The Mind and the Brain (12 page)

Figure 3
. PET scan showing decreased energy use in the right caudate nucleus (which appears on the left side in a PET scan) in a person with OCD after successful treatment with the Four-Step Method. PRE shows the brain before and POST ten weeks after behavioral therapy with no medication. Note the decrease in “size,” which signifies decrease in energy use, in the right caudate (rCd) after doing the Four-Step Method. The drawings show where the caudate nucleus is located inside the head. (All illustrations reprinted from
Brain Lock
© 1996 by Jeffrey M. Schwartz)

Copyright © 1996, American Medical Association, from
Archives of General Psychiatry,
February 1996, Volume 53, pages 109–113.

This was the first study ever to show that cognitive-behavior therapy—or, indeed, any psychiatric treatment that did not rely on drugs—has the power to change faulty brain chemistry in a well-identified brain circuit. What’s more, the therapy had been self-directed, something that was and to a great extent remains anathema to psychology and psychiatry. The changes we detected on PET scans were the kind that neuropsychiatrists might see in patients being treated with powerful mind-altering drugs. We had demonstrated such changes in patients who had, not to put too fine a point on it, changed the way they thought about their thoughts. Self-directed therapy had dramatically and significantly altered brain function. There are now a wealth of brain imaging data supporting the notion that the sort of willful cognitive shift achieved during Refocusing through mindful awareness brings about important changes in brain circuitry as we will see in later chapters.

With this evidence in hand, my group therapy sessions increasingly took on the air of an informal neuroscience seminar. In addition to showing PET scans, I began to lecture patients on the OCD circuit. If the basal ganglia is like a car’s transmission—which in OCD patients can stick like the gear shift in an old Plymouth Valiant—what I was showing them was that simply by practicing, they could learn how to shift behavioral gears themselves, changing the functioning of the brain’s transmissions. As a result, their OCD symptoms would become less intense, and shifting to an alternative, adaptive behavior would become more automatic. Done regularly, Refocusing strengthens a new automatic circuit and weakens the old, pathological one—training the brain, in effect, to replace old bad habits programmed into the caudate nucleus and basal ganglia with healthy new ones. When the focus of attention shifts,
so do patterns of brain activity. (Quantum physics, as we’ll see later, is consistent with this.) Regular Refocusing helps patients resist giving in to OCD thoughts and urges because engaging in intentional rather than automatic behavior—gardening rather than counting cans—puts in play different brain circuitry. Just as the more one performs a compulsive behavior, the more the urge to do it intensifies, so if a patient resists the urge and substitutes an adaptive behavior, the metabolic activity of the caudate, anterior cingulate, orbital frontal cortex, and thalamus changes in beneficial ways. The bottom line, I told my patients, is that Refocusing holds out the tantalizing promise of systematically substituting healthy circuitry for pathological circuitry—of literally reprogramming your brain.

In the winter of 1995–1996, Eda Gorbis began work as cotherapist in my OCD group. Gorbis came by her interest in fears honestly: born and raised in what was then the Soviet Union, she grew up in an atmosphere poisoned by very real threats, yet one where imagined threats thrived, too. Even as a child Gorbis was acutely aware that some of her parents’ friends were riddled with anxiety over the dangers inherent in their world, while others seemed immune to them. The question of why—what enabled one person to shrug off real and ever-present threats while another became psychologically crippled by them?—lingered in her mind for years, even after she and her family fled the Soviet Union when Gorbis was a young teenager. She hopscotched to five different countries, before she arrived in the United States and earned the degree in clinical psychology that would let her pursue an answer to the question of her childhood. Baxter and I had just opened the OCD treatment center, and Gorbis signed on as a volunteer.

As had virtually everyone else in the field, she had pored over
Stop Obsessing
, by Edna Foa and Reid Wilson, which laid out the standard behaviorist approach to OCD: expose patients to the “triggers” that cause them distress (have them touch a doorknob if they are obsessed with germs, for instance), but prevent them from
engaging in the ritualistic behavior that ordinarily dissipates that distress (prohibit them from running to a sink to wash, in this case). “I had the book like a Bible on my night table,” Gorbis said. But even as she practiced what Foa preached, Gorbis had her doubts. “The strict behaviorist approach seemed, to me, a bit too mechanical,” she recalls. “It was treating patients as if they had no humanity; it was not recognizing that they had a thinking, feeling mind inside.” Despite her doubts, in the autumn of 1995 Gorbis left her family and spent several months with a group of leading behaviorists, including Foa. When she returned to UCLA that winter, she began coleading my OCD group, integrating the Four Steps with her own approach to behavior therapy.

As its reputation grew, the UCLA Four Steps approach began to draw intractable OCD cases from around the United States, people so enslaved by their obsessions and compulsions that they could hardly get through a day, much less hold a job. Yet by blending the Four Steps with standard behavioral therapy methods, Gorbis was achieving a success rate of over 80 percent with no relapse to anything close to pretreatment severity. That compares to Foa’s 65 to 75 percent initial success rate (that is, excluding relapse rates, which are significant), and 60 percent or less at other centers toeing the strict behaviorist line. “We were changing the lives of people who before had been almost totally paralyzed by their OCD,” Gorbis says. And she was not removing the rearview mirrors from patients’ cars. “Mindfulness became an empowering tool for the patients, giving them—finally—control over their lives,” she says. By the late 1990s, the UCLA group was treating hundreds of patients a year, and the Four Steps was at the center of the group practice. It was gratifying to get independent confirmation of the power of this approach in 2002, when Dr. Nili Benazon of Wayne State University published a major study showing that a mindfulness-based cognitive-behavioral method closely related to ours is very effective at treating children with OCD.

As I thought about the therapy sessions, and of how the
patients’ mental effort and acts of will had the power to regate the circuitry of their brain, a simple but deeply important question arose. What happens at the instant a person decides not to wash her hands, after decades of doing so in response to the false signals from the orbital cortex and despite her anterior cingulate’s making her heart race and her gut churn? Why and how does this person switch gears, activating circuits in the dorsal prefrontal cortex connecting to adaptive basal ganglia circuits, rather than the OCD circuits connecting the orbital frontal cortex to the anterior cingulate and caudate? (See Figure 4.) At the instant of activation, both circuits—one encoding your walk to the garden to prune roses, the other a rush to the sink to wash—are ready to go. Yet something in the mind is choosing one brain circuit over another. Something is causing one circuit to become activated and one to remain quiescent. What is that something? William James posed the question this way: “We reach the heart of our inquiry into volition when we ask, by what process is it that the thought of any given action comes to prevail stably in the mind?”

The demonstration that OCD patients can systematically alter their brain chemistry through cognitive-behavioral therapy such as the Four Steps regimen has inescapable implications for theories trying to explain the relationship between mind and brain. As I began to consider how best to make the OCD work relevant to questions of how the mind can change the brain, I became more and more intrigued by the idea that there must be a force to account for the observed brain changes. The willful effort OCD patients generate during treatment, I suspected, was the most reasonable way to account for the generation of this force. The results achieved with OCD supported the notion that the conscious and willful mind differs from the brain and cannot be explained solely and completely by the matter, by the material substance, of the brain. For the first time, hard science—for what could be “harder” than the metabolic activity measured by PET scans?—had weighed in on the side of mind-matter theories that, as explained in
the previous chapter, question whether mind is nothing but matter. The changes the Four Steps can produce in the brain offered strong evidence that willful, mindful effort can alter brain function, and that such self-directed brain changes—
neuroplasticity
—are a genuine reality. Let me repeat this: the Four Steps is not merely a self-directed therapy; it is also an avenue to self-directed neuroplasticity.

Figure 4
: The exertion of willful effort during cognitive-behavioral therapy can activate a “therapy” circuit in the dorsal prefrontal cortex.This can help to override the effects of the OCD circuit.

I anticipated the objections that materialist reductionists would raise. Surely what is happening here, they would say, is that one part of the brain is changing another. The brain is changing itself; there is no need to invoke a separate, nonmaterial entity called mind to account for the changes documented by the PET scans. But a materialist explanation simply cannot account for these findings. To train people suffering from OCD requires tapping into their natural belief in the efficacy of their own willful actions. Explanations based exclusively on materialist causation are both infeasible and inappropriate for conveying to OCD patients the steps they must follow to change their own brain circuitry systematically. In order to work, behavioral medicine (of which the Four Steps is an example) absolutely requires the use of the patient’s
inner experience, including the directly perceived reality of the causal efficacy of volition. The clinical and physiological results achieved with OCD support the notion that the conscious and willful mind cannot be explained solely and completely by matter, by the material substance of the brain. In other words, the arrow of causation relating brain and mind must be bidirectional. Conscious, volitional decisions and changes in behavior alter the brain. And as we will see, modern quantum physics provides an empirically validated mathematical formalism that can account for the effects of mental processes on brain function.

The demonstrated success of mindfulness-based cognitive-behavioral therapy for OCD led me to posit a new kind of studyable force. I called it directed mental force. It would arise, I thought, from willful effort. What mental force does is activate a neuronal circuit. Once that new circuit begins to fire regularly, an OCD patient does not need as much effort to activate it subsequently; the basal ganglia, responsible for habitual behaviors, take care of that. My still-nascent thesis held that directed mental force is the physical aspect of the willful effort to bring healthy circuitry on line. With regular use of the frontal cortex, changes occur in the gating function of the caudate, and mental function improves. Relabeling and Refocusing attention begin to be automatic. In this way, frontal cortex thought processes begin to be wired directly into the caudate. As the brain takes over, less mental force is needed.