The Mind and the Brain by Jeffrey M. Schwartz, Sharon Begley Page B

hospital. Exposures are also conducted at home; the patient works at stopping himself from acting on his compulsive urges. The patient, needless to say, can become extremely anxious during this phase, which often lasts an hour or more. Ideally, however, as therapy continues, he begins to master his responses to triggers further up the distress scale, the anxiety ignited by the triggers lessens, and he gains control of his thoughts and actions.
    Controversy swirls around exposure and response prevention therapy, however. The most common claim for the treatment is that three out of four patients who complete therapy do well, experiencing a 65 percent reduction in their OCD symptoms. But that little phrase “who complete” hides a land mine. “The trouble is, a lot ofpeople won’t do it at all, they’re so afraid to confront their obsessions and not be allowed to carry out their compulsions,” says Kozak. During his work with Edna Foa in Philadelphia, where they developed one of the best programs in the United States, some 25 percent of patients refused to undergo a single session once they learned what was involved. With less adept clinicians, refusal rates can run even higher. Some clinicians manipulate their dropout rates by fiddling with the entry criteria: by doing a little exposure and response prevention and rejecting patients who can’t take it, researchers make their results look better. Even then, 10 to 30 percent of patients who agree to start therapy drop out. And not every clinician practicing exposure and response prevention has done it well, or wisely. “There have been quite some mistakes, with therapists abusing the method or going faster than patients would have liked,” says Dr. Iver Hand of the University of Hamburg in Germany, a pioneer in the field who developed a variant of ERP. “It is easy for a badly-trained therapist to abuse the method.” Compared to drugs, behavioral therapy seemed to produce better results for patients who could tolerate it. But the hidden statistics made it clear: for millions of OCD patients, exposure and response prevention was not the answer.
    This was the state of play when I entered the field in the mid-1980s. It wasn’t so much psychology, or even physiology, that attracted me to the study of obsessive-compulsive disorder. It was philosophy. OCD, I thought, offered a wedge into the mind-brain enigma. Because symptoms are usually so clear-cut that patients can describe precisely what they feel, I realized that there should be no problem establishing the mental, experiential aspect of the disease. And since it was becoming clear even in the 1980s that psychiatric illness was rooted in the functional neuroanatomy of the brain, I was also optimistic that it would be possible to establish what was happening in the brain of people with the disease. Finally, the disease’s ego-dystonic nature suggested that although the brain was acting up, an intact mind was struggling to overcome it: the eventsof the brain and the state of the mind were, at least partly, separable. Obsessive-compulsive disorder thus seemed to be the perfect vehicle for pursuing such profound questions as the schism between mind and brain and, in particular, the distinction between active and passive mental activity: the symptoms of OCD are no more than the products of passive brain mechanisms, but patients’ attempts to resist the compulsions represent active, mental effort.
    What attracted me most to the psychological treatment of OCD, however, was a tantalizing possibility. Cognitive therapy—a form of structured introspection—was already widely used for treating depression. The idea is to help patients more clearly assess the contents of their thought stream, teaching them to note and correct the conceptual errors termed “cognitive distortions” that characterize psychopathological thinking. Someone in the grips of such thinking would, for instance, regard a half-full glass not merely as