The Mind and the Brain (10 page)

By mid-1987 I was leading my OCD therapy group of eight to ten patients every Thursday afternoon from 4:30 to 6:00 on the second floor of the Neuropsychiatric Institute. Though the behaviorists had pioneered an effective approach to treating what had, before 1966, been regarded as an untreatable condition (largely because psychoanalytic attempts to treat it generally yielded abysmal results), I was reluctant to adopt exposure and response prevention wholesale. I recoiled at the intense distress it caused many patients; I just couldn’t see myself hauling patients to a public restroom, forcing them to wipe their hands all over the toilet seats, and then preventing them from washing. And since experienced clinicians were already estimating (at least in their more candid conversations) that at least 25 to 30 percent of OCD patients refuse, or are unable, to comply with exposure response prevention, I already knew that such therapy alone could never be the final answer to OCD. But most of all, I hated the way exposure and response prevention rendered patients almost completely passive during therapy.

The culture of behaviorism and its approach to therapy disturbed me at a philosophical level, too. Behaviorists adopted only treatment techniques that could also be used to train an animal. They were enormously proud of this, believing it somehow rendered their approach more “scientific.” But I balked at it. I didn’t doubt that behaviorist approaches could play a useful and even necessary role for patients who suffer from severe cases of OCD, especially in the early stages of treatment. But for patients capable of willful self-directed activity either at the outset or once the most crippling symptoms lifted, I was convinced that it was time to try a different approach. Throughout 1987, as the OCD therapy group blossomed, I decided to extract the useful parts of behaviorist practice—those that could be applied as part of self-directed treatment—and integrate them with the uniquely human characteristics that a willful, conscious person could use in treatment.

A good part of my decision reflected a change in my own life the summer before. In August 1986, I had resumed the daily practice of Buddhist mindfulness meditation, which I had begun in 1975 but fell away from in 1979. In those years, I had been deeply influenced by
The Heart of Buddhist Meditation
, by the German-born Buddhist monk Nyanaponika Thera. In this book, Nyanaponika coined the term
Bare Attention
. As I noted in the Introduction, this mental activity, he wrote, is

Bare Attention, the key to Buddhist meditation, is the act of viewing one’s experience as a calm, clear-minded outsider. “Mindfulness is kept to a bare registering of the facts observed,” wrote Nyanaponika. A method for doing this, developed by Nyanaponika’s meditation teacher, the Burmese master Mahasi Sayadaw, is called “making mental notes.” This involves mindfully noting the facts as they are observed in order to enhance the mental act of bare registration.

Thus mindfulness, or mindful awareness, was very much on my mind when I began the OCD group the following February with several UCLA colleagues. We kept, at first, well within the tradition of cognitive-behavioral therapy, teaching patients to correct the cognitive distortions described earlier. But I wasn’t content with that. The cognitive approach might be fine for depression, in which there are genuine cognitive distortions that need to be corrected (“It’s not true that everyone hates me; those who like me include…”) and the correction actually helps. But this doesn’t work with OCD. To teach a patient to say “My hands are not dirty” is just to repeat something she already knows. The problem in OCD is not failure to realize that your hands are clean; it’s the fact that the obsession with dirt keeps bothering you and bothering you until you capitulate and wash—yet again. Cognitive distortion is just not an intrinsic part of the disease; a patient basically knows that failing to count the cans in the pantry today won’t really cause her mother to die a horrible death tonight. The problem is, she doesn’t feel that way.

Because cognitive therapy alone seemed to lack what OCD patients needed, I cast about for something else. My return to meditation now convinced me that the best way to treat OCD would involve an approach informed by the concept of mindfulness. I felt that if I could help patients to experience the OCD symptom without reacting emotionally to the discomfort it caused, realizing
instead that even the most visceral OCD urge is actually no more than the manifestation of a brain wiring defect, it might be tremendously therapeutic. The more patients could experience the feeling impersonally, as it were, the less they would react emotionally or take it at face value. They would not be overwhelmed by the sense that the obsession had to be acted on and could better actualize what they knew intellectually: that the obsession makes no sense. The appropriate cognitive awareness was already on board: patients generally know, with the rational, thinking part of their mind, that it makes no sense to check the oven a dozen times before leaving the house. It was now necessary for patients to engage their healthy emotions to strengthen that insight and act on it. To do this would require persistent effort, and habitual practice would be crucial.

Might the use of mindful awareness, I wondered, help an OCD patient achieve that goal? Might mindfulness practice, and systematic mental note taking (as people do during meditation), allow OCD patients to become instantly aware of the intrusion of symptoms into conscious awareness and then to redirect attention away from these persistent thoughts and feelings and onto more adaptive behaviors? It seemed worth investigating whether learning to observe your sensations and thoughts with the calm clarity of an external witness could strengthen the capacity to resist the insistent thoughts of OCD. Not that I had any illusions about how easy it would be. To register mentally the arrival of each and every OCD obsession and compulsion, and to identify each as a thought or urge with little or no basis in reality, would require significant, willful effort. It would not be sufficient just to acknowledge superficially the arrival of such a symptom. Such superficial awareness is essentially automatic, even (almost) unconscious. Mindful awareness, in contrast, comes about only with conscious effort. It is the difference between an off-handed “Ah, here’s that feeling that I have to count cans again,” and the insight “My brain is generating another obsessive thought. What does it feel like? How am I responding? Does the feeling make sense? Don’t I in fact know it to be false?”

I began showing patients in the treatment group their PET scans, to drive home the point that an imbalance in their brains was causing their obsessive thoughts and compulsive behaviors. Initially, some were dismayed that their brain was abnormal. But generally it dawned on them, especially with therapy, that they are more than their gray matter. When one patient, Dottie (the woman with the 5s and 6s obsession), exclaimed, “It’s not me; it’s my OCD!” a light went off in my head: what if I could convince patients that the way they responded to the thoughts of OCD could actually change their brains? I developed a working hypothesis that making mental notes could be clinically effective and decided to introduce mindfulness into the OCD clinic. Making mental notes became, in my own mind, “Relabeling” the feeling that accompanies an OCD obsession. This would be the first step in what came to be called the Four Step method.

Having rejected standard exposure and response prevention, I instead told patients to describe their symptoms and the situations in which they arose. I then explained that the feeling that the door is unlocked, for instance, is the disorder itself, and that our brain imaging research had shown that the cause was a biochemical imbalance in the brain. I never told patients just to resist the urge and it would go away. Instead, I emphasized the importance of identifying as clearly and quickly as possible the onset of an OCD symptom—not just recognizing that an obsessive thought was intruding or a compulsive urge was demanding to be carried out, but recognizing exactly what each of these feelings was. As soon as the thought that your hands are dirty seizes your attention, I counseled them, use mindfulness to enhance awareness of the fact that you do not truly think your hands need washing; rather, tell yourself that you are merely experiencing the onslaught of an obsessive thought. The patient would start saying to herself, That’s not an urge to wash; that’s a bothersome thought and an unpleasant feeling caused by a brain wiring problem. Or, if the compulsion to check a door lock intruded, the patient was to regard it as the result of a
nasty compulsive urge, and not of any real need to check the lock. The feeling of doubt, I told patients repeatedly, is a false message, due to a jammed transmission in the brain. To enhance the recognition that the thoughts and urges are symptoms of OCD, I taught patients to make real-time mental notes, in effect creating a running stream of mindful commentary on what they were experiencing. This enabled them to keep a rational perspective on the intrusive thoughts and urges and not get caught up in automatic compulsive responses and thus a destructive run of compulsive rituals.

By refusing to accept obsessive thoughts and compulsive urges at face value, and instead recognizing that they are inherently false and misleading, the patients took the first step toward recovery. Done regularly, Relabeling stops the unpleasant feelings of OCD from being unpleasant in the same way: understanding their true nature gives a feeling of control, even of freedom. By Relabeling their thoughts and urges as manifestations of a medical disorder, patients make a purposeful cognitive shift away from self-identification with the experience intruding into the stream of consciousness.

The week after patients started relabeling their symptoms as manifestations of pathological brain processes, they reported that they were getting better, that the disease was no longer controlling them, and that they felt they could do something about it. I knew I was on the right track. By this time, the PET data had clearly shown that the orbital frontal cortex of OCD patients is hypermetabolic. One day, just a few months after starting the group, I happened to be carrying around some plain black-and-white PET scans. One patient asked me, “Doc, can you just tell me why the damn thing keeps bothering me—why it doesn’t go away?” I looked at him. “You want to know why it doesn’t go away?” I asked. “I’ll show you why it doesn’t go away. You see this dark spot in the brain on this scan? That is why: it means this region of the brain is hugely overactive in people with OCD. That’s why the bad feeling doesn’t go away.”

It was as if a lightbulb went off in his head—indeed in all the
patients’ heads. At that moment what was to become the second of the Four Steps, Reattribute, was born. Whenever a patient told me an obsession was bothering her, I responded, This is why: I printed slides of color PET scans and showed patients the neuroanatomical basis of their symptoms.
This
is why you feel you have to wash, or check, or count, I said, photographic evidence in hand. This reattribution of OCD feelings to a brain glitch was the breakthrough that pushed us beyond simple Relabeling. Cognitive techniques that merely teach the patient to recognize OCD symptoms as false and distorted—something called
cognitive restructuring
—do not make much of a dent in OCD. Relabeling was essentially just a form of cognitive restructuring. Reattributing went further: having Relabeled an intrusive thought or insistent urge as a symptom of OCD, the patient then attributes it to aberrant messages generated by a brain disease and thus fortifies the awareness that it is not his true “self.” By first making mental notes of the arrival of an OCD obsession, and immediately attributing it to faulty brain wiring, I hoped, patients could resist that false message. “The brain’s gonna do what the brain’s gonna do,” I told them, “but you don’t have to let it push you around.”

Two patients in particular picked up on this idea. One was Anna, then twenty-four, a graduate student in philosophy. She asked her boyfriend about every detail of his daily life because she was obsessed with the (baseless) suspicion that he was unfaithful. Although she never truly believed he was cheating on her, she was unable to stop obsessing about it. What had he eaten for lunch? Who were his girlfriends when he was a teenager? Did he ever look at pornographic magazines? Had he had butter or margarine on his toast? The slightest discrepancy in his accounts set Anna off, making her whole world crumble under the suspicion that he had betrayed her. The other patient was Dottie, then fifty-two, whose obsession with “magical numbers” is described at the beginning of this chapter. Both women realized that the reason they were experiencing these false thoughts was an abnormality in their brain’s
metabolism. “Once I learned to identify my OCD symptoms as OCD rather than as ‘important’ content-laden thoughts that had to be deciphered for their deep meaning,” Anna explained later, as described in my 1996 book
Brain Lock
, “I was partially freed from OCD.”

As I worked with Dottie and Anna as well as the other group members throughout 1988 and 1989, I began using Relabeling and Reattributing via mindfulness as a core part of their treatment. Accentuating Relabeling by Reattributing the condition to a rogue neurological circuit deepens patients’ cognitive insight into the true nature of their symptoms, which in turn strengthens their belief that the thoughts and urges of OCD are separate from their will and their self. By Reattributing their symptoms to a brain glitch, the patients recognize that an obsessive thought is, in a sense, not “real” but, rather, mental noise, a barrage of false signals. This improves patients’ ability not to take the OCD thoughts at face value. Reattributing is particularly effective at directing the patient’s attention away from demoralizing and stressful attempts to squash the bothersome OCD feeling by engaging in compulsive behaviors. Realizing that brain biochemistry is responsible for the intensity and intrusiveness of the symptoms helps patients realize that their habitual frantic attempts to wash (or count or check) away the symptoms are futile.