Mindfulness and Cognitive Behavioral Therapy for OCD

by Jon Hershfield, MFT, & Tom Corboy, MFT

Jon Hershfield, MFT, is the associate director of the UCLA Child OCD Intensive Outpatient Program at Resnick Neuropsychiatric Hospital, and is a psychotherapist specializing in the treatment of OCD and related disorders using mindfulness-based cognitive behavioral therapy (MBCBT).

Tom Corboy, MFT, is the executive director of the OCD Center of Los Angeles, where he is a licensed psychotherapist specializing in MBCBT for the treatment of OCD and related anxiety-based conditions.

 Hershfield and Corboy are also the authors of the new book, The Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioral Therapy (New Harbinger Self-Help Workbooks, 2013).

This article was initially published in the Spring 2014 edition of the OCD Newsletter

If you suffer from obsessive compulsive disorder (OCD) and you take the brave step of getting professional help, you’re likely to start hearing the word “mindfulness” used in reference to some part of your treatment.  Mindfulness is really “in” right now, and there’s good reason for this.  Over the years, research and clinical experience has shown mindfulness to be an important tool in addressing a number of mental health issues.  More recently, many who specialize in treating OCD are finding that mindfulness may be useful at improving the effectiveness of cognitive behavioral therapy (CBT).  However, there are concerns that mindfulness strategies can be used incorrectly as a “neutralizing” technique, or, in other words, that it may “cancel out” or weaken the effectiveness of traditional exposure and response prevention (ERP) treatment. So, we are left with two questions: What is mindfulness? And how can it be used to improve, not take away from, traditional CBT treatment of OCD?

In general, mindfulness means paying attention to the present moment without judgment.  When you have OCD, this is no easy feat.  The present moment can include painful and confusing intrusive thoughts, feelings, and sensations that seem to lend themselves to judgment.  Rather than attempting to neutralize (or get rid of) these internal experiences with compulsions, mindfulness asks that we allow the moment to stay as it is.  In this way, mindfulness is not very different from exposure with response prevention (ERP).  In ERP, you are being asked to confront your triggers and resist responding to them with compulsions.  In mindfulness, you are being asked to simply remain aware when you are triggered, to accept the discomfort it causes, and to resist trying to change it with compulsions.  This technique can be strengthened by accepting that the thoughts are simply mental events, capable of being observed without being automatically thought of as warning signs or threats of danger.  However, mindfulness may get in the way of the therapeutic process when the concept of “it’s just a thought” instead becomes a mantra used to reassure oneself that one’s fears will not come true.

While a chicken-and-egg debate may be present in the clinical community over which should come first — behavioral change through ERP, or a change in perspective through an acceptance-focused approach (for an interesting discussion on the subject, see Grayson’s 2013 article, “ACT vs. ERP for OCD,” and its subsequent follow-ups) — our shared clinical experience suggests three main areas in which mindfulness can be used along with traditional CBT to boost the effectiveness of CBT.  In other words, an “and” approach instead of an “either/or” approach can improve these three elements of CBT:

Acceptance – OCD wants you to be afraid of your internal world, driving you to do compulsions to push thoughts away, which then keeps the disorder alive.  Psycho-education on how the brain interacts with the mind is often the first step in introducing the CBT model to someone seeking treatment.  Understanding this interaction and the obsessive-compulsive cycle is essential for preparing someone to engage in the therapy.  Thus, understanding first what it means to be mindful can be as useful as understanding what it means to be cognitive or behavioral in your approach to treatment.  To be “mindful” means observing and accepting unwanted thoughts, feelings, and physical sensations without judging or attaching meaning to them or trying to stop or change them. This can be implemented moment to moment during a person’s day, simply by noticing what’s going on inside as you go about your day (for example, noticing the sound of running water during a shower or the sensation of your body pressing against the seat you are in).  Formal meditation — the practice of setting aside a specific period of time to focus on an “anchoring concept,” such as one’s breathing or heartbeat, while letting the internal world come and go without judgment or analysis— also provides a strategy to practice confronting OCD.

Assessment – Traditional cognitive therapy focuses on figuring out the distorted thinking at the heart of OCD.  The use of automatic thought records (writing down your thoughts to review with your therapist) and learning to notice and identify cognitive distortions (problematic styles of thinking and beliefs that are getting in your way) offer those with OCD a way to assess how they are thinking about their experience without attempting to get rid of thoughts or push them down.  Consider the difference between trying to mindfully accept the thought “Because my hands are not 100% clean, I am going to get a terrible disease” versus “I don’t know if my hands are clean in this moment and can’t predict the future.”  By helping people be more aware of the way in which they are thinking about their uncomfortable thoughts, feelings, and sensations, mindfulness can help people redirect themselves away from their desire to do compulsions.  Instead of challenging the likelihood of fears coming true, one can challenge the seriousness with which they understand their internal world in the first place by using mindfulness concepts.

Action – Effective action against OCD ultimately means confronting one’s feared thoughts, feelings, and sensations using ERP.  This behavioral component of CBT — intentionally exposing one’s self to the very thoughts and situations that cause so much suffering — naturally increases the urge to do compulsions.  Mindfulness strengthens ERP by encouraging acceptance of one’s uncomfortable reactions to exposures, thus reducing the powerful draw of compulsive behaviors.  Rather than being used as a tool for resistance to compulsions, the inclusion of mindfulness in ERP allows for an openness to discomfort — a curiosity toward what happens when you lean in to it instead of running away.

Research Supporting Mindfulness for the Treatment of OCD

With any update to OCD treatment, clinical experience is going to have a longer history than clinical research.  However, a growing pool of research coming out over the last few years suggests that those who are adding mindfulness into treatment for OCD are on the right track:

  • A 2013 study (Wahl) examined the effectiveness of mindfulness and meditation compared to the use of distraction in 30 patients with OCD who were doing brief exposure to their unwanted thoughts. The results showed that those who used mindfulness skills (i.e. letting thoughts come and go without judgment) felt less of an urge to neutralize thoughts with compulsions, while those who used only distraction strategies (i.e. trying to think of something else) saw no change in their urge to use compulsions.
  • A 2012 German study (Hertenstein et al.) researched the impact of an 8-week mindfulness-based group therapy program on adults with OCD. All study participants had already completed a course of ERP within a two-year period before the study began.  Of the 12 participants, 8 reported having fewer OCD symptoms as a result of the group therapy program.  Additional benefits reported by study participants included an increased willingness and ability to allow unpleasant emotions to surface, feeling able to handle these emotions more flexibly, a sense of living more consciously in the present, a calmer attitude towards their OCD, and generally improved mood and sleep.
  • A small 2010 study (with only 3 participants) on intrusive thoughts in OCD (Wilkinson-Tough) looked at whether mindfulness-based therapy could help those who were using thought suppression (that is, trying to stop thinking certain things) and experiencing thought-action fusion (in other words, believing that thinking something in your head means it actually happens in real life). Three participants received a six-session mindfulness-based intervention with an emphasis on using mindfulness skills every day.  Following treatment, all participants received improved scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), an assessment tool used to figure out which OCD symptoms are present and how severe they are.
  • A 2010 study on group treatment for OCD (Fairfax) explored several different clinical interventions that could strengthen evidence-based practices and found that the participants responded well to mindfulness-based interventions in particular. The authors suggested that the use of mindful awareness and strategies focused on attention may support efforts to participate in ERP.
  • A 2008 Dutch study (Hanstede et al.) examined the impact of mindfulness meditation on a group of 17 university students. Subjects were taught the mindfulness techniques of “meditative breathing, body-scan, and mindful daily living,” as applied to OCD, over the course of eight one-hour sessions.  Researchers found that mindfulness meditation had “a significant and large effect” on OCD symptoms, specifically on thought-action fusion (again, the belief that having a thought is the same as acting on the thought), and the ability to “let go” of unwanted thoughts.
  • A 2006 study (Twohig et al.) explored the effect of Acceptance and Commitment Therapy (ACT), a treatment modality that in part includes a focus on developing mindfulness skills and participants’ willingness to accept and tolerate unwanted obsessive thoughts. Study participants reported decreased avoidance of uncomfortable or unwanted internal experiences (negative thoughts and feelings), decreased believability of obsessions, and decreased anxiety and depressive symptoms, as well as fewer compulsions by the end of treatment for all participants.

Mindfulness, the ability to remain in the presence of the moment (even the unpleasant moment), also seems to be a very flexible approach.  OCD sufferers who struggle with intrusive thoughts of a sexual or aggressive nature may find that a well-developed ability to watch thoughts go by makes the difference between desperately using compulsions to make the thoughts go away, or instead successfully managing their OCD.  But, a person trapped by an endless cycle of washing, checking, or cleaning is experiencing exactly the same struggle with accepting thoughts, feelings, and sensations as people with intrusive thoughts.  So, mindfulness is really for anyone who wants to stop feeling like what is going on inside their mind is a burden.  It’s hard to imagine anyone with OCD who would wish to continue feeling that way.

References:

  1. Fairfax, H. (2010). A group-based treatment for clients with Obsessive Compulsive Disorder (OCD) in a secondary care mental health setting: Integrating new developments within cognitive behavioural interventions – An exploratory study. Counselling & Psychotherapy Research, 10(3), 214-221.
  2. Grayson, J. (2013). ACT vs. ERP for OCD: Is It War or Marriage?  The Behavior Therapist, 36(4), 84-89.
  3. Hanstede, M., Gidron, Y., & Nyklícek, I. (2008). The effects of a mindfulness intervention on obsessive-compulsive symptoms in a non-clinical student population. Journal of Nervous Mental Disorders,196 (10):776-9.
  4. Hertenstein, E., Rose, N., Voderholzer, U,. Heidenreich, T., Nissen, C., Thiel, N., Herbst, N., Katrin Külz, A. (2012). Mindfulness-based cognitive therapy in obsessive-compulsive disorder – A qualitative study on patients’ experiences. BMC Psychiatry, 12:185.
  5. Twohig, M., Hayes, S., & Masuda, A. (2006).  Increasing willingness to experience obsessions: acceptance and commitment therapy as a treatment for obsessive-compulsive disorder.  Behavior Therapy 37(1):3-13.
  6. Wahl, K. (2013). Managing Obsessive Thoughts During Brief Exposure: An Experimental Study Comparing Mindfulness-Based Strategies and Distraction in Obsessive-Compulsive Disorder. Cognitive Therapy & Research, 37(4), 752-761.
  7. Wilkinson-Tough, M. (2010). Is mindfulness-based therapy an effective intervention for obsessive–intrusive thoughts: a case series. Clinical Psychology & Psychotherapy, 17(3), 250-268.