activity. The indirect pathway inhibits cortical activity. Refocusing, I hoped, would change the balance of gating through the striatum so that the indirect, inhibitory pathway would become more traveled, and the direct, excitatory pathway would lose traffic. The result would be to damp down activity in this OCD circuit.

When patients changed the focus of their attention, in other words, the brain might change, too. I thought that if I could somehow induce the patient to initiate virtually any adaptive behavior other than whatever the compulsion was, this process would activate neuronal circuitry different from the pathways that were pathologically overactive. Then I could exploit the brain’s tendency to pick up on repetitive behaviors and make them automatic—that is, to form new habits. Ideally, this alternative behavior would be one the patient already knows so well that it is almost automatic. When patients change their focus from “I have to wash again” to “I’m going to garden,” I suspected, the circuit in the brain that underlies gardening becomes activated. If done regularly, that would produce a habitual association: the urge to wash would be followed automatically by the impulse to go work in the garden. I therefore began encouraging patients to plan sequences of
Refocusing behaviors that they could call on, in order to make them as automatic as possible. Refocusing is the step that, more than any other, produces changes in the brain.

In the fall of 1988 a UCLA medical student was working as my cotherapist in the OCD group sessions. We had recently begun using the group as part of a major research study on the effect of psychological interventions for OCD on brain function. Robert Liberman, who was supervising this student, asked me one day how I was conducting the group therapy. When I explained the Relabeling and Reattributing steps, and how I was teaching patients to recognize that their brain is sending them a false message, Liberman was intrigued. I had to meet a friend of his, he said: Dr. Iver Hand of the University of Hamburg in Germany. Hand had developed a technique called
exposure response management
, which is based on the insight that there is no need to make an OCD patient wait passively in an angst-ridden state for her compulsive urge to dissipate. If you instead help her to manage the anxiety caused by the exposure, Hand found, she will tolerate more exposures and improve more quickly. When I dug up some of his published papers, I saw that Hand had found that when patients acquired specific cognitive skills, they were better able to tolerate the presence of, say, a dirty washrag, and therefore more exposures. They even began to do some of the treatment on their own. I recognized a kindred spirit: Hand was finding that patients could learn to exploit their understanding of OCD to manage their anxiety.

Iver and I met in San Francisco at the American Psychiatric Association conference in 1989 and hit it off immediately. The following spring, Liberman suggested that Iver and I write the OCD chapter for a textbook on biobehavioral treatments for psychiatric disorders. We holed up at the Veterans Administration Hospital in Brentwood, a few blocks from my office. The chapter would never be written (partly because Iver and I could never quite reconcile our beliefs about whether biology or psychosocial factors caused
OCD; he was convinced that OCD symptoms are the product of a patient’s need to distance himself from intimate relations). But we agreed strongly on approaches to treatment. We spent hours in the coffeehouses of West L.A., debating whether exposure and response prevention was mechanistic and inhumane. Iver argued that his version of ERP was nothing of the sort: because he varied the exposures and, critically, motivated patients to resist the compulsion, he very much involved patients in their own treatment rather than treating them as a behaviorist’s pet pigeons. As Iver talked, it hit me: up to that point I was explaining treatment in a sort of shoot-from-the-hip style. If I could explain things to patients more methodically, perhaps by breaking mindfulness into discrete, straightforward, teachable steps, it could become the basis for self-treatment.

I was sitting at the keyboard, typing out a case history to describe the treatment, with Iver beside me. How to explain what I was doing with patients? Okay, Relabel, Reattribute, Refocus—but what else was going on? It suddenly hit me. In 1989 I had begun reading the Austrian economist Ludwig von Mises, who defined
valuing
as “man’s emotional reaction to the various states of his environment, both that of the external world and that of the physiological conditions of his own body.” This was exactly what the OCD therapy was changing. Combining Buddhist philosophy with Austrian economics, I had a name for the last of the Four Steps: Revalue. “This might actually be important,” I thought, for I now had, in a simple and usable form, a strategy for treating OCD: Relabel, Reattribute, Refocus, Revalue.

Revaluing is a deep form of Relabeling. Anyone whose grasp of reality is reasonably intact can learn to blame OCD symptoms on a medical condition. But such Relabeling is superficial, leading to no diminution of symptoms or improved ability to cope. This is why classical cognitive therapy (which aims primarily to correct cognitive distortions) seldom helps OCD patients. Revaluing went deeper. Like Relabeling, Reattributing, and Refocusing, Revaluing
was intended to enhance patients’ use of mindful awareness, the foundation of Theravada Buddhist philosophy. I therefore began teaching Revaluing by reference to what Buddhist philosophy calls wise (as opposed to unwise) attention. Wise attention means seeing matters as they really are or, literally, “in accordance with the truth.” In the case of OCD, wise attention means quickly recognizing the disturbing thoughts as senseless, as false, as errant brain signals not even worth the gray matter they rode in on, let alone worth acting on. By refusing to take the symptoms at face value, patients come to view them “as toxic waste from my brain,” as the man with chapped hands put it.

In both my individual and my group practice, I was getting encouraging results with the Four Steps by the early 1990s. With continued self-treatment—for I always intended that patients be able to follow the treatment regimen on their own—the intensity of their OCD symptoms kept falling. As it did, the patients found they needed to expend less effort to dismiss OCD symptoms through Relabeling, and less effort to Refocus on another behavior.

Some of the OCD patients, especially those willing to be treated without drugs, were recruited into the brain imaging study that Lew Baxter and I were starting, with the goal of measuring whether the positive behavioral changes we were seeing in patients were accompanied by brain changes. Our UCLA group therefore performed PET scans on eighteen drug-free OCD patients before and after they underwent ten weeks of the Four Steps, with individual sessions once or twice a week in addition to regular group attendance. The patients who signed on exhibited moderate to quite severe symptoms. What they all had in common was a willingness to be PET-scanned twice and to try a largely self-directed, drug-free treatment. Twelve of the patients improved significantly during the ten-week study period. In these, PET scans after treatment showed significantly diminished metabolic activity in both the right and the left caudate, with the right-side decrease particularly striking. (See Figure 3.) There was also a significant decrease in the
abnormally high, and pathological, correlations among activities in the caudate, the orbital frontal cortex, and the thalamus in the right hemisphere. No longer were these structures functioning in lockstep. The interpretation was clear: therapy had altered the metabolism of the OCD circuit. Our patients’ brain lock had been broken.