Self-Help Article

The Use of Mindfulness in the Treatment of Obsessive Compulsive Disorder (OCD)

by Dr. Jeffrey Schwartz

There are very effective treatments available for treating obsessive compulsive disorder, and the suffering from the symptoms can be very profound--even to the point where people seriously contemplate ending their lives through suicide in an attempt to escape them.

There are now ways to treat this disorder effectively, combining both the use of medication as well as things you can learn to do with your mind itself. Mental training can be really effective in helping people with obsessive compulsive disorder change not only their functioning and the pragmatic clinical course of the disorder, but also as we're going to see change the brain itself.

This brings us to the second aspect, perhaps as important as the first: the profound implications of medical science demonstrating that what people do with their mind affects how the brain works. I see it as our mission going forward as a society to increasingly have people realize that how you focus your attention, and what you focus your attention on, has very significant affects on how your brain works.

I think that in the materialist culture that the 20th century bequeathed us there is a tendency for people to view themselves as just passive recipients of their own mental contents. Essentially viewing themselves as almost like machines, people can come to believe there is nothing very much you can do about your troublesome feelings unless you take some drug, and that you're basically doomed to more or less to sit there experiencing the affects of a problem like OCD until someone finds a drug to make it better.

Now in no way am I implying that medications are not very helpful in treating neuropyschiatric conditions with a clear cut biological basis, such as obsessive compulsive disorder. However I think that to go forward as a medical community and as a society we need to realize that the materialist approach not only to mental and physical health, but even to life itself, tends to strip us of our capacity to connect with the power we all have within us. And it is this power, with which we are all endowed, that enables us to bring about tremendous changes in the way we live and even the way our brain works.

I think its relatively clear, if you just think about the implications of all this, that it can have profound societal affects in terms of issues of personal responsibility. Actions truly have consequences not only in the most ordinary way of how they affect other people but even how it affects your brain and how it works. This is the big message going forward and the great implications it has for treating mental health problems, and medical disorders in general, are extremely important.

In the next few minutes I'm going to try to explain to you how much the symptoms of this condition can be understood as a brain related medical problem. The first point is that people with obsessive compulsive disorders have increased metabolism, or another way of saying the same thing is excessive energy use, in a specific region of their brain. This excessive energy sits right over the eye orbit or the eye socket, an area of the brain called the orbital frontal cortex. There is a picture of this in my book Brain Lock on the back cover and on page xxiii.

It is well known from a lot of neurobehavioural research that this part of the brain is involved in people making emotional assessments of their environment. More specifically, it is involved in getting the feeling that something isn't right in the environment, or what we can sometimes call an error detection signal. The big point is that people with obsessive compulsive disorder have shown increases in metabolism in this part of the brain that gives one the feeling that something is wrong. This part of the brain is really overactive in people with OCD.

There is almost certainly a connection between that biological change and for instance the description we just heard of feeling like you live in a dump, and the reason why the bothersome feeling doesn't go away is just because the brain is overactive.

Another important brain structure for understanding OCD is the caudate nucleus. There is a picture of it on page 59 of Brain Lock. The caudate nucleus is like an automatic transmission in the brain. What is happening and where the term brain lock comes from, is that an error detection circuit that's contained in the orbital frontal cortex literally gets locked in gear. The result is you are bombarded with these very bothersome troubling feelings.

This is the situation in overview--at the bottom of the front of the brain is the orbital frontal cortex, which can send error detection signals. It sends its signals by a direct connection to the caudate nucleus, which acts like an automatic transmission. Largely because of biologically inherited traits the caudate nucleus gets stuck in gear again and again and again and these very bad thoughts, these bothersome troubling thoughts, keep bombarding into the persons conscious awareness.

Now what can one do about this? The really good news is that there is a lot that can be done about this problem. While it is quite common, affecting one person in forty in the general population, there is also a huge amount of data that it is a very treatment responsive illness.

There are certainly medications that can help with the treatment process. What those medications do is actually act on the neurochemical transmitter serotonin, which is very widespread throughout the brain, particularly in that caudate nucleus and orbital frontal cortex area. By modulating serotonin levels in the brain, the medications over a period of several months bring down the intensity of the intrusive bothersome feelings.

We can also change the activity in those very same structures of the brain by learning how to redirect our attention and the way to redirect our attention is largely a function of a mental process called mindfulness. This has profound philosophical significance and was first described 2500 years ago by Gotama Buddha.

Mindfulness is the foundation of Buddha's philosophy and of the practice of meditation. However, when used as a form of mental development for something like treating OCD, it has no religious content at all. This is really important to stress--nothing in the use of mindfulness would ever impinge on the religious beliefs of any other religion. Even though in some sense it has what you might call a spiritual content, this is in a general sense of having the mind influence the brain.

Mindfulness as a mental action is described in the abstract in the conference program book (which I have attached as an appendix at the end of this paper). I really encourage you to read the abstract to have a record to refer back to. Understand that mindfulness is an action in which you learn and train yourself to direct your attention in a wholesome and healthy manner.

Mindfulness is a training process to observe your inner experience with calm and with a feeling of clarity. Observing the inner experience calmly, clearly and without responding to it. For instance in the case that we just heard one would make mental notes reminding oneself that although the experience is very unpleasant, it is not something that one needs to worry about in terms of taking over control of ones mind. The process of observing in itself helps people increasingly come to the realization that they can change their responses to those thoughts in very adaptive ways.

The Four Steps are the basis of the treatment approach presented in the book Brain Lock (they are listed in a chart on page 219). The term brain lock refers to the error detection circuit that is locked in the on position. The Relabel step, which is the first step and recognizes the intrusive thoughts and urges as nothing but the symptoms of OCD, is essentially the equivalent of what I have just described as mindfulness. Another way of thinking of the Relabeling step is called "making mental notes."

What you want to train your mind to do in the Relabel step is to recognize that the reason why you feel like you do when you are having on OCD symptom is simply because of a medical condition, a treatable medical condition. What this does is begin to put things in a real life perspective. You can begin to understand why your consciousness is being bombarded by such bothersome experiences.

We are now taking advantage of advancements in medical science, which have shown us without a doubt that there are brain mechanisms that are responsible for those feelings being there. Then we are coupling that to a traditional process of mental observation. We are using that traditional process of clear-minded mental observation to really put in a context why these thoughts are bothering us so much--because we have a treatable medical condition. The second step answers the question why does it keep bothering us.

The first step is to Relabel. We put an accurate notation in our own mind that answers the question, "What is this that's bothering me?" and the answer is a treatable medical condition, OCD. In fact this process works equally well for panic attacks, panic disorder, social phobia and essentially all the anxiety disorders. We must realize that the feeling itself is not what is important, it is our understanding of the fact that we can mindfully observe the feeling and thereby change our responses to it. This will make us well and make our minds more powerful and even change the underlying chemistry of our brain in ways that move us toward the healthy path.

So the second step, Reattribute is answering the question, "Why do they keep bothering me?" The thing that really makes them debilitating is that they don't go away, they keep bothering you and bothering you. The answer to that question is that the intensity and intrusiveness of the thought or urge is caused by the medical condition OCD, and it's probably the result of a biochemical imbalance in the brain. So you attribute the bad feeling to OCD and stop blaming yourself for it.

We then came up with this little aphorism that a patient actually said, "it's not me it's the OCD". Now that has a lot to do with mindfulness because it's mindfulness that is allowing you to see clearly that you are not the disease and that your mind and your consciousness are not the disease process. There is an observing aspect of the mind that can really maintain its independence even though the contents of the consciousness are being flayed around by the disease process. We are really training the mind to not identify with those experiences but to see ourselves as separable from those experiences.

Now once we see our mind as separable from those experiences we can go on to the critical third step. This step, called Refocus, actually changes how the brain works. In the Refocus step the critical key phrase is "work around." Work around, I am using as a technical term. Work around the OCD symptoms by focusing attention on something else by doing something else and the key phrase here is do another behaviour. The term "work around" means don't wait for the feeling to go away--Work Around it by doing another behaviour, even though the feeling is still bothering you.

Now why is that so important? The reason why work around is a technical term is because the hard part of this treatment that really requires will and stick-to-it-iveness and courage is remembering that you can't make those feelings go away in the short term. You really are working around them, and in that way its like an obstacle course.

You have to go over or around or any way you can get past getting locked into compulsive behaviours like washing and checking. You remind yourself I want to do something useful, and generally what you want to do is something that you like to do that's both familiar and useful.

When you do this on a regular basis you literally change the gearbox shifting capacity of the caudate nucleus. What you have happen is that the gearbox now starts shifting to good behaviours. Because of the underlying medical disease process it won't shift to the good behaviours unless you literally shift it yourself by refocusing your attentions willfully on an adaptive behaviour. The key phrases are do another behaviour while working around the fact that the bothersome thoughts and urges are still there.

The most important rule of thumb for this critical step is not to try to make the thoughts go away, because in the short term that's something you can't do. There are powerful brain mechanisms going on and that's where people need a lot of support with this treatment. There is a natural tendency to want to make these symptoms just go away. However you have to accept the fact that the symptoms are there but realize with mindfulness that they don't have to control what you do. This is why we say "It's not how you feel it's what you do that counts," and that's such an important principle for life.

In practice this means that if you want to change how you feel you have to do good things. If you put all of the focus of your attention on doing good things, your feelings will naturally follow. If you put too much of your attention on how you feel then you get a lot of emotional responses because you are too wrapped up in your feelings, and things can just spiral into becoming more and more intense and out of control.

Now when you do things in the proper way and put your attention on your action what ends up happening is that you really come to Revalue which is step four and is the last step of this process. It can often take several weeks or months to kick in. Revalue means that you really learn not to take the OCD or what ever anxiety symptom we're talking about at face value. Instead you literally recognize the feeling in a different way. This is the most powerful part of mindfulness because with mindfulness you can literally have the same feeling but have a totally different meaning than it did before you were mindful.

So it is not the feeling that needs the change, it is your understanding of the truth that needs to change. As your understanding of the truth develops then this feeling that I need to wash, I need to check, I can't breathe if it's a panic attack, whatever the phobia might be changes. The key is to put a different value on that feeling and say "oh well that's just the symptom, that's just the medical symptom I don't need to listen to that I'm going to refocus and do an adaptive behaviour." Yes it takes mindfulness. Yes it takes mental strength. But it's a powerful process with powerful results.

When you do this it literally changes your brain in a very significant way. You literally have used your mind to change your brain. We can also use the standard medications, the so-called Serotonin Reuptake Inhibitors to change the activity in the gearbox in ways that are helpful. As we said before the medications change the activity in the gear box and the feelings do decrease on account of that. I'm more than happy to use medications in people for whom they are appropriate, and in more than half the people with significant OCD they are appropriate at least in some course of the treatment. The fact that is so encouraging for us that you can cause those same changes to occur in the metabolism of the gear box by using just your mind and its capacity to refocus on a new behaviour.

With the learning of new and better habits, and the new patterns of focusing attention, you literally see biological changes in the area of the brain that functions as the gearbox. I strongly believe this lowers the need for medications, too, although much more research needs to be done on this aspect of treatment. I think all of the clinicians here at the conference would agree that when people do the cognitive behaviour therapy there is often a progressive decrease in the amounts of medication that are needed.

Slowly over time you can see people needing less medication than they would if they did not do the cognitive behaviour therapy. I would strongly urge clinical researchers in the field to really pursue this hypothesis in a systematic way. I think it would be really good to collect more data that says as people work on cognitive behaviour therapy and change how their brain works their requirement for medication decreases along with that. Already we have a lot of clinical evidence that this is true.

This is very helpful and it's also financially helpful to. It's certainly helpful on the side effect picture. But another point that is even more important is that we are now empowered and we realize that our mind has real power to affect how our brain works.

The focus of our will through the utilization of refocusing of our attention and doing another behaviour empowers us to change inborn pathological circuitry in the brain. In that message I think comes an awareness that can really affect our entire culture in terms of the power of mindfulness to change not only our lives but even the inner workings of our brain. Thank you very much.



The Use of Mindfulness in the Treatment of OCD

About Mindfulness

Mindfulness, to put it as plainly as possible, is the ability to observe one's own internal sensations with the calm clarity of an external witness. It has been described by the great Buddhist monk Nyanaponika as "the clear and single-minded awareness of what actually happens to us and in us, at the successive moments of perception." The mental act of adverting attention in this manner can enable sufferers of OCD and related problems to develop the insight necessary for consciously choosing new and more adaptive responses to the intrusive and intensely bothersome thoughts and urges which bombard their consciousness. As a practical matter, shifting one's perspective in this way requires substantial and quite directed effort, especially when it is done in the presence of significant anxiety and fear. For that reason, in my book Brain Lock I developed Four Steps -- Relabel, Reattribute, Refocus, Revalue -- to help people working on OCD and related problems utilize mindfulness more effectively

The Four Step approach to treatment is essentially an enhancement of traditional cognitive-behavioral therapy methods. It involves systematically training people with OCD to recognize their symptoms as being related to brain biochemical imbalances that can be responded to adaptively and in ways that lead to improved function. A great deal of personal therapeutic empowerment occurs when OCD sufferers clearly realize that their symptoms are, in effect, "false messages from the brain" which the medical condition OCD is causing them to experience, and that they have the ability to willfully change their behavioral and emotional responses to these "false messages."

The goal of treatment is to learn to respond to these "false brain messages" in new and much more adaptive ways. This is accomplished through the utilization of techniques of behavioral refocusing, in which functional activities are systematically performed in place of habitual OCD responses. These cognitive-behavioral training techniques enable patients to utilize improved self-monitoring capabilities in order to more accurately interpret their symptoms, resulting in an improved ability to manage their emotional and behavioral responses to the intense anxiety they cause. This results in an enhanced ability to maintain attentional focus on the performance of consciously chosen adaptive behaviors, rather than capitulating to automaton like compulsive responses such as repetitive washing and checking, when besieged by the fearsome thoughts and urges of OCD.

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