OCD – Why Include Mindfulness into Exposure Therapy

Research is always looking at improving patient engagement and to decrease drop-out rates. A pilot study to integrate Mindfulness into ERP (Strauss et al., 2015) showed the drop-out rate was twenty-five percent. It could be said that the reason for this is that people on the OCD spectrum who show poor distress tolerance need the combined approach to help them complete their course of ERP treatment.

What about those who do ERP successfully, how can Mindfulness help them?

While some do complete their course of exposure-response prevention (ERP) successfully, others don’t fully engage with the assigned ERP homework tasks out of the therapy room. It means treatment outcome is poorer than it is for others who do fully engage. Bringing in Mindfulness can be an additional benefit either way.

If ERP effectively desensitises a person from the things they fear, wouldn’t Mindfulness distract away from this goal?

No, because Mindfulness, as opposed to distraction, are two different concepts. The first represents a state of awareness where the focus is the accepted attention towards intrusive thoughts in a non-judgmental way and distraction is non-acceptance of intrusive thoughts. Distraction involves a person’s negative evaluation (thinking errors) about the situation and avoidance or escape behaviours (rituals), which are the corresponding compulsions that reinforce the problem.

But what about anxiety, how can someone manage distress while accepting the thoughts?

Mindfulness training is also about accepting feelings and bodily sensations. It means a person remains concentrated on the exposure situation and leans into the anxiety. Therapy teaches them that anxiety rises until it reaches a plateau, and before decreasing naturally.

So would you say acceptance enhances therapy?

Yes, because when a person learns to be non-judgmental about their intrusive thoughts, it frees them from ruminations (thinking compulsion).  They learn three things, which are to Acknowledge unwanted thoughts are there. Next, to Accept the thoughts as intrusive and nothing more and finally, to Allow the intrusions to come and go without negative appraisal or giving into compulsions.

How does Mindfulness help a person manage emotions such as guilt and shame when they have pure-intrusive thoughts?

It teaches someone that it’s counterproductive to dwell on these emotions. Guilt and shame are best seen as intrusive and treated as such. For example, if their intrusive thoughts are about harm, then Acknowledging the thoughts, Accepting them and Allowing them to come and go is the goal. A person can apply the same to guilt, shame and disgust. That’s because the harm obsession is null and void; therefore, the person’s guilt and other destructive emotions would be misplaced.

What if guilt is carried over from a real-live event and has become part of the obsession related to that guilt?

Despite past events morphing into an obsession, it’s essential to recognise that resulting emotions about the obsession are sensations that make us believe something is right about us. As we’ve seen, one cannot rely on feelings as though they are real, because the obsession is irrational, which makes the resulting belief illogical. In other words, imagine someone suffered sexual abuse as a child. Now imagine when they grow up, they label themselves “disgusting” for suddenly developing paedophilia-intrusive thoughts. They also feel guilty about having those thoughts. However, the labelling and guilt would be the unwarranted result of erroneous beliefs about the obsession, not the past event involving abuse. Active listening from a therapist can help to redirect and resolve self-blame and guilt from the real-life event. It then moves on and concentrates on the process of Mindfulness exposure to reduce the obsession and intrusive guilt.

Does Mindful-based ERP combine well with medication?

Yes, medication can help reduce the symptoms of OCD by changing the brain’s chemistry on a passive level. It can help clear foggy thinking, and also reduce the symptoms of depression. A person is more able to engage in the cognitive side of therapy once they can think more clearly. The benefit from cognitive change and improved mood further prepare for the active part in treatment (ERP), which can lead to recovery or much-reduced symptoms.

How else can Mindfulness encourage people to respond more positively to ERP?

To understand that it provides an opening for full awareness, and to see that people are in charge of their choices. This way, they learn to mindfully influence what happens in any situation (rationally), instead of reacting automatically (emotionally). A Mindfulness-based approach to ERP helps someone better recognise the urges that make them yield to compulsions for temporary gain. It gives them the awareness of choosing to resist these for long-term benefit.

Which Mindfulness book do you recommend?

Everyday Mindfulness for OCD: Tips, Tricks, and Skills for Living Joyfully” by Jon Hershfield, MFT and Shala Nicely, LPC.

Discover how you can stay one step ahead of your OCD. You’ll learn about the world of mindfulness, and how living in the present moment non-judgmentally is so important when you have OCD. You’ll also explore the concept of self-compassion; what it is, what it isn’t, how to use it, and why people with OCD benefit from it. Finally, you’ll discover daily games, tips, and tricks for outsmarting your OCD, meditations and mindfulness exercises, and much, much more.



Exposure-response prevention has been practised for almost half-a-century and remains the most effective therapy for treating OCD. With Mindfulness integrated into the process, this offers a solution for improving task engagement (in and out of the therapy room) and provides scope for preventing relapse.

By Carol Edwards

Get a FREE online counselling consultation with Sunil Punjabi

Sunil Punjabi is a confident therapist and highly recommended for his expert approach in delivering mindful-based ERP with acceptance commitment therapy, the treatment of choice for OCD.

Sunil is available:

  • In-person, over the phone, or online, so that distance is not a constraint
  • Between sessions, for quick consultations, if you get stuck somewhere
  • To the caregiver for coping with the stress

Call Sunil on +91 98925 46024 or write to him on snpunjabi@gmail.com and quote the letters CTE for your FREE consultation!

Find more about what Sunil does at unshackle.in

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