Question 1

What kind of mindfulness exercises could I try with clients who change their OCD behavior constantly (e.g., shopping, eating, washing the car)?

David Keuler · Accepted Answer

I would have your clients pay very close attention to their thoughts, emotions, physical urges, and cognitive-behavioural responses before, during, and after these various activities. What do they have in common? Psychological monitoring (mindful observation) can then be used to answer many important assessment questions: “What is happening now?” “What am I thinking?” “What am I feeling?” “Which physical sensations, if any, are present?” “What am I trying to achieve in this moment?” “How do I know when to stop a particular behaviour?” All of these data can then be used to help clients develop a comprehensive plan for intervention.

Question 2

What’s the difference between a traditional exposure based treatment and one that has a mindfulness focus?

David Keuler · Accepted Answer

Traditional exposure-based treatments ask individuals to “sit with” or otherwise endure discomfort while eliminating compulsions, avoidance, and escape responses. They sit with their anxiety/discomfort until it abates or until they learn what is necessary to disconfirm their expectations.

Mindfulness-based exposure asks individuals to adopt a very particular observational and attitudinal stance during exposure exercises. Individuals are asked to observe carefully and nonjudgmentally the thoughts, emotions, images, memories, or physical sensations that define their OCD. They are then asked to adopt an attitude that permits these experiences—an attitude that is open, curious, and accepting.

Question 3

How to work to prevent mindfulness from becoming a compulsion?

David Keuler · Accepted Answer

We can educate individuals with OCD who attempt mindfulness interventions to be on the lookout for rigid rules, needing to “get it just so,” or excessive doubt about “doing it correctly.” Relaxing those rules and assigning “imperfection” as a standard of practice can at times prevent mindfulness from becoming a compulsion. Should mindfulness become a compulsion, we then treat it like a compulsion: exposing individuals repeatedly to “mindlessness” during exposure work rather than “mindfulness.”

Question 4

How does one incorporate mindfulness in the treatment of OCD?

David Keuler · Accepted Answer

Treatment of OCD requires individuals to observe their actions and reactions to trigger situations. These actions and reactions are often both obvious and subtle. Identifying them can be a quick and haphazard effort or a careful, systematic, curious, and nonjudgmental exercise. When individuals pause long enough to witness their actions and reactions mindfully—that is, with intentional, concentrated focus—they come to know their OCD intimately. This intimate knowledge then serves as the necessary foundation for responding to OCD skilfully. Skilful responses are essential in OCD treatment since compulsions, avoidance, and escape behaviours fuel the condition. Mindfulness training, often in the form of meditation, helps individuals turn towards their discomfort. In doing so, they discover a path out of their suffering.

Question 5

Do you have a specific way that you teach self-compassion for someone with OCD?

David Keuler · Accepted Answer

Mindfulness training of speech and thought are essential skills when combatting the harsh, critical, and judgmental commentaries that arise in OCD. When we learn to pay exquisite attention to these thoughts, we can replace them with the language of compassion. For some, “silence” in response to repugnant or unwanted experiences can be an important first step. Deciding to “say nothing at all” can break the cycle of well-rehearsed critical responses to undesirable experiences. If clients require a more in-depth study of self-compassion, I refer them to the published self-compassion workbooks by Kristin Neff, Ph.D. (https://psychwire.com/ask/profiles/x3clyu/kristin-neff) and Christopher Germer, Ph.D. (https://psychwire.com/ask/profiles/4usjjt/chris-germer).

Question 6

What are the main misconceptions about what mindfulness is that you have encountered (in OCD tx and in general) ?

David Keuler · Accepted Answer

* Mindfulness in OCD treatment merely involves paying attention to one’s thoughts in a nonjudgmental way.

Mindfulness is so much more than this! Mindfulness can include the entirety of one’s experience, moment-to-moment. When clients are mindful of what is happening now, they can learn to select particular responses that move them toward healing and avoid those responses that maintain or strengthen their OCD. They learn to pay attention to far more than just their thoughts.

* Mindfulness, when taught through meditative practice, is something that “I can’t do.”

Everyone can learn to be mindful—to become more aware of what is happening in the here-and-now. It is true that mindfulness takes practice and commitment; however, with practice, everyone can learn to take that important first step in examining their internal landscape.

* Mindfulness is simply the latest fad
                              
              Mindfulness, in one form or another, has been around for millennia in a number of Eastern traditions. Mindfulness made its way to the West over the last half of the 20th century, and it is here to stay. Mindfulness has been incorporated into virtually every cognitive-behavioral treatment protocol for anxiety and depression over the last 10 years or so, and it shows no signs of abating. In fact, mindfulness interventions play a central role in Acceptance & Commitment Therapy (ACT), Mindfulness-Based Cognitive Therapy for OCD (MBCT), and Inference-Based Therapy (IBT)—three increasingly evidence-based treatments for OCD.

Question 7

Can there be a danger in using mindfulness approaches in OCD? for example could it be used by the therapist and client to avoid or delay ERP?

David Keuler · Accepted Answer

In rare cases, mindfulness interventions may go awry. Dr. Jason Linder does a fine job explaining some of the general adverse events associated with mindfulness (see https://www.psychologytoday.com/us/blog/mindfulness-insights/202107/the-potential-dangers-mindfulness). When it comes to OCD in particular, the “dangers” often involve clients who are already paying too much attention to their internal experiences. For them, mindfulness may become the next tool they use to engage in compulsions such as mental review (reviewing past events looking for reassurance) or scanning the body for arousal (as in the case of sexual obsessions). Mindfulness interventions alone have been shown to diminish OCD, so there is little risk that they would be used to delay or avoid ERP.

Question 8

Is there evidence supporting self-help approaches for OCD? Is your book something someone could try without seeing a therapist? Thank you

David Keuler · Accepted Answer

Yes, a growing body of scientific literature exists demonstrating the effectiveness of self-help and self-directed exposures for OCD. And yes, the book was written for those who do not have access to competent care (i.e., without seeing a therapist). Part I of the book provides an unusually long introduction to OCD and how it operates. That said, many individuals choose to combine self-help readings with therapeutic guidance if it is available.

Question 9

How can mindfulness help with clients who are reluctant to engage in ERP for OCD?

David Keuler · Accepted Answer

Mindfulness interventions are often perceived as gentle and nurturing. Clients learn about openness, nonjudgmental stances, and quiet observation before engaging in direct exposure. For many, this is a welcome departure from the “let’s figure out how to expose you to what you fear” approach that often characterizes (poorly) administered ERP.

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