재명명, 재귀인, 강박증, 강박에 빠진 뇌
강박장애는 뇌가 보낸 잘못된 메시지때문에 근거없는 두려움에 시달리게 되는 병이다. 그 생각을 없애려고, 그 생각에서 빠져나오려고 하면할수록 집요하게 달라붙어 더욱 괴롭게 하는 징글징글한 질환이다. 게다가 걱정할 가치가 없다는 사실을 아는데도 걱정하는 자신에 대한 자괴감이 더해져 더욱 미칠 것 같은 감정적 혼란과 괴로움을 일으킨다.정도의 차이는 있겠지만 나의 뇌에서도 때때로 이같은 일이 벌어지고 있다. 불안스러운 느낌이 반복적으로 침습해 머릿속에서 쉽게 사라지지 않는다.
첫 번째 단계 : 재명명 (사고의 흐름을 관찰하여 뇌가 보낸 잘못된 메시지임을 인지하고 강박장애 증상이라고 정확한 이름을 붙인다)
두 번째 단계 : 재귀인 (나를 괴롭히는 이유는 뇌의 문제이고 반응하는 방식을 바꾸면 뇌가 잘 작동해서 개선될거야하고 정확하게 인식한다)
세 번째 단계 : 재초점 (강박적 충동을 돌려서 다른 행동에 집중한다)
네 번째 단계 : 재평가(강박사고를 액면 그대로 받아들이지 말것)
이 책이 말하는 핵심 치료법인 자기 주도 치료는 '자신의 뇌와 거리를 두는 것'이다. 즉, 마음챙김을 수련하는 것이라 할 수 있다. 질병과 자신을 분리해서 "이건 강박사고일 뿐이야"라고 의식적으로 인지하여 증상에 반응할 필요가 없다는 사실을 일깨운다. 그래서 뇌가 작동하는 방식을 바꿀 수 있게 되는 것이다. 여기에서 일단 받아들여야 하는 사실이 있다. 강박증상은 단기간에 바꿀 수 없다. 강박을 앓고 있는 사람이라면 누구나 인정하지 않을 수 없는 사실이다. 뇌가 보낸 잘못된 메시지라는 것을 알지만, 어떻게든 굴복시키기위해 엄청난 공포를 몰고 협박하기 때문에 굴복당하기 십상이다. 마치 세상에서 가장 중요한 일처럼, 곧 해결해야 하는 일처럼 보인다. 그래서 책은 그런 생각과 말씨름하지 않는 것이 중요하다고, 그냥 화학작용일 뿐이라고 '재명명'부터 시작해야 한다고 말한다.
하지만 '재명명'만으로 한번 들러붙은 생각(행동)은 사라지지 않는다. 왜 계속 나를 괴롭히는 이유가뭘까?라는 질문에 '재귀인' 해야 한다. "뇌의 자동 전환장치가 말을 듣지 않아서 생긴 문제다. 나는 병을 앓고 있고 내 뇌는 생각과 경험을 적절히 걸러내지 못해서 내가 생각과 충동에 부적절하게 반응하는 거야. 잘못된 메시지에 반응하는 방식을 바꾸면 뇌가 더 잘 작동해서 나쁜 생각과 느낌도 개선될거야." 라고 말이다. 이렇게 재명명과 재귀인으로 뇌에서 나온 잘못된 정보임을 알아채는 인지적 이해가 함께 작용하면 강박장애와 맞서 싸울 기반이 생기게 된다.
세 번째 단계인 '재초점'은 강박적 생각이 공격할 때 충동을 돌려서 다른 행동을 하는 것이다. 강박장애는 우리의 정신력보다 힘이 세지만 다른 곳에 관심을 두면 힘이 약해질 수 있다. 최소 15분정도 다른 일에 몰두하다보면 강박적 생각도 서서히 줄어든다고 하니 천천히 꾸준하게 초점을 돌려보자. 이 때 "이 생각을 없애야 해"가 아닌, "난 사라지든 말든 신경 안써" 마인드로 해야 증상이 사라질 가능성이 더 크다는 점을 명심하자.
이렇게 세 단계를 실천해나가면 강박사고는 무시해도 되는 가치없는 것에 불과하다는 '재평가'가 자연스럽게 이루어진다. 어떤 두려운 생각이 몰려와도 곧이곧대로 믿지 않을 수 있으려면 꾸준한 훈련말고는 없다. 훈련이 거듭되면 증상도 줄게 될 것이고 재평가가 이어져 강박장애의 증상은 확연히 약해질 것이다.불편한 느낌에 굴복하면 그 느낌이 더 강해져서 나를 짓누른다는 사실을 항상 기억해야 한다!
결국 강박장애는 의지와의 싸움이다. 원하지 않지만 받아들여야 하고, 어렵지만 행동해야 한다.
강박장애(Obsessive-Compulsive Disorder : OCD)에 응용된 불교명상의 원리
강박장애에서 고통의 원천은, 안심하지 못하는 반추적 사고(강박사고: obsessions)와 일시적으로 고통(distress)을 감소시키는 행동(강박행동: compulsions)이다. 강박장애가 있는 환자는 어떤 것을 안전하게 만들려고 애쓴다.
강박적 걱정의 한 예로는 “내가 문을 잠갔나?”이며, 강박행위에는 잠자러 가기 전에 세 번이나 문을 실제로 점검하는 것이다. 강박장애는 공포증, 물질남용 장애, 그리고 우울증 다음으로 네 번째로 가장 일반적인 정신의학적 장애이다. 비록 환자의 25%가 노출 치료를 거부하지만, 행동 치료(실제적 상황 노출 그리고 반응 방지)와 함께 약물 치료가 표준적 치료다.
제프리 슈와르츠는 마음 챙기는 알아차림(mindful awereness)과 신경영상(neuro-imaging) 연구에 기반을 두고 강박장애를 위한 치료계획안(protocol)를 개발했다.5) 이 프로그램은 새롭고, 수행하기가 쉬우며, 생각이나 행동에 대한 반복적인 순환에 자물쇠를 잠그려는 환자의 성향을 표적으로 한다.
슈와르츠는 먼저 뇌의 기능과 강박장애에 대해서 환자를 교육한다. 그러고 나서 네 가지 R을 제시한다. 만일 강박장애가 있는 사람에게 이미 문단속을 하고 외출하는 도중에 ‘내가 문을 제대로 잠갔나?’라는 강박사고가 생겨나면, 다음과 같은 자기-지시 방법을 적용하라고 한다.
①재명명(Relabel. “이건 잠기지 않은 문에 대한 것이 아니냐. 내 강박장애야.”)
②재귀인(Reattribute. “내 뇌가 이걸 하고 있는 것이지, 내가 아니야.”)
③재초점(Refocus. “왜 유용한 일을 하지 않지? 오늘 해야 할 쇼핑을 해야지.”)
④재평가(Revalue. “이 반복적 사고는 방해되며 시간낭비야.”)
환자는 뇌 활동의 새로운 패턴을 실행하고, 옛 패턴은 소거시키도록 교육받는다. 게다가 환자는 자신을 인질로 붙잡고 있는 사고로부터 탈중심화(decentering)하는 법을 배우며, 새로운 가능성을 위한 공간을 만든다. 슈와르츠의 접근에 대한 연구결과는 다음의 뇌 영상 사진을 통해 확인할 수 있다.
이 뇌영상 사진은 9명의 강박증상 환자들을 대상으로 한 10주간의 치료의 전후에 실시한 양전자 발사 단층 X선 사진 촬영법(PET) 스캔 결과를 보여주고 있는데, PET 스캔은 강박장애 환자의 경우 과잉 활성화되는 뇌의 중심부위인 꼬리핵(caudate nucleus)의 활동이 저하되었음을 보여주고 있다.
이 연구는 불안과 그 치료에 대한 신경생리학적 근거를 이해하는 데 흥미로운 진전을 이룬 성과로 PET 스캔을 사용함으로써 강박 장애가 있는 환자의 노출과 행동 반응 방지책에 의해 뇌에서 관찰 가능한 변화가 일어난다는 것을 발견한 것이다.
뇌는 전기적 활동에 의해 작동된다. 뇌파(腦波, electroencephalography, brainwave)는 신경계에서 뇌신경 사이에 신호가 전달될 때 생기는 전기의 흐름이다. 심신의 상태에 따라 각각 다르게 나타나며 뇌의 활동 상황을 측정하는 가장 중요한 지표이다. 뇌전도는 뇌의 전기적 활동에 대한 신경생리학적 측정방법으로, 두피에 부착한 전극을 통해 기록한다.
경우에 따라 전극을 피질에 부착하기도 한다. 이 결과 얻어지는 궤적을 뇌전도(EEG:electroencephalogram) 또는 뇌파(brain wave)라고 부른다. 이 장치는 뇌 손상, 간질 또는 여러 질환을 평가하거나, 법률적으로 뇌사를 진단하는 데 사용한다. 뇌전도는 다른 종류의 뇌영상화 시스템과 함께 사용할 수 있다.
명상연구에서 뇌파상의 변화 패턴에 대해서는 어느 정도는 공통 견해가 형성되었다. 대부분의 연구 결과가 명상 중에는 뇌파상의 알파파에 변화가 있는 점을 지적하고 있다. 알파파란 눈을 감은 상태에서 정상인의 뇌파에서 나타나는 8~13Hz의 주파수를 가진 파이지만, 명상에서는 눈을 감은 상태가 아니어도 알파파가 나타나고 또, 거기에 알파파의 서파화(徐波化)경향과 동기화의 증대를 볼 수 있는 것이 확인되고 있다.
뇌파 동기화(EEG synchroniz-ation/coherence)는 뇌의 전후좌우 네 부분의 알파파가 동일해지는 것을 말한다. 그리고 명상 수행을 오래한 피검사자에게는 알파파 보다 큰 서파화와 세타파(4~7Hz)의 패턴도 나타난다는 보고도 몇몇 연구자에 의해 인정되고 있다. 뇌파의 변화에 대한 연구를 정리해 보면 아직 결론을 내릴 수 있는 상황에는 이르지 않았지만, 명상을 하면 알파파에 서파화 경향과 동기화가 일어나는 것은 확실하다고는 말할 수 있다.
뇌영상 연구의 최신 성과로 데이비슨은 ‘감정과 행복감의 차이에 기초가 되는 전전두엽의 비대칭적 활동’에 대한 50여 편의 논문을 2006년에 발표하였다. 좌측 전전두엽이 행복과 같은 긍정적 정서와 깊이 연결되어 있고, 우측 전전두엽 피질이 활성화되면, 불행하다고 느끼며 우울해진다.
하지만 연민 명상을 수십년간 수행한 티베트 고승이 연민 명상을 할 때 좌측 전전두엽의 활동이 놀랄 만큼 상승한다는 사실을 통해서 뇌의 정서회로를 변화시킬 수 있다는 것이 판명되었고, 우리는 마음 수행에 의해서 행복을 의도적으로 계발할 수 있다고 한다. 이는 기본적인 행복 수준을 말하는 행복기준점을 변화시킬 수 있음을 밝혀주고 있는 것이다.
이는 데이비슨의 연구실에서 티베트 스님들이 연민 명상을 하는 동안에 감마파가 증가되었는데, 이는 대학생들이 연민명상을 할 경우보다 현저하게 증가되었다. 이 사실은 수행에 의해 뇌가 일시적으로 변하는 것이 아니라, 뇌의 지속적인 특성이 바뀐다는 것을 의미했다.
6) 최근의 신경 과학의 연구에 의하면, 뇌는 죽는 순간까지 변한다고 한다. 문제는 변화의 방향이다. 뇌의 변화는 좋은 방향으로도 좋지 않은 방향으로도 진행될 수 있다.7) 좋은 방향으로 뇌를 변화시키려면, 주의집중과 노력이 있어야 한다.8) 이는 불교에서 말하는 현명한 주의(如理作意, yoniso manasika)와 바른 노력에 해당한다.
신경영상(neuroimaging) 기법은 몸-마음의 개입을 이해하는데 몇 가지 중요한 공헌을 해왔다. 첫째, EEG, 기능적 자기 공명 영상(fMRI), 그리고 양전자 방출 단층 사진 촬영(PET)을 사용하는 연구들에 의하면, 명상 상태는 수면 혹은 휴식과는 다르다는 것을 분명히 보여준다.
9) 흥미롭게, 이 연구들은 단 하나의, 독특한 ‘명상 상태’가 있는 것이 아니라, 오히려 다른 형태의 명상수행은 뇌 활동의 다른 형식을 이끌어낸다는 것도 보여준다. 이것은 이들 다른 형태의 명상을 실행한 후에 질적으로 다른 심적 상태를 이야기하는 명상 수행자들의 주관적인 보고와 선을 같이 한다.
뇌파 패턴 연구의 한계
명상을 하면 알파파의 서파화나 동기화 또는 세타파가 나타난다고 하더라도 명상적 의식 상태를 나타내는 특유의 뇌파 패턴이 있다고 생각할 수는 없다. 각종의 간질 발작에 특유의 패턴이나 수면시의 특유의 패턴 등, 의학상 경험적으로 증명된 몇 가지의 뇌파 패턴은 존재한다. 뇌파 패턴에 의해 인간이 꿈을 꾸고 있는지 어떤지를 아는 일도 어느 정도는 가능하다.
즉, 어느 특정한 뇌파 패턴은 어느 특정한 의식 상태에 대응하고 있다고 일단은 말할 수가 있지만, 연구가 발전되어, 명상 상태에 동반하는 특유의 뇌파 패턴이 인정된다면, 명상하는 사람이 명상 상태에 있는지 어떤지를 뇌파 패턴으로부터 판단할 수 있게 될 것이다. 그러나 뇌파 패턴으로부터 말할 수 있는 것은 거기까지일 것이다. 아직은 뇌파에 의해 인간의 심리적인 상태까지 알 수 없다.
신경현상학적인 접근
인간의 마음에서 일어나는 심리적 현상을 EEG, PET, fMRI등으로 측정한다고 해서 그 사람이 마음속의 내용까지 알 수는 없다. 칠레 출신의 신경과학자 프란시스코 바레라(Francisco Varela, 1946~2001)는 명상가의 일인칭적인 체험과 객관적인 3인칭적인 데이터 연구를 결합한 신경현상학(neuropheno-menology)의 필요성을 주장하였다.
11) 1974년부터 불교를 접하고 실천해온 바레라는 80년대 중반 달라이 라마를 만났고, 서양과학에 관심이 많던 달라이 라마를 모시고 1987년 마음과 생명연구소(Mind and Life Institute)를 만들었다. 바레라가 주창한 신경현상학은 이후 신경과학자, 심리학자, 정신의학자들과 달라이 라마를 중심으로 한 불교명상가들을 연결하게 되었고, 이후 주기적인 학술회의를 통해 명상과 과학의 접점을 모색하고 있다. 이러한 신경현상학적 연구의 흐름 가운데 하나가 제프리 슈와르츠의 연구라고 할 수 있을 것이다.
제프리 슈와르츠(Jeffrey M. Schwartz, 1951~)
의학박사이자 미국의 정신과 의사로 신경가소성 분야와 강박장애 전문 연구자다. 슈와르츠는 로제스터 대학에서 철학전공으로 학사과정을 마쳤으며, 이후 의학을 전공하였다. 1970년대 이후 불교 특히 마음챙김(깨어있는 알아차림)에 대한 관심을 가지고 수행과 연구를 해왔다. 의학박사학위를 취득한 후, UCLA의과대학에서 연구조교수로 재직하고 있으며, 영국 국립 강박증 후원단체의 후원자이다.
그는 자기-지시적 신경가소성(self-directed neuroplasticity) 분야의 연구자로 뇌과학과 정신의학에 관련된 100여편의 논문의 저자이자 강박증 치료에 관련된 대중적인 저술을 하였다. 지난 20년 동안 그의 주요 연구 관심은 뇌 영상·기능 뇌해부학(brain imaging·functional neuroanatomy)과 인지행동치료였는데, 연구의 초점은 강박장애의 병리적 기제와 심리학적 치료이다. 1990년대에 중요한 발견을 했는데, 4단계의 인지행동치료에 의해서 강박장애가 있는 환자들의 특정한 뇌회로 활동의 변화를 줄 수 있다는 것이었다.
이 발견의 결과는 1996년에 논문으로 발표되었다.2) 이 논문은 최근까지 452차례 인용될 정도로 이후 불안장애에 대한 fMRI, PET를 이용한 신경영상학과 인지행동치료를 결합한 연구의 중요한 초석이 되었다.3) 슈와르츠는 같은 해 강박장애 치료를 위한 자조 서적인 『뇌 잠그기』를 출판였다. 이후 이 책을 근간으로 하여 4단계 인지행동치료를 제공해오고 있다.
슈와르츠의 강박장애에 대한 치료법은 마음이 뇌의 화학반응을 조절할 수 있다는 분명한 증거가 되었으며, 그는 인간 신경생리학 분야에서 의지의 역할에 대한 심리철학적 논문들을 발표하고 있다.4) 이처럼 슈와르츠는 심리학적인 치료 영역에 불교명상의 원리를 적용시켜 왔다. 이 분야의 그의 주저에는 다음과 같은 것이 있다. 최근에는 뇌와 마음에 대해서 양자역학적 입장에서 연구하고 있다.
Dr. Jeffrey Schwartz's Four Steps for OCD
Principles from Brainlock Help Overcome OCD
If you have obsessive thoughts and compulsive behaviors, you will be relieved to learn of significant advances in the treatment of this condition. Over the past twenty years, behavior therapy has been shown to be extremely effective in treating obsessive-compulsive disorder (OCD).
The concept of self-treatment as part of a behavioral therapy approach is a major advance. In this manual, I will teach you how to become your own behavioral therapist. By learning some basic facts about OCD, and recognizing that it is a medical condition that responds to treatment, you will be able to overcome the urges to do compulsive behaviors and will master new ways to cope with bothersome, obsessive thoughts.
At UCLA, we call this approach "cognitive-biobehavioral self-treatment." The word cognitive is from the Latin word "to know"; knowledge plays an important role in this approach to teaching basic behavior therapy techniques.
Research has shown that exposure and response prevention are very effective behavior therapy techniques for treating OCD. In traditional exposure and response prevention, people with OCD learn — under the continuing guidance of a professional therapist — to expose themselves to stimuli that intensify their obsessive thoughts and compulsive urges and then learn how to resist responding to those thoughts and urges in a compulsive manner.
For example, people who obsess irrationally about contamination from dirt may be instructed to hold something dirty in their hands and then not wash for at least three hours. We've made some modifications in this method to allow you to do it on your own.
The technique is called response prevention because you learn to prevent your habitual compulsive responses and to replace them with new, more constructive behaviors. We call our method "biobehavioral" because we use new knowledge about the biological basis of OCD to help you control your anxious responses and to increase your ability to resist the bothersome symptoms of OCD.
Our treatment differs from classic exposure and response prevention in one important way: We have developed a four-step method that enhances your ability to do exposure and response prevention on your own without a therapist being present.
The basic principle is that by understanding what these thoughts and urges really are, you can learn to manage the fear and anxiety that OCD causes. Managing your fear, in turn, will allow you to control your behavioral responses much more effectively. You will use biological knowledge and cognitive awareness to help you perform exposure and response prevention on your own. This strategy has four basic steps:
Step 1: Relabel
Step 2: Reattribute
Step 3: Refocus
Step 4: Revalue
The goal is to perform these steps daily. (The first three steps are especially important at the beginning of treatment.) Self-treatment is an essential part of this technique for learning to manage your responses to OCD on a day-to-day basis. Let's begin by learning the Four Steps.
Step 1: Relabel
The critical first step is to learn to recognize obsessive thoughts and compulsive urges. You don't want to do this in a merely superficial way; rather, you must work to gain a deep understanding that the feeling that is so bothersome at the moment is an obsessive feeling or a compulsive urge. To do so, it is important to increase your mindful awareness that these intrusive thoughts and urges are symptoms of a medical disorder.
Whereas simple, everyday awareness is almost automatic and usually quite superficial, mindful awareness is deeper and more precise and is achieved only through focused effort. It requires the conscious recognition and mental registration of the obsessive or compulsive symptom. You should literally make mental notes, such as, 'This thought is an obsession; this urge is a compulsive urge." You must make the effort to manage the intense biologically mediated thoughts and urges that intrude so insistently into consciousness.
This means expending the necessary effort to maintain your awareness of what we call the Impartial Spectator, the observing power within us that gives each person the capacity to recognize what's real and what's just a symptom and to fend off the pathological urge until it begins to fade and recede.
The goal of Step 1 is to learn to Relabel intrusive thoughts and urges in your own mind as obsessions and compulsions~and to do so assertively. Start calling them that; use the labels obsession and compulsion. For example, train yourself to say, "I don't think or feel that my hands are dirty. I'm having an obsession that my hands are dirty." Or, "I don't feel that I have the need to wash my hands. I'm having a compulsive urge to perform the compulsion of washing my hands." (The technique is the same for other obsessions and compulsions, including compulsive checking of doors or appliances and needless counting.) You must learn to recognize the intrusive, obsessive thoughts and urges as OCD.
In the Relabeling step, the basic idea is: Call an obsessive thought or compulsive urge what it really is. Assertively Relabel it so you can begin to understand that the feeling is just a false alarm, with little or no basis in reality. As the result of much scientific research we now know that these urges are caused by biological imbalances in the brain. By calling them what they really are — obsessions and compulsions — you begin to understand that they do not really mean what they say. They are simply false messages coming from the brain.
It is important to remember that just Relabeling these thoughts and urges won't make them go away. In fact, the worst thing you can do is to try to make them vanish. It won't work because the thoughts and urges have a biological cause that is beyond your control. What you can control is your behavioral response to those urges. By Relabeling, you begin to understand that no matter how real they feel, what they are saying is not real. The goal: to learn to resist them.
Recent scientific research on OCD has found that by learning to resist obsessions and compulsions through behavior therapy, you can actually change the biochemistry that is causing the OCD symptoms. But keep in mind that the process of changing the underlying biological problem, and by doing so changing the urge itself, may take weeks or even months. It requires patience and persistent effort. Trying to make these thoughts and urges go away in seconds or minutes will cause only frustration, demoralization, and stress.
It will, in fact, tend to make the urges worse. Probably the most important thing to learn in this behavioral treatment is that your responses to the thoughts and urges are within your control, no matter how strong and bothersome they may be. The goal is to control your responses to the thoughts and urges, not to control the thoughts and urges themselves.
The next two steps are designed to help you learn new ways to control your behavioral responses to OCD symptoms.
Step 2: Reattribute
The key to our self-directed behavioral therapy approach to treating OCD can be summed up in one sentence: "It's not me--it's my OCD." That is our battle cry. It is a reminder that OCD thoughts and urges are not meaningful, that they are false messages from the brain. Self-directed behavior therapy lets you gain a deeper understanding of this truth.
You are working toward a deep understanding of why the urge to check that lock or why the thought that "my hands are dirty" can be so powerful and overwhelming. If you know the thought makes no sense, why do you respond to it? Understanding why the thought is so strong and why it won't go away is the key to increasing your willpower and enabling you to fight off the urge to wash or check.
The goal is to learn to Reattribute the intensity of the thought or urge to its real cause, to recognize that the feeling and the discomfort are due to a biochemical imbalance in the brain. It is OCD--a medical condition. Acknowledging it as such is the first step toward developing a deeper understanding that these symptoms are not what they seem to be. You learn not to take them at face value.
brainDeep inside the brain lies a structure called the caudate nucleus. Scientists worldwide have studied this structure and believe that, in people with OCD, the caudate nucleus may be malfunctioning. Think of the caudate nucleus as a processing center or filtering station for the very complicated messages generated by the front part of the brain, which is probably the part used in thinking, planning, and understanding. Together with its sister structure, the putamen, which lies next to it, the caudate nucleus functions like an automatic transmission in a car.
The caudate nucleus and the putamen, which together are called the striatum, take in messages from very complicated parts of the brain--those that control body movement, physical feelings, and the thinking and planning that involve those movements and feelings. They function in unison like an automatic transmission, assuring the smooth transition from one behavior to another. Typically, when anyone decides to make a movement, intruding movements and misdirected feelings are filtered out automatically so that the desired movement can be performed rapidly and efficiently. There is a quick, smooth shifting of gears.
During a normal day, we make many rapid shifts of behavior, smoothly and easily and usually without thinking about them. It is the functioning of the caudate nucleus and the putamen that makes this possible. In OCD, the problem seems to be that the smooth, efficient filtering and the shifting of thoughts and behavior are disrupted by a glitch in the caudate nucleus.
As a result of this malfunction, the front of the brain becomes overactive and uses excessive energy. It's like having your car stuck in a ditch. You spin and spin and spin your wheels, but without traction you can't get out of that ditch. With OCD, too much energy is being used in a frontal part of the brain called the orbital cortex. It's as if the orbital cortex, which has an error-detection circuit, becomes stuck in gear. This is probably why OCD causes people to get a "something is wrong" feeling that won't go away.
You have to do the work to get it out of gear--to shift the gears. You have a manual, rather than an automatic, transmission. In fact, the person with OCD has a sticky manual transmission; he or she must shift the gears. This takes great effort because the brain tends to get "stuck in gear." But, whereas an automobile transmission is made of metal and can't fix itself people with OCD can teach themselves how to shift gears through self-directed behavior therapy. In doing so, they can actually fix this broken gearshift in the brain. We now know that you can change your own brain biochemistry.
The key to the Reattribute step is to realize that the awful intrusiveness and ferocious intensity of OCD thoughts are due to a medical condition. Underlying problems in brain biochemistry are causing these thoughts and urges to be so intrusive. That is why they won't go away. By doing this Four-Step Method of self-directed behavior therapy, you can change the brain's biochemistry. This takes weeks or even months of hard work.
In the meantime, understanding the role the brain plays in OCD thoughts and urges will help you to avoid one of the most demoralizing and destructive things people with OCD almost invariably do: the frustrating attempt to "get rid of" the thoughts and urges. There is nothing you can do to make them go away immediately. But remember: You don't have to act on them. Don't take them at face value. Don't listen to them. You know what they are. They are false messages from the brain that are due to a medical condition called OCD. Use this knowledge to avoid acting on them.
The most effective thing you can do something that will help you change your brain for the better in the long run — is to learn to put these thoughts and feelings aside and go on to the next behavior. This is what we mean by shifting gears: Do another behavior. Trying to make them go away will only pile stress on stress--and stress just makes OCD thoughts and urges worse.
Using the Reattribute step will also help you to avoid performing rituals in a vain attempt to "get the right feeling" (for example, a sense of "evenness" or a sense of completion). Knowing that the urge to get that "right feeling" is caused by a biochemical imbalance in the brain, you can learn to ignore the urge and move on. Remember, "It's not me--it's my OCD." By refusing to listen to the urge or to act on it, you will actually change your brain and make the feeling lessen. If you take the urge at face value and act on it, you may get momentary relief but within a very short time the urge will just get more intense. This is perhaps the most important lesson that people with OCD must learn. It will help you avoid being the "sucker" and taking the false bait of OCD every time.
The Relabel and Reattribute steps are usually performed together to bring about a deeper understanding of what is really happening when an OCD thought or urge causes you such intense pain. You Relabel it, call it what it is--an obsession or a compulsion. Use mindful awareness to get beyond a superficial understanding of OCD and to gain the more profound understanding that the thoughts and urges are nothing more than fallout from a medical condition.
Step 3: Refocus
The Refocus step is where the real work is done. In the beginning, you may think of it as the "no pain, no gain" step. Mental exercise is like a physical workout. In Refocusing, you have work to do: You must shift the gears yourself. With effort and focused mindfulness, you are going to do what the caudate nucleus normally does easily and automatically, which is to let you know when to switch to another behavior.
Think of a surgeon scrubbing his hands before surgery: The surgeon doesn't need to wait for a timer to go off to know when it's time to stop scrubbing. After a while, the behavior is simply automatic. After a while he gets a "feel" for when he's scrubbed enough. But people with OCD can't get the feeling that something is done once it's done. The automatic pilot is broken. Fortunately, doing the Four Steps can usually fix it.
In Refocusing, the idea is to work around the OCD thoughts and urges by shifting attention to something else, if only for a few minutes. Early on, you may choose some specific behavior to replace compulsive washing or checking. Any constructive, pleasant behavior will do. Hobbies are particularly good. For example, you may decide to take a walk, exercise, listen to music, read, play a computer game, knit, or shoot a basketball.
When the thought comes, you first Relabel it as an obsessive thought or a compulsive urge and then Reattribute it to the fact that you have OCD — a medical problem. Then Refocus your attention to this other behavior that you have chosen. Start the process of Refocusing by refusing to take the obsessive-compulsive symptoms at face value. Say to yourself, "I'm experiencing a symptom of OCD. I need to do another behavior."
You must train yourself in a new method of responding to the thoughts and urges, redirecting your attention to something other than the OCD symptoms. The goal of treatment is to stop responding to the OCD symptoms while acknowledging that, for the short term, these uncomfortable feelings will continue to bother you. You begin to "work around" them by doing another behavior. You learn that even though the OCD feeling is there, it doesn't have to control what you do. You make the decision about what you're going to do, rather than respond to OCD thoughts and urges as a robot would. By Refocusing, you reclaim your decision-making power. Those biochemical glitches in your brain are no longer running the show.
The Fifteen-Minute Rule
Refocusing isn't easy. It would be dishonest to say that dismissing the thoughts and urges and moving on does not take significant effort and even tolerance of some pain. But only by learning to resist OCD symptoms can you change the brain and, in time, decrease the pain. To help you manage this task, we have developed the fifteen-minute rule.
The idea is to delay your response to an obsessive thought or to your urge to perform a compulsive behavior by letting some time elapse--preferably at least fifteen minutes--before you even consider acting on the urge or thought. In the beginning or whenever the urges are very intense, you may need to set a shorter waiting time, say five minutes, as your goal. But the principle is always the same: Never perform the compulsion without some time delay.
Remember, this is not a passive waiting period. It is a time to perform actively the Relabeling, Reattributing, and Refocusing steps. You should have mindful awareness that you are Relabeling those uncomfortable feelings as OCD and Reattributing them to a biochemical imbalance in the brain. These feelings are caused by OCD; they are not what they seem to be. They are faulty messages coming from the brain.
Then you must do another behavior~any pleasant, constructive behavior will do. After the set period has lapsed, reassess the urge. Ask yourself if there's been any change in intensity and make note of any change. Even the smallest decrease may give you the courage to wait longer. You will be learning that the longer you wait, the more the urge will change. The goal will always be fifteen minutes or more. As you keep practicing, the same amount of effort will result in a greater decrease in intensity. So, in general, the more you practice the fifteen-minute rule, the easier it gets. Before long, you may make it twenty minutes or thirty minutes or more.
It's What You Do That Counts
It is vitally important to Refocus attention away from the urge or thought and onto any other reasonable task or activity. Don't wait for the thought or feeling to go away. Don't expect it to go away right away. And, by all means, don't do what your OCD is telling you to do. Rather, engage in any constructive activity of your choosing. You'll see that instigating a time delay between the onset of the urge and even considering acting on it will make the urge fade and change. What is more important, even if the urge changes hardly at all, as sometimes happens, you learn that you can have some control over your response to this faulty message from the brain.
This application of mindful awareness and the Impartial Spectator will be empowering to you, especially after years of feeling at the mercy of a bizarre and seemingly inexplicable force. The long-range goal of the Refocus step is, of course, never again to perform a compulsive behavior in response to an OCD thought or urge. But the intermediate goal is to impose a time delay before performing any compulsion. You're learning not to allow OCD feelings to determine what you do.
Sometimes the urge will be too strong, and you will perform the compulsion. This is not an invitation to beat yourself up. Keep in mind: As you do the Four Steps and your behavior changes, your thoughts and feelings will also change. If you give in and perform a compulsion after a time delay and an attempt to Refocus, make a special effort to continue to Relabel the behavior and to acknowledge that this time the OCD overwhelmed you. Remind yourself "I'm not washing my hands because they are dirty, but because of my OCD. The OCD won this round, but next time I'll wait longer." In this way, even performing a compulsive behavior can contain an element of behavior therapy. This is very important to realize: Relabeling a compulsive behavior as a compulsive behavior is a form of behavior therapy and is much better than doing a compulsion without making a clear mental note about what it is.
A tip for those who are fighting checking behaviors--checking locks, stoves, and other appliances: If your problem is, say, checking the door lock, try to lock the door with extra attention and mindful awareness the first time. This way, you'll have a good mental picture to refer to when the compulsive urge arises. Anticipating that the urge to check is going to arise in you, you should lock the door the first time in a slow and deliberate manner, making mental notes, such as "The door is now locked. I can see that the door is locked." You want a clear mental image of that locked door; so when the urge to check the door seizes you, you will be able to Relabel it immediately and say, "That's an obsessive idea. It is OCD." You will Reattribute the intensity and intrusiveness of the urge to check again to your OCD. You will remember, "It's not me--it's just my brain."
You will Refocus and begin to "work around" the OCD urges by doing another behavior, with a ready mental picture of having locked that door because you did it so carefully and attentively the first time. You can use that knowledge to help you Refocus actively on doing another behavior, even as you Relabel and Reattribute the urge to check that has arisen, as you anticipated it would.
Keeping a Journal
It is important to keep a behavior-therapy journal as a record of your successful Refocusing efforts. It need not be anything fancy. The idea is simply to have a written record to remind you of your successes in self-directed behavior therapy. The journal is important because you can refer back to it to see which behaviors most helped you to Refocus. But — and this is equally important — it helps you to build confidence as you see your list of achievements grow. In the heat of battle against a compulsive urge, it isn't always easy to remember which behavior to Refocus on. Keeping a journal will help you to shift gears when the going gets tough, when the obsessive thought or compulsive urge heats up, and will train your mind to remember what has worked in the past. As your list of successes gets longer, it will be inspirational.
Record only your successes. There is no need to record your failures. You have to learn to give yourself a pat on the back. This is something people with OCD need to learn to do more of. Make sure to give yourself encouragement by consciously acknowledging your successful use of Refocusing behaviors as a job well done. Reinforce that success by recording it in your behavior-therapy journal and giving yourself a little reward, even if it's only to tell yourself how terrific you are for working so hard to help yourself.
Step 4: Revalue
The goal of the first three steps is to use your knowledge of OCD as a medical condition caused by a biochemical imbalance in the brain to help you clarify that this feeling is not what it appears to be and to refuse to take the thoughts and urges at face value, to avoid performing compulsive rituals, and to Refocus on constructive behaviors. You can think of the Relabel and Reattribute steps as a team effort, working together with the Refocusing step.
The combined effect of these three steps is much greater than the sum of their individual parts. The process of Relabeling and Reattributing intensifies the learning that takes place during the hard work of Refocusing. As a result, you begin to Revalue those thoughts and urges that, before behavior therapy, would invariably lead you to perform compulsive behaviors. After adequate training in the first three steps, you are able in time to place a much lower value on the OCD thoughts and urges.
We have used the concept of the "Impartial Spectator," developed by 18th-century philosopher Adam Smith, to help you understand more clearly what you are actually achieving while performing the Four Steps of cognitive biobehavioral therapy. Smith described the Impartial Spectator as being like a person inside us who we carry around at all times, a person aware of all our feelings, states, and circumstances. Once we make the effort to strengthen the Impartial Spectator's perspective, we can call up our own Impartial Spectator at any time and literally watch ourselves in action. In otherwords, we can witness our own actions and feelings as someone not involved would, as a disinterested observer.
As Smith described it, "We suppose ourselves the spectators of our own behavior." He understood that keeping the perspective of the Impartial Spectator clearly in mind, which is essentially the same as using mindful awareness, is hard work, especially under painful circumstances, and requires the "utmost and most fatiguing exertions.". The hard work of which he wrote seems closely related to the intense efforts you must make in performing the Four Steps.
People with OCD must work hard to manage the biologically induced urges that intrude into conscious awareness. You must strive to maintain awareness of the Impartial Spectator, the observing power within that gives you the capacity to fend off pathological urges until they begin to fade. You must use your knowledge that OCD symptoms are just meaningless signals, false messages from the brain, so you can Refocus and shift gears.
You must gather your mental resources, always keeping in mind, "It's not me--it's my OCD. It's not me--it's just my brain." Although in the short run, you can't change your feelings, you can change your behavior. By changing your behavior, you find that your feelings also change in time. The tug-of-war comes down to this: Who's in charge here, you or OCD? Even when the OCD overwhelms you, and you give in and perform the compulsion, you must realize that it's just OCD and vow to fight harder the next time.
With compulsive behaviors, simply observing the fifteen-minute rule with consistency and Refocusing on another behavior will usually cause the Revalue step to kick in, which means realizing that the feeling is not worth paying attention to and not taking it at face value, remembering that it's OCD and that it is caused by a medical problem. The result is that you place a much lower value on--devalue--the OCD feeling. For obsessive thoughts, you must try to enhance this process by Revaluing in an even more active way.
Two substeps — the two A's — aid you in Step 2: Reattribute: Anticipate and Accept. When you use these two A's, you are doing Active Revaluing. Anticipate means "be prepared," know the feeling is coming, so be ready for it; don't be taken by surprise. Accept means don't waste energy beating yourself up because you have these bad feelings. You know what's causing them and that you have to work around them. Whatever the content of your obsession--whether it is violent or sexual or is manifested in one of dozens of other ways--you know that it can occur hundreds of times a day.
You want to stop reacting each time as though it were a new thought, something unexpected. Refuse to let it shock you; refuse to let it get you down on yourself. By anticipating your particular obsessive thought, you can recognize it the instant it occurs and Relabel it immediately. You will simultaneously, and actively, Revalue it. When the obsession occurs, you will be prepared. You will know, "That's just my stupid obsession. It has no meaning. That's just my brain. There's no need to pay attention to it."
Remember: You can't make the thought go away, but neither do you need to pay attention to it. You can learn to go on to the next behavior. There is no need to dwell on the thought. Move ahead. This is where the second A--Accept--comes in. Think of the screaming car alarm that disturbs and distracts you. Don't dwell on it. Don't say, "I can't do another thing until that blankety-blank car alarm shuts off." Simply try to ignore it and get on with things.
You learned in Step 2 that the bothersome obsessive thought is caused by OCD and is related to a biochemical imbalance in the brain. In the Acceptance substep of Reattributing, you realize that truth in a very deep, perhaps even spiritual, way. Do not get down on yourself. it makes no sense to criticize your inner motives just because of an imbalance in the brain. By accepting that the obsessive thought is there despite you, not because of you, you can decrease the terrible stress that repetitive obsessive thoughts usually cause. Always keep in mind, "It's not me — it's the OCD. It's not me — it's just my brain." Don't beat yourself up trying to make the thought go away because in the short run, it will not. Most important, don't ruminate and don't fantasize about the consequences of acting out a terrible obsessive thought.
You won't act it out because you don't really want to. Let go of all the negative, demeaning judgments about "the kinds of people who get thoughts like this." For obsessions, the fifteen-minute rule can be shortened to a one minute rule, even a fifteen-second rule. There is no need to dwell on that thought, even though it lingers in your mind. You can still go on--indeed, you must go on — to the next thought and the next behavior. In this way, Refocusing is like a martial art. An obsessive thought or compulsive urge is very strong, but also quite stupid. If you stand right in front of it and take the full brunt of its power, trying to drive it from your mind, it will defeat you every time. You have to step aside, work around it, and go on to the next behavior. You are learning to keep your wits about you in the face of a powerful opponent. The lesson here goes far beyond overcoming OCD By taking charge of your actions, you take charge of your mind — and of your life.
Conclusion
We who have OCD must learn to train our minds not to take intruding feelings at face value. We have to learn that these feelings mislead us. In a gradual but tempered way, we're going to change our responses to the feelings and resist them. We have a new view of the truth. In this way, we gain new insights into the truth. We learn that even persistent, intrusive feelings are transient and impermanent and will recede if not acted on.
And, of course, we always remember that these feelings tend to intensify and overwhelm us when we give in to them. We must learn to recognize the urge for what it is--and to resist it. In the course of performing this Four-Step Method of behavioral self-treatment, we are laying the foundation for building true personal mastery and the art of self-command. Through constructive resistance to OCD feelings and urges, we increase our self-esteem and experience a sense of freedom. Our ability to make conscious, self-directed choices is enhanced.
By understanding this process by which we empower ourselves to fight OCD and by clearly appreciating the control one gains by training the mind to overcome compulsive or automatic responses to intrusive thoughts or feelings, we gain a deepening insight into how to take back our lives. Changing our brain chemistry is a happy consequence of this life-affirming action. True freedom lies along this path of a clarified perception of genuine self-interest.
QUICK SUMMARY OF THE 4 STEPS OF COGNITIVE BEHAVIORAL SELF-TREATMENT FOR OCD
Step 1: RELABEL
Recognize that the intrusive obsessive thoughts and urges are the RESULT OF OCD.
Step 2: REATTRIBUTE
Realize that the intensity and intrusiveness of the thought or urge is CAUSED BY OCD; it is probably related to a biochemical imbalance in the brain.
Step 3: REFOCUS
Work around the OCD thoughts by focusing your attention on something else, at least for a few minutes: DO ANOTHER BEHAVIOR.
Step 4: REVALUE
Do not take the OCD thought at face value. It Is not significant in itself.