Mindfulness-Based Therapy for OCD by Jon Hershfield, LCMFT
BRIEF DESCRIPTION:
Mindfulness refers to the state of paying attention to the present moment without judgment. It can be a key component in changing the way you experience and respond to intrusive thoughts and difficult emotions.
Mindfulness-based therapy (sometimes called mindfulness-based cognitive therapy or mindfulness-based cognitive behavioral therapy) is a treatment approach to OCD that, as the name implies, emphasizes the role of mindfulness in changing one’s relationship to thoughts, feelings, and sensations. Put another way, mindfulness-based therapy looks at traditional cognitive behavioral therapy (CBT) and exposure and response prevention (ERP) through a mindfulness lens. It emphasizes increasing awareness of mental activity, disentangling from rumination, and engaging more effectively with the way things are (as opposed to narratives about the way they could be).
As in standard CBT/ERP, the first few sessions are largely psychoeducational, assessing the obsessions and compulsions, identifying the obsessive-compulsive cycle, and developing a list of strategies (i.e., exposures or non-avoidances) for provoking obsessions and resisting compulsions. During this phase, patients are also educated on fundamental mindfulness concepts, understanding the nature of thoughts, feelings, and sensations as objects of attention.
In other words, these are things that can be observed without being identified with. Meditation practices that promote mindfulness are developed through a variety of exercises that may include insight meditation, breathing meditation, walking meditation, mindful eating, body scan or progressive muscle relaxation exercises, or related experiential activities.
Mindfulness-based therapy often pays equal attention to the cognitive process that precedes distress and the behavioral process that follows it. In other words, mindfulness of sensations in the body and of activity in the mind itself is used to identify the distorted thinking processes that lead people with OCD to catastrophic conclusions. In this phase of treatment, participants engage in modified cognitive restructuring. Unlike traditional cognitive restructuring (e.g., for depression), the objective here is not to change the thoughts, but to change one’s relationship to the thoughts. Rather than debating the probability of thought content, the skill developed here is recognizing the objective reality of the presence of the thought and its coinciding feelings and sensations that can be observed.
Additionally, while intentionally engaging with triggering stimuli to practice resisting compulsive responses, changes in the mind and body are observed mindfully, accepted as observable changes and not threats to be negotiated with. As with traditional CBT/ERP, cognitive and behavioral assignments are practiced in session and also as homework between sessions. Assignments for developing a daily meditation practice are typically involved as well.
Traditional ERP often anticipates a gradual reduction of distress after repeated exposures. This is also true in mindfulness-based therapy, though greater emphasis is placed on making space for whatever arises, distressing or otherwise. When doing exposures mindfully, one is asked to observe what arises during the activity, notice resistance to it, and remain in an observer’s stance towards that resistance rather than give into it with compulsions. The desired outcome is an increased sense of trust in one’s ability to objectively observe reality, improved attentional control, an open (or radical) acceptance of uncertainty, the ability to identify the difference between having thoughts and being lost in stories, and an instinct for self-compassion.
A typical course of mindfulness-based therapy spans anywhere from 12 to 20 sessions but can be adjusted based on individual needs. Sessions typically last about one hour each. As with traditional CBT/ERP, the format can vary, including individual therapy sessions (once per week or more), group sessions, intensive outpatient programs, or teletherapy options. Self-help resources can also complement the therapy.
Mindfulness-based therapy is typically administered by licensed mental health professionals, such as psychologists, social workers, or counselors who have specific training and expertise in mindfulness, CBT, and ERP. To find a qualified provider, it is best to consult professional organizations specializing in OCD (like the IOCDF) or seek referrals from other professionals.
WHY/HOW IT WORKS:
The fundamental challenge faced by people with OCD is the tendency to immediately react, rather than mindfully respond to what arises. This reactivity leads people with OCD to get immersed in obsessive thoughts/narratives and to fail to notice when this process is beginning. Once an individual becomes aware that they are stuck in an OCD narrative, the disorder makes one feel as if a specific behavior must take place before abandoning the narrative (i.e., a compulsion or other certainty-seeking strategy).
By developing an increased awareness of the mind and body through mindfulness practice, individuals with OCD can better perceive when they are being pulled out of the present moment and better drop out of their stories without the precondition of compulsive behavior. This concept is sometimes referred to as “attentional control” and simply means being able to track where your attention is and direct it back to the present moment without judgment.
Mindfulness is better thought of as a perspective than an intervention. It is not something that is done so much as it is something that is experienced. By recognizing thoughts, feelings, and sensations as objects of attention and not the threats they appear to be, increased confidence and competence in the face of OCD triggers naturally develop.
SUMMARY OF THE RESEARCH SUPPORT:
Mindfulness training and mindfulness-based therapeutic interventions have been found to be effective and impactful for a variety of psychiatric conditions. Several studies over the last decade specifically support the use of mindfulness-based interventions, in combination with ERP, in the treatment of OCD.
AGE CONSIDERATIONS
Mindfulness skill development can be modified for each developmental stage.
OTHER IMPORTANT CONSIDERATIONS:
Mindfulness-based treatment as a general term can mean several different things. Mindfulness-based cognitive therapy and mindfulness-based stress reduction have specific protocols that don’t always apply to OCD. Similarly, many OCD specialists use a traditional or eclectic approach to CBT and ERP that emphasizes the role of mindfulness, though this may not always be called mindfulness-based therapy.
WHEN TO TRY THIS TREATMENT:
As of this writing, ERP is considered the first-line treatment for OCD. Mindfulness-based therapy can be a potential add-on to ERP and/or other first-line treatment. Infusing mindfulness with ERP concepts may produce the best results. However, not everyone easily gravitates towards the fundamental concepts behind mindfulness and that should not be looked at as a negative prognostic factor. The key to effective OCD treatment is finding an approach that makes sense to you and that you are willing to engage in.