OCD – Why Include Mindfulness into Exposure Response Prevention

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, there are others who don’t fully engage with the assigned ERP homework tasks out of the therapy room. This 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 with negative appraisal and avoidance/escape, which are the corresponding compulsions that reinforce the problem.

But what about anxiety, how can someone manage this whilst 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 and falls and eventually reaches a plateau.

So Mindfulness enhances therapy, is that right?

Yes, many take very well to Mindfulness because learning to be non-judgmental about their intrusive thoughts frees them from ruminations.  They learn to Acknowledge unwanted thoughts are there, to Accept the thoughts as intrusive and nothing more, and to then Allow the thoughts to come and go without giving into compulsions.  

How does Mindfulness help with emotions such as guilt and shame within a pure-obsessional manifestation?

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, just like an intrusive thought might be about harm and Acknowledging it, Accepting it, and Allowing it to come and go, the same would apply to guilt, shame and disgust. This is because the harm obsession is null and void; therefore, 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 important to recognise that resulting emotions about the obsession are sensations that make us believe something is true about us, yet are non-factual. In other words, if someone suffered sexual abuse as a child, and later were to label themselves “disgusting” for having paedophilia-intrusive thoughts, and feeling guilty about that, the labelling would be the result of erroneous beliefs about the obsession, not the past event involving abuse. Active listening from a therapist can help to address and resolve blame/guilt from the real-life event, and then it moves on and concentrates on the process for Mindfulness exposure to treat 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 prepares for the active part in therapy, 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 would have them give in to compulsions for temporary gain, and to make a choice to resist these for long-term gain.

Which 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 practiced 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 offers scope for preventing relapse.

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