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 and distraction are two different concepts. The first represents a state of awareness. It is the accepted attention towards intrusive thoughts in a non-judgmental way. Distraction, on the other hand, represents non-acceptance of intrusive thoughts. It involves a person’s thinking errors about the situation. Along with other rituals, it is an avoidance or escape behaviour that corresponds with the obsession and reinforces 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 so they learn to lean into the anxiety. It teaches them to accept that anxiety gets higher until it reaches a plateau, and before decreasing naturally.
So would you say one’s acceptance enhances therapy?
Yes, because when a person learns to be non-judgmental about their intrusive thoughts, it helps them move away from ruminating (thinking compulsion). They learn three crucial things. These are to:
- Acknowledge the unwanted thoughts are there
- Accept that intrusive thoughts will come and go
- Allow the thoughts to pass without attaching meaning and yielding to 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 the person’s intrusive thoughts are about molesting a child, then they should follow the acknowledge, accept and allow rule. Also, to acknowledge that guilt, shame and disgust are as intrusive as the harming thoughts. Next, to accept that the feelings are associated with the unwanted thoughts. Afterwards, to allow such feelings to pass with the thoughts.
The point is that an obsession is invalid, which means the person suffers from misplaced negative emotions. When they let the intrusive thoughts pass, they can let the feelings pass too.
What if guilt is carried over from a real-life 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 real about a specific event, and self. However, one cannot rely on feelings as though they are real, because, as we’ve seen, the obsession is irrational. It means one’s belief about it will always be illogical.
In what way do you mean?
To put it another way, imagine a person suffered sexual abuse as a child. Now picture that person when they’ve grown up. In their adulthood, they label themselves “disgusting” for suddenly developing paedophile-intrusive thoughts. They also feel guilty about having those thoughts. Would labelling themselves disgusting be warranted? Would their guilt be valid? Or would their self-labelling be the erroneous belief about the obsession, not the past event involving abuse? And would their feelings of guilt be the intrusive component attached to the obsession, not them?
What can they do?
Active listening from a therapist can help them redirect and resolve self-blame and guilt from the real-life event. Bringing in mindful exposures can then concentrate on the process of weakening the obsession. It may also involve trauma-focused cognitive-behavioural strategies.
Which Mindfulness book do you recommend?
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.Review
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.
Online counselling with Sunil Punjabi
My colleague, 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. He does call and skype and offers a sliding scale. For more details you can contact me here.