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International Journal of Cognitive Therapy

, Volume 11, Issue 1, pp 58–79 | Cite as

Mindfulness-Based Cognitive Therapy for OCD: Stand-Alone and Post-CBT Augmentation Approaches

  • Steven Selchen
  • Lance L. Hawley
  • Rotem Regev
  • Peggy Richter
  • Neil A. Rector
Advancements in Cognitive-Behavioral Modeling and Treatment of OCD

Abstract

Mindfulness, defined as the awareness that emerges through paying attention on purpose, in the present moment and nonjudgmentally, promotes engagement with internal experience and has been shown to reduce symptoms of anxiety and depression in meta-analyses, but few have tested its potential benefits in Obsessive Compulsive Disorder (OCD). The following study aimed to test the preliminary efficacy of an OCD-tailored 8-week course of Mindfulness Based Cognitive Therapy (MBCT) to treatment-seeking patients with OCD. Treatment-seeking participants (N = 37) with a principal DSM-5 (APA 2013) diagnosis of OCD completed an 8-week MBCT group intervention (adapted from Segal et al. 2013) tailored to OCD either prior to receiving CBT (n = 19) or following a 14-week CBT intervention (n = 18). Participants completed measures of obsessive–compulsive symptoms (including the Y-BOCS), depression (BDI-II), mindfulness (FFMQ), and Obsessive Beliefs Questonnaire (OBQ) at baseline and post-treatment. Repeated measures analysis of variance demonstrated significant change from pre- to post-treatment in both MBCT treatment groups, with no condition or condition by time effects. These preliminary results demonstrate the potential efficacy of MBCT for OCD with large and significant reductions in obsessive–compulsive symptoms from pre- to post-treatment both as a stand-alone treatment, prior to other first-line interventions and as an augmentation treatment for patients showing only partial response to CBT.

Keywords

Mindfulness MBCT OCD CBT 

Mindfulness can be defined as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to things as they are” (Williams et al. 2007). Meta-analyses demonstrate the efficacy of mindfulness-based interventions (MBIs), such as Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR), across a broad range of outcomes in clinical and non-clinical samples, including reducing stress, reducing depressive symptoms, and reducing risk of relapse in recurrent depression (e.g., Chiesa and Serretti 2009; Hofmann et al. 2010; Piet and Hougaard 2011). There is also an emerging literature supporting the efficacy of MBIs in the treatment of specific anxiety disorders (see review by Hofmann et al. 2010), such as generalized anxiety disorder (GAD; Craigie et al. 2008; Evans et al. 2008), panic disorder with or without agoraphobia (PD/A; Kabat-Zinn et al. 1992; Kim et al. 2009; Lee et al. 2007), and social anxiety disorder (SAD; Bogels et al. 2006; Koszycki et al. 2007). Notwithstanding some inconsistencies, meta-analytic summaries provide substantial empirical support for MBIs for mood and anxiety disorders (Hofmann et al. 2010).

Despite emergent efficacy data for MBI’s in the mood and anxiety disorder spectrum, mindfulness treatments have been less well-developed in obsessive–compulsive disorder (OCD) where first-line evidence-based treatments focus on the delivery of exposure and response prevention (ERP), cognitive therapy (CT) and/or their combination (CBT) (NICE 2007). ERP is an effective intervention strategy that involves systematic, graded exposure to contexts that trigger obsessions and distress. Optimal exposure practices involve preventing compulsive rituals which are intended to alleviate distress or reduce distress. The presumed mechanisms of ERP result from the process of habituation (Ponniah et al. 2013) or through inhibitory learning (Craske et al. 2014). Further, the putative treatment mechanisms of CT focus on identifying and modifying the maladaptive cognitive appraisals and dysfunctional obsessive beliefs through which patients misinterpret the significance of intrusive, ego-dystonic thoughts and images (Clark 2004). Although CBT treatment is highly efficacious (e.g., Abramowitz 1997; Rosa-Alcázar et al. 2008), there are limitations to CBT; patients may refuse treatment, they may leave treatment prematurely (Kozak et al. 2000), and they may experience difficulties with adhering to the protocol (Simpson et al. 2005). Hence, despite the demonstrated efficacy of CBT treatments for OCD (Ost et al. 2015), not all patients receiving treatment respond adequately (Clark 2004; Foa et al. 2005). Further, access to CBT is often limited. Considering the current evidence derived from clinical research, these limitations suggest that there is value in expanding viable treatment options for the management of OCD.

In this context, given the demonstrated efficacy of MBI’s for mood and anxiety disorders, there is a potential role for MBI’s in the treatment of OCD. In MBCT, participants are encouraged to intentionally attend to present moment experiences with a sense of curiosity, in a non-judgmental manner; this includes difficult or unpleasant thoughts, images, emotions and sensations (Kabat-Zinn 1994; Segal et al. 2013). Individuals experiencing OCD have been shown to typically avoid and/or suppress intrusive thoughts and images, which paradoxically increases their distress (e.g., Clark and Purdon 1993; Rachman 1997; Salkovskis 1989). Therefore, mindfulness practices might offer an alternative set of strategies to approach intrusive content without fueling the obsessive–compulsive cycle.

To date, a few studies have evaluated mindfulness-based approaches like MBCT for the treatment of OCD. Fairfax (2008) provided anecdotal evidence from clinical practice where participants with OCD responded well to group-format mindfulness-based interventions, and rated these interventions favorably. Wilkinson-Tough et al. (2010) provided supportive evidence for mindfulness-based treatment of OCD, examining a three-participant case series in which participants achieved considerable symptom improvement as measured by Yale Brown Obsessive Compulsive Scale (YBOCS-SR; Baer et al. 1993). Notably, post-treatment scores were below clinical levels, and two participants maintained gains at two-month follow-up. Further, Singh et al. (2004) and Patel et al. (2007) described positive results in single client case studies. And, finally, Hanstede et al. (2008) lend further support for the potential for MBIs for OCD by demonstrating symptom reduction in a non-clinical population.

Most recently, Squazzin et al. (2017) have published a qualitative study supporting the acceptability and perceived efficacy of MBCT in OCD for the treatment of residual symptoms following a course of treatment with CBT. Thirty-two patients completed an 8-week course of MBCT for OCD, and they were interviewed 2 weeks after the course was completed. They completed a set of 21 questions, and results indicated that patients experienced a perceived decrease in OCD-related symptoms and improvements in mindfulness, coping, and quality of life. The MBCT treatment was rated as being highly acceptable (94% said they would recommend MBCT to a friend who suffers from OCD and/or as a general life skill). The same group (Key et al. 2017) then published quantitative data from a randomized waitlist control trial to assess the feasibility and impact of an 8-week MBCT treatment as an augmentation treatment for residual symptoms following treatment with CBT. Compared to the waitlist control group, MBCT participants reported large decreases in OCD symptoms (d = 1.38) and obsessive beliefs (d = 1.20).

This emerging literature provides proof of principle for the delivery and potential efficacy of MBI treatments for OCD. Importantly, the most robust data has focused on MBCT as an augmentation strategy following treatment with OCD (Squazzin et al. 2017; Key et al. 2017). No studies published to date have tested whether MBCT (or MBIs) represent an efficacious, stand-alone treatment, and whether there are equal or distinctive treatment effects as a stand-alone versus augmenting treatment following other first-line treatments, such as CBT. The present study aims to test the feasibility and preliminary efficacy of an 8-week course of MBCT adapted for the treatment of OCD—both as an adjunctive treatment for non-responders to CBT and as a stand-alone treatment for participants who had not previously received CBT for OCD. It was hypothesized that patients receiving MBCT as both a stand-alone intervention and an augmentation following CBT would experience statistically significant improvement in the reported severity of obsessive–compulsive symptoms and depressive symptoms. It was further hypothesized that both groups would experience significant improvements in mindfulness-related skills and decreases in obsessive beliefs. Given the absence of any previous published studies testing the clinical efficacy of MBCT for OCD as a stand-alone or augmenting treatment following CBT, no between-group hypotheses were established a priori. Beyond the quantitative goals of the study, we also present clinical case material to provide an overview of the structure and process of MBCT for the treatment of OCD.

Method

Treatment-seeking participants (N = 37) to a large, university-based OCD and related disorders assessment and treatment service with a principal Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis of OCD who experienced significant obsessive–compulsive symptoms (Y-BOCS > 16) completed an 8-week MBCT group intervention (Segal et al. (2013) tailored to OCD. All participants met DSM-5 (American Psychiatric Association 2013) criteria for primary OCD based on the Structured Clinical Interview for DSM Disorders (Version 2.0/Patient Form) (SCID-I/P; First et al. 2002) adjusted with supplemental content to assess changes with the DSM-5 for OCD and OCD-Related Disorders. Exclusion criteria for MBCT treatment were as follows: (1) active substance abuse/dependence within 3 months of study entry, (2) recent suicide attempt/active suicidality, (3) current diagnosis of post-traumatic stress disorder, and (4) active bipolar or psychotic disorder. As part of the intake assessment, each participant was interviewed using the SCID-I/P and then completed a series of self-report measures. Participants completed O-C symptom measures at baseline and post-treatment (Y-BOCS). Cohorts completed MBCT before receiving program-specific CBT (n = 19) or MBCT following the completion of and OCD-specific CBT (n = 18). All participants receiving CBT prior to receiving MBCT had received CBT within the past 2 years within our specialty OCD assessment and treatment program.

Procedures

All aspects of the clinical protocol were approved by the Sunnybrook Health Sciences Centre (SHSC) Research Ethics Board. All participants were recruited from the Thompson Anxiety Disorders Centre (TADC) at SHSC. Two participant MBCT streams were identified. The first stream involved physician referred patients who were referred specifically for MBCT. These patients indicated they were interested in the study following a routine clinical screen, and they were invited to be in contact with the study coordinator to learn more about the study. A second stream involved patients who were originally referred to the TADC for CBT treatment and who completed the TADC’s CBT for OCD treatment program. These patients were introduced to the MBCT study stream by clinical staff separate to the research team and invited to be in contact with the study coordinator. In both streams, a research assistant contacted potential participants over the phone and provided an overview of the study goals and requirements, and if the patient was interested, they provided written consent and completed the baseline assessment battery of scores questionnaires.

Treatment Protocol: MBCT for OCD

A session by session overview of this adapted MBCT protocol is seen in Table 1. Participants who received treatment engaged in a manualized 8-week MBCT group that was offered once per week, for 2 h. Groups typically consisted of eight to ten patients. Groups were led by an experienced psychiatrist or clinical psychologist with expertise in MBCT and OCD. The MBCT protocol was largely informed by content derived from the manual “Mindfulness Based Cognitive Therapy for Depression—Second Edition” (Segal et al. 2013). There were several modifications made to this well-established MBCT protocol—the specific details of these modifications are included in Table 1. Prior to and following each treatment session, clinicians met with the senior staff to discuss clinical issues, review session content, and ensure adherence to the MBCT protocol. The original eight-session MBCT protocol involves an integration of mindfulness practices and cognitive behavioral principles, in order to assist clients with preventing depressive relapse (Segal et al. 2013). The MBCT protocol involves many thematic elements, including discussions of aversion, attachment, and acceptance, as related to specific mindfulness practices, in the context of managing depressive mood. There were several noteworthy modifications to the protocol, with the most substantial changes occurring on sessions 4 and 6. In particular, the session 4 “Defining the Territory of Depression” content was adapted in order to discuss OCD symptomatology and related thought processes, considering beliefs that clients have about obsessive thoughts and images. The session six’s “Thoughts Are Not Facts” content was adapted in order to discuss how triggering situations are associated with specific obsessive thoughts, compulsive behaviors, emotions, physical sensations, and how these experiences may ultimately maintain the OCD cycle.
Table 1

Overview of MBCT treatment sessions and modifications

Session and theme

Agenda

Modified content

Home practice

Pre-class participant interview

 

Introductory handout modified to focus on OCD rather than depression; white bear (pink elephant) experiential exercise to discuss counter-productivity of trying to control thoughts; presentation of intrusions endorsed by general population demonstrating that it is not the intrusions themselves but the reactions to intrusions that lead to pathology (adapted from Clark and Purdon (1993); interactive discussion of MBCT Model of OCD (adapted from Clark (2004)) with focus on how maladaptive reactions to each component of experience (intrusion, emotion, urge, etc.) fuel the OCD cycle and how relating differently to each component can interrupt the cycle

 

1. Awareness and Automatic Pilot

Mindful eating (raisin exercise)

Discussion of “automatic pilot”

Body scan and inquiry

Revisited MBCT model of OCD in session and handout with themes as above; inquiry throughout session involved contextualizing content based on OCD symptomatology.

Body scan (daily)

“Everyday mindfulness”—awareness of a routine daily activity

Mindful eating

2. Living in Our Heads

Body scan and inquiry

Home practice review (practice barriers)

Thoughts and feelings exercise

Pleasant Events Calendar

Ten-minute sitting meditation

Minimal adaptation, primarily involving contextualizing content based on OCD symptomatology.

Body scan (daily)

Mindfulness of breathing

Awareness of a routine daily activity

Pleasant Events Calendar

3. Gathering the Scattered Mind

Mindfulness of Seeing

Sitting with Breath, body

Home practice review

Mindful Stretching and Movement

3-minute Breathing Space

The Unpleasant Events Calendar was modified, with the context of improving awareness of specific OCD-related thoughts, emotions, physical symptoms, rituals, and urges to ritualize.

Mindful movement

3-minute Breathing Space OCD experiences diary

4. Recognizing Aversion

Sitting meditation—Awareness of Breath, Body, Sound, Thought, and Open Awareness

Home practice review

Automatic thoughts in OCD

3-minute Breathing Space

Mindful Walking

This modified content focuses on thoughts, beliefs, or appraisals that can arise in reaction to intrusive thoughts or images, inviting mindful awareness of these reactions and the opportunity to cultivate an alternate relationship to these thoughts, rather than relating to them as a narrative of reality.

Guided sitting meditation

Mindful movement

Mindful Walking

Regular breathing space

Additional breathing space

(when you notice unpleasant experiences)

5. Allowing/Letting Be

Sitting meditation, including noticing reactions and introducing a difficulty

Home practice review

Breathing space—extra guidance

Minimal adaptation, primarily involving inquiry and discussion of specific OCD content

Working with difficulty meditation

Breathing spaces (regular)

Breathing spaces (additional/responsive)

6. Thoughts Are Not Facts

Sitting meditation

Home practice review

Thoughts are not facts—discussion

Working wisely with OCD worksheet

In-session and home practice worksheet was adapted to increase awareness of the components of the OCD cycle and how it is maintained.

Worksheet: working wisely with OCD

At least 40 min per day of selected meditation(s).

Breathing spaces (regular)

Breathing spaces (additional/responsive)

7. Responding Wisely to OCD

Sitting meditation

Home practice review

Responding wisely to OCD, including befriending OCD

Substantial departure from the MBCT for depression protocol which focuses on “How can I best take care of myself?”; instead, the focus here is on various ways of responding mindfully and more adaptively to OCD, including “befriending” OCD (with material adapted from Siegel (2010), “Mindsight”)

Worksheet: Responding wisely to OCD meditation practice select a pattern of practice intended to be used regularly going forward

Breathing spaces (regular)

Breathing spaces (additional/responsive)

8. Maintaining and Extending New Learning

Body scan

Homework review

Home practice plan

What I value closing practice

A “Home Practice Plan” is developed in order to develop a specific plan for relating differently to OCD, in order to maintain and extend progress.

Develop and implement a “Home Practice Plan”

Measures

SCID-5 (First et al. 2002)

The SCID-5 is a semi-structured clinician-administered interview that assesses current and lifetime DSM-5 axis I disorders. In the present study, interviewers included clinical psychologists, psychometrists, pre-doctoral clinical interns, and graduate students in clinical psychology, all of whom were trained to “gold standard” reliability status (Grove et al. 1981). Diagnoses were coded independently, and 100% agreement was required between the interviewers before trainees conducted interviews independently. Trainees continued to receive ongoing supervision by a licensed clinical psychologist, and each participant’s diagnoses were reviewed in supervision.

BDI-II (Beck et al. 1996)

The Beck Depression Inventory–—II (BDI-II) is a 21-item self-report measure of depression symptom severity with well-established internal consistency, reliability, and validity (Dozois and Covin 2004).

FFMQ (Baer et al. 2006)

The Five Facet Mindfulness Questionnaire (FFMQ) is a 39-item self-report measure that assesses five facets of mindfulness, including observing, describing, acting with awareness, non-reactivity to inner experience, and non-judging of inner experience. Each item is rated on a five-point scale, ranging from 1 (never or very rarely true) to 5 (very often or always true). The FFMQ has demonstrated good psychometric properties, including acceptable to good internal consistency in meditating and non-meditating samples (Baer et al. 2008).

OBQ (OCCWG 2001, 2003, 2005)

The OBQ consists of 44 statements developed to measure obsessive beliefs (OCCWG 2005). The OBQ has three-factor analytically determined subscales: (a) inflated personal responsibility and the tendency to overestimate threat (responsibility/threat), (b) perfectionism and intolerance of uncertainty (perfectionism/certainty), and (c) overimportance and overcontrol of thoughts (importance/control). Respondents indicate their level of agreement with items on a seven-point rating scale. Higher scores indicate a greater strength of beliefs. The OBQ is internally consistent and evidences good test–retest reliability, convergent validity, and discriminant validity (OCCWG 2001, 2003, 2005).

YBOCS-SR (Baer et al. 1993)

The YBOCS-SR is a 10-item scale that assesses the severity of OCD symptoms. Respondents report the time occupied by obsessions or compulsions, interference and related distress, and perceived control over obsessions or compulsions. The YBOCS-SR yields similar scores to the interviewer-administered version of the YBOCS and demonstrates good internal consistency (Baer et al. 1993; Steketee et al. 1996).

Results

Participant Demographic/Clinical Background

A total of 37 participants were included in the final sample. The mean age of the sample was 42 years, and 60% of the sample was female. In addition, 54% were single, 35% were either married or cohabitating, 8% were either separated or divorced, while 3% did not report.1 Further, 62% reported attending some or completing college/university, 22% attended or completed graduate school, 8% reported only attending some or completing high school, while 8% did not specify. In terms of participant ethnicity, 81% identified themselves as Caucasian, 11% as Asian, 3% as Black, 3% as others, and 3% did not specify. Twenty-seven percent reported their religious affiliation as Catholic, 14% as Protestant, 14% as Jewish, 5% as Hindu, 5% as others, 3% as Muslim, and 32% as none. As seen in Table 2, there were no significant differences between the pre or post-CBT MBCT groups on any of the above participant characteristics.
Table 2

Demographic breakdown by condition

 

Pre-CBT MBCT (n = 19)

Post-CBT MBCT (n = 18)

Total (N = 37)

Statistical analyses

Significance

Age

   

t(35) = 0.63

p = .53

M (SD)

40.68 (15.03)

43.61 (13.02)

42.11 (13.97)

  

Gender (%)

   

χ2(1) = 0.22

p = .64

 Male

7 (36.8)

8 (44.4)

15 (40.5)

  

 Female

12 (63.2)

10 (55.6)

22 (59.5)

  

Marital status (%)

   

χ2(5) = 4.27

p = .51

 Single

11 (57.9)

9 (50.0)

20 (54.1)

  

 Married/cohabitating

6 (31.6)

7 (38.9)

13 (35.1)

  

 Divorced/separated

2 (10.5)

1 (5.6)

3 (8.1)

  

Education (%)

   

χ2(6) = 5.37

p = .50

 Some or completed high school

1 (5.3)

2 (11.1)

3 (8.1)

  

 Some or completed college

12 (63.2)

11 (61.1)

23 (62.2)

  

 Some or completed graduate school

4 (21.0)

4 (22.2)

8 (21.6)

  

Occupation (%)

   

χ2(3) = 1.47

p = .69

 Working full time

5 (26.3)

7 (38.9)

12 (32.4)

  

 Working part time

4 (21.1)

3 (16.7)

7 (18.9)

  

 Unemployed

8 (42.1)

8 (44.4)

16 (43.2)

  

 Casual

1 (5.3)

0 (0.0)

1 (2.7)

  

Ethnicity (%)

   

χ2(3) = .974

p = .81

 Caucasian

15 (78.9)

15 (83.3)

30 (81.1)

  

 Asian

2 (10.5)

2 (11.1)

4 (10.8)

  

 Black

1 (5.3)

0 (0.0)

1 (2.7)

  

 Other

1 (5.3)

1 (5.6)

1 (2.7)

  

Religion (%)

   

χ2(6) = 3.77

p = .71

 None

6 (31.6)

6 (33.3)

12 (32.4)

  

 Catholic

6 (31.6)

4 (22.2)

10 (27.0)

  

 Protestant

3 (15.8)

2 (11.1)

5 (13.5)

  

 Jewish

3 (15.8)

2 (11.1)

5 (13.5)

  

 Other

0 (0.0)

2 (11.1)

2 (5.4)

  

 Hindu

1 (5.3)

1 (5.6)

2 (5.4)

  

 Muslim

0 (0.0)

1 (5.6)

1 (2.7)

  

Continuous variables are reported as mean (standard deviations); categorical variables are listed as number of participants (percentages)

*Of 37 participants, the following demographic information was missing: education (n = 3), ethnicity (n = 1), marital status (n = 1), and occupation (n = 1)

MBCT Treatment Retention and Adherence

Overall, there was a 95% retention rate across the two conditions with one dropout occurring in the pre-CBT MBCT condition and one dropout occurring in the post-CBT MBCT condition.

MBCT Treatment Effects

The means and standard deviations for the study measures as well as the tested within and between-group effects are seen in Table 3. Prior to commencing treatment, groups were found to be equivalent on study measures. A series of repeated measures analysis of variance (ANOVA) were computed where the repeated measure constituted symptom (Y-BOCS, BDI-II), mindfulness (FFMQ), or cognitive (OBQ) change from pre- to post-treatment and where the between-subject variable was conditioned: pre-CBT MBCT versus post-CBT MBCT. As seen in Table 3, there were significant within-group effects on all measures with OCD and depression symptoms, mindfulness, and obsessive beliefs significantly improving across the 8-week MBCT treatment. While there were main effects for time, there were no significant conditions or time by condition interactions. As seen in Table 3, Cohen’s d pre–post effect sizes are reported, with large effects occurring for O–C symptom reduction (see Fig. 1), medium effects on depression, and small to medium effects occurring on mindfulness and cognitive change for the combined samples.
Table 3

Means, standard deviations, and pre-post treatment effects for MBCT treatment groups

 

Pre-CBT MBCT group

Post-CBT MBCT group

Time effect

Condition effect

Pre

Post

 

Pre

Post

 

M

SD

M

SD

d

M

SD

M

SD

d

YBOCS

24.21

5.03

18.37

5.32

1.10

21.56

6.13

13.56

5.84

1.31

F(1, 35) = 81.08

p = 0.001

d = 1.18

F(1, 35) = 5.01

p = 0.03

BDI-II

19.44

11.79

14.94

11.59

0.38

18.47

16.12

12.59

12.56

0.82

F(1, 33) = 10.71

p = 0.003

d = 0.42

F(1, 33) = 0.22

p = 0.64

OBQ-44

166.12

54.00

154.59

51.24

0.22

163.15

47.18

132.92

53.77

0.60

F(1, 28) = 11.22

p = 0.002

d = 0.38

F(1, 28) = 0.47

p = 0.50

FFMQ

117.41

19.81

128.53

21.15

0.54

117.36

25.27

135.57

29.89

0.66

F(1, 29) = 22.55

p = 0.001

d = 0.60

F(1, 29) = 0.19

p = 0.67

YBOCS Yale–Brown Obsessive–Compulsive Scale, BDI-II Beck Depression Inventory—Second Edition, OBQ-44 Obsessive Beliefs Questionnaire-44, FFMQ Five Facet Mindfulness Questionnaire

Fig. 1

YBOCS symptom ratings at baseline and post-treatment for MBCT groups

Case Illustration: Step-by-Step MBCT for OCD

Below we illustrate the structure and process of the MBCT protocol with a case illustration. The patient’s identifying information has been altered in order to protect her confidentiality. “Jennifer” is a single Caucasian woman who is 50 years old. She listed “musician and graphic designer” as her occupation. She previously completed a clinical diagnostic interview which confirmed that she met DSM-5 (American Psychiatric Association 2013) criteria for primary OCD based on the Structured Clinical Interview for DSM Disorders (version 2.0/patient form) (SCID-I/P; First et al. 2002) adjusted with supplemental content to assess changes with the DSM-5 for OCD and OCD-related disorders. Based on this assessment, it was determined that she experienced a primary diagnosis of OCD, as well as co-morbid Major Depressive Disorder, Recurrent. She reported experiencing several significant stressors, including occupational, social, and financial stressors (directly related to her professional roles). She had been referred for treatment by her family doctor.

Considering her presenting problems, she reported that she experienced distressing intrusive, ego-dystonic thoughts involving contamination themes and aggressive harm-related themes. Notably, she experienced obsessive thoughts involving contamination (i.e., concerns that she has been “contaminated” by coming into contact with objects such as doors, elevator buttons, items in public bathrooms, and bodily fluids). In order to experience temporary relief from her symptoms, she engaged in rituals including frequent, elaborate hand washing (occurring for up to 2 h per day), excessive showering, discarding “contaminated” clothing, and using various strong cleaning agents on household items in order to avoid personal contamination as well as potentially “spreading” the contamination to other objects or individuals.

Whenever she experienced ego-dystonic, intrusive thoughts involving these themes, her interpretation of the obsessive thought involved cognitive appraisal processes involving overgeneralized threat, inflated responsibility, and intolerance of uncertainty, leading to experiential avoidance. For example, she might experience the thought “the hospital floor is dirty,” and the associated “overgeneralized threat” appraisal would lead her to believe that this is a high-risk scenario that will likely cause her to become seriously ill. Further, she experienced the “inflated responsibility” appraisal, leading her to believe that she may be responsible for managing the health and welfare of others. For example, she was concerned that she might unintentionally “spread the contamination” to others, leading them to become sick as a result of her “irresponsible behavior.” As a result, she experienced significant emotional distress involving increased anxiety (feeling that she was in a threatening situation) and disgust (feeling that the physical sensations she experienced were unpleasant and intolerable).

She also experienced aggressive harm-related obsessions (e.g., doubting whether she had locked her apartment door, whether she has turned off appliances, and whether she may have unintentionally harmed someone while driving). Whenever this occurred, she engaged in rituals involving elaborated checking behaviors (e.g., checking whether the door has been closed, plugging and unplugging appliances, getting out of her car to check whether she had harmed someone), as well as covert mental rituals involving counting, thought replacement and thought suppression. Related safety behaviors include reassurance seeking (e.g., asking others whether they think the situation is dangerous), as well as avoidance (e.g., not using objects which may ultimately cause harm to herself or others). By engaging in these rituals, safety behaviors, and avoidance behaviors, she experienced temporary relief from her symptoms over the short term; unfortunately, these behaviors reinforced her perception that she was putting herself and others at risk, thereby perpetuating the OCD cycle. She estimated that she spent up to 5 h per day, engaging in ritual behaviors. She completed the YBOCS at baseline, which indicated that she experienced OCD symptoms within the moderate to severe range (YBOCS = 26). She also completed the OBQ-44 which indicated that she experienced cognitive appraisal processes involving themes of overgeneralized threat, inflated responsibility, and intolerance of uncertainty.

Session-By-Session Case Material: Elements of the MCBT Intervention for Jennifer

Generally, MBCT treatment involves cultivating greater experiential awareness—when individuals are able to attend to their experience, adopting a curious, non-judgmental approach, they may cultivate a more accepting, non-judgmental perspective regarding their physical sensations, thoughts, emotions, and behaviors. Historically, Jennifer had experienced heightened emotional reactivity accompanied by experiential avoidance whenever she experienced ego-dystonic, intrusive thoughts. A central treatment goal was that, as a result of engaging in mindfulness practices, she might cultivate a more accepting and non-judgmental perception of these intrusive obsessive thoughts, thereby promoting “decentering” or “taking a step back” from thoughts, observing an obsessive thought as a mental event. As individuals become more aware of habitual patterns of thinking, feeling, and behaving, “the opportunity arises for people to make choices about their behaviour” (Teasdale et al. 2002). For example, clients may choose to respond differently to an obsessive thought, rather than choosing to engage in ritual behaviors.

The theme for session 1 involved a general discussion of mindfulness principles (e.g., how individuals experience “Automatic Pilot” mode). Mindfulness practices included the raisin exercise, and the body scan. During the inquiry following the body scan, Jennifer indicated that she was able to notice unpleasant physical sensations, as well as “unpleasant” thoughts involving the possibility that she may have come into contact with germs when she entered the hospital today (e.g., opening a door, pressing an elevator button). Further, she was concerned about how other group members might perceive her behavior, leading her to experience guilt and shame. This led to a discussion of how her awareness of these processes during the body scan differed in comparison to her “everyday” experience; she noted that she was able to notice an obsessive thought, and then return her focus to her body. As a result, she eventually became able to tolerate these experiences. She was aware of the difference between noticing the urge to engage in a ritual, in comparison to immediately engaging in rituals (e.g., hand-washing), which ultimately maintain the OCD cycle. There was a related discussion regarding goal-oriented striving to “do this mindfulness practice right,” particularly as related to the perceived goal of inducing relaxation (which was not the specific intention of the practice). Homework included an overview of the OCD model, and clients were encouraged to complete the body scan each day, choose one “everyday” mindfulness practice involving a routine activity, and eat at least one meal “mindfully.”

The theme for session 2 involved “Dealing with Barriers.” Mindfulness practices include the body scan and the “mindfulness of the breath” practice. During the inquiry following the body scan practice, she reported that she had noticed unpleasant physical symptoms (e.g., her legs felt uncomfortable), and her thoughts focused on a recent difficult interaction she experienced with her partner. She indicated that she was still concerned about her partner following the practice; however, she also mentioned that it was “interesting to be curious about the emotion” she experienced, particularly since she typically believes that anger is “negative and unhelpful,” and therefore should be avoided. During the homework review, she reported that she had found the “mindful eating” practice to be somewhat challenging, due to contamination concerns. However, on several occasions, she decided to mindfully eat a meal that others had prepared, despite doubting whether the food might be contaminated. Further, she spontaneously reported experiencing several “barriers” with regard to her home practices over the last week. She had been physically ill (experiencing flu symptoms), she experienced difficulty with lying down on a “contaminated” floor during the body scan, she was experiencing more intense emotion (anger and irritation), and she was particularly concerned that her mind “wandered constantly.” As a result, she became critical of her progress, experiencing a sense of failure. We discussed the non-goal-directed nature of mindfulness practice, and how adopting an open, curious approach was the conceptual basis for the practice.

The theme for session 3 involved “Gathering the Scattered Mind.” Mindfulness practices included the “mindfulness of seeing or hearing” practice, a sitting meditation involving mindfulness of breath and body, mindful stretching and movement, and the 3-min breathing space. During the inquiry involving the mindful stretching and movement practice, she reported that she had been experiencing numerous unpleasant physical symptoms, and that these symptoms improved somewhat by the end of the practice. However, she indicated that she became “somewhat more tolerant” of these experiences over time. During the discussion of the “Pleasant Events Calendar” exercise, she reported that she had experienced pleasure (and other strong emotions) when creating a musical score over the past week. She reported that this was an “extremely difficult week” in which she had experienced many stressful situations. However, she noticed that her mood improved whenever she was mindfully aware of a creative process in which she “allowed [herself] to experience strong emotion, which led to a brief sense of release.” Further, she believed that she was less critical of the music she created and that this process was “more interesting and authentic” as a result of her mindful approach.

The theme for session 4 involved “Recognizing Aversion.” Mindfulness practices included a sitting meditation involving awareness of breath, body, sounds and thoughts, and the 3-min breathing space (regular version). During the discussion of the OCD Experiences Diary, she noticed that she typically becomes quite frustrated and self-critical whenever she feels “compelled” to engage in compulsive hand washing behaviors, feeling as if she “has no choice.” Further, she reported that she noticed that there were several occasions in which she was able to “notice the urge” to wash her hands, allowing her to either delay or reduce the frequency of engaging in hand washing. During the discussion of OCD thought processes, she was able to recognize that when she is concerned about becoming contaminated, she experiences the “overestimated threat” appraisal in which she believes that she may develop a severe illness if she comes into contact with a contaminant. She provided an example that occurred as she was en route to the MBCT session: there was an announcement of a “Code Brown” environmental spill in the hospital. She stated that, several years ago, she would have likely “turned around and left the building” due to the high level of distress she experienced. However, she reported that in this instance, she was able to become aware of her distress, focus on her current experience, and as a result, she was able to attend the session without engaging in any washing rituals. Further, she discussed the “inflated responsibility” appraisal, in which she is often concerned that she would be an “irresponsible person” if she were to not clean her hands, particularly since she believed that others would become sick as a result of her behavior.

The theme for session 5 involved “Allowing and Letting Be.” Mindfulness practices included the 3-min breathing space, and a sitting meditation involving awareness of breath, body, sounds, and thoughts, with the added element of “inviting in a difficult experience” to the practice. During the homework review, she reported that she has noticed an improved ability to be aware of OCD thoughts and rituals, leading her to choose to limit and/or delay hand washing rituals at home and when entering the hospital. When discussing the mindfulness practice, she reported that she was able “turn towards” several painful experiences involving recent interactions with a friend who was experiencing significant medical difficulties. Initially, she was concerned that this event would elicit distressing obsessive thoughts involving contamination themes, resulting in “overwhelming, unmanageable emotion.” However, she also recognized that she had “taken a step towards accepting” these difficult circumstances, and she also recognized the value of behaving in a compassionate, supportive manner towards those she cares for. She was able to recognize that this situation was not as threatening as she had previously believed it to be. Further, she noticed that by engaging in mindful awareness, she “does not rush” to complete important tasks as frequently as she used to, and surprisingly, she observed the paradoxical effect that this approach has improved her efficiency as well as her mood.

The theme for session 6 involved Thoughts Are Not Facts. Mindfulness practices included a sitting meditation involving awareness of breath, body, sounds, and thoughts, and “inviting in a difficult experience” to the practice. Following the sitting meditation practice, Jennifer indicated that it was not difficult for her to “invite a difficulty” into the exercise, since over the last several months she has been forced to confront many challenging (personal and professional) events “head on.” She indicated that she was aware of contamination-related thought processes when taking out the garbage and was surprised that she was able to “notice the urge to engage in hand washing” rituals as opposed to engaging in this behavior. In general, she reported that she has become better able to “welcome the difficult events in” and “tolerate these experiences without becoming emotionally overwhelmed.” During the discussion of “Working Wisely with OCD,” she stated that she was increasingly aware of her reaction to triggering situations involving perceived contamination at home and/or when coming into contact with people experiencing medical issues. She indicated that this approach helps her to notice the urge to ritualize, allowing her to “slow things down,” and engage in fewer compulsions, in comparison to when she is “on autopilot.” She provided an example of recognizing that she is having the thought “I am going to lose everyone (due to illness)” and then choose how she will respond to the thought using her “wise mind.” This facilitated a compassionate group conversation regarding OCD-related beliefs involving “inflated responsibility,” and group members commented on her compassionate ability to support others autonomy without “trying to fix” them.

The theme for session 7 involved “How Can I Best Take Care of Myself?” Mindfulness practices included a sitting meditation involving awareness of breath, body, sounds, and thoughts, with the added element of “inviting in a difficult experience” to the practice. Jennifer reported that she found the sitting meditation practice to be “tolerable” and that there were moments in which she “appreciated [her] life.” She indicated that she has become able to develop an “accepting stance” towards intrusive thoughts rather than attempting to suppress, ignore, or change these thoughts. Following the discussion of nourishing and depleting activities exercise, she indicated that she would engage in several creative processes “on [her] own terms” as opposed to having a specific goal and timeline. Further, she would schedule in the nourishing activity of meeting with friends and family over the next week.

The theme for session 8 involved “Using What Has Been Learned to Deal with Future Moods.” Mindfulness practices included the body scan practice. During the inquiry, Jennifer reported that she has experienced improvement in her symptoms as a result of attending these sessions. She reported that she believed that the “most important point” of these practices involves “having more options” when she experiences obsessive thoughts.

Case Summary

As seen in Fig. 2, Jennifer’s YBOCS symptoms improved throughout treatment, with a final YBOCS of 10. Qualitative feedback also provided treatment insights: considering each practice, she stated that the sitting practices were particularly helpful, since focusing on her breathing leads her to feel “centered and grounded,” allowing her to choose how she will work with a difficult situation when it occurs. In general, she reported “having developed a new skill” where she can notice the arrival of an obsession or urge to engage in a compulsive ritual and then shift her awareness to her body and breath, in order to “anchor” herself. She further indicated that the MBCT treatment had helped her become “less reactive” to triggering situations, thereby allowing her to better function at home and in public settings.
Fig. 2

Case example—patient’s YBOCS scores during MBCT treatment

Discussion

This preliminary study provides evidence supporting the efficacy of a manualized 8-week MBCT protocol adapted from Segal et al. (2013) for the treatment of OCD. The results are similar to those reported by Key et al. (2017) where MBCT produces large treatment effects on obsessive–compulsive symptoms in patients with OCD who did not fully respond to a previous CBT intervention. However, our results also provide preliminary feasibility, acceptability, and efficacy results for MBCT as a stand-alone treatment for OCD. Meta-analyses of CBT for OCD indicate a large treatment effect size in comparison to control conditions on primary symptom outcome measures at post-treatment (Olatunji et al. 2012) and in comparison to medication treatment (Eddy et al. 2004). In our study, participants in both cohorts (augmentation post-CBT and stand-alone no-CBT) experienced significant decreases in OCD symptoms, as determined by changes in YBOCS scores. YBOCS scores for participants in the post-CBT adjunctive group decreased from the moderate (21.56) to the mild (13.56) range, demonstrating a large effect size (Cohen’s d = 1.31). Patients who participated in MBCT but not CBT showed a similarly robust decrease in YBOCS scores, in this case from the severe (24.21) to the moderate (18.37) range, again demonstrating a large effect size (Cohen’s d = 1.10). As reported, while there were no significant between-group differences between the pre- and post-CBT MBCT treatment groups, the pre-post effect size was trending to be larger in the post-CBT MBCT group. Furthermore, the final end-point YBOCS scores in the pre-CBT MBCT treatment group were found to be higher than typically reported in CBT trial studies. Future research will ideally focus on further testing of MBCT as a stand-alone intervention in relation to first-line interventions in randomized controlled trial designs.

Considering treatment process variables, many individuals find that ERP is both challenging and distressing; as a result, individuals can experience significant difficulties with adherence and attrition. Notably, clinical studies report an attrition rate of up to 26% during CBT for OCD (Aderka et al. 2011; Kozak et al. 2000). In contrast, retention rates in this MBCT study were high (95%). We speculate that the invitational stance of MBCT might appeal to some who are uncomfortable with the more strict expectations of ERP. Further, some might prefer a meditation-based approach to the standard CBT/ERP approach. In addition, the lower time commitment in MBCT (eight-group sessions) might reduce barriers to engagement for others. In addition to the issue of acceptability or patient preference, and the need for augmentation strategies, cost-effectiveness is an important population-based consideration. While we did not compare MBCT and CBT head-to-head in this study, it is noteworthy that MBCT’s fewer sessions and potential higher capacity indicate that significant therapeutic change may occur in a more economically sparing fashion. It would be worthwhile in future studies to analyze the health economics of treatment.

Therapeutic mechanisms would be worth exploring in future studies. Metacognitive awareness is one such possibility (Crane 2009; Teasdale et al. 2002; Williams et al. 2007). CBT for OCD appears to focus on identifying and separating intrusions from appraisals, followed by a process of evaluation and reappraisal. Notably, there is some skepticism in the literature about how successful one can be at distinguishing appraisal from intrusion (e.g., Jakes 1989a, b). In contrast, rather than focusing on changing appraisals in order to modify the impact of intrusions, MBCT appears to promote direct metacognitive awareness, or the experience of thoughts as transient mental phenomena (Teasdale et al. 2002). Mindfulness encourages metacognitive awareness at all levels—all thoughts, whether intrusions or appraisals, are taken as mental events which can be observed and engaged with without being controlled by them or compelled to act upon them.

Although this is conjecture that goes beyond the scope of the data of this study (and requires further empirical study), we can generate hypotheses of potential mechanisms of MBCT at each phase of the obsessive–compulsive cycle. The results of the OBQ analyses suggest that changes in specific dysfunctional beliefs (which drive the negative appraisal of intrusive thoughts) may relate to symptom improvement in MBCT (see Frost and Steketee 2002, for a review of the clinical literature involving the OBQ). Further, the results of the FFMQ analyses demonstrated that mindfulness-related concepts improved pre- to post-treatment for both groups, suggesting that improvement in mindfulness may underlie symptom alleviation in OCD; however, this will require further study. Further, during MBCT treatment, individuals develop the capacity to “approach” instead of “avoid” their experience, which is a cornerstone of MBCT theory. In the first half of the MBCT course, patients practice monitoring without acting (Crane 2009; Teasdale et al. 2002), and cultivate the capacity to direct attention with intentionality and wakefulness (e.g., Jha et al. 2007; but see Anderson et al. 2007 for opposing findings). This is seemingly used in the service of developing metacognitive awareness, as discussed above. The second half of the MBCT course capitalizes on this ability to direct attention without being swept away by the content of experience, in order to cultivate the capacity to face that from which people normally turn away. Patients are guided to deliberately introduce a difficulty into their mindfulness practice (Crane 2009; Teasdale et al. 2002). They learn to approach difficulty rather than avoid it; to turn towards negativity and difficulty with openness, curiosity, and acceptance (acceptance not as resignation but as the opposite of denial); they learn to tolerate, explore, and even become interested in the thoughts, feelings, and sensations associated with their difficulties. This practice of mindfully approaching difficulty could offer a powerful framework for engagement in exposure and direct experiential learning. Patients can bring meta-level awareness to all aspects of the unfolding aftermath of exposure to feared stimuli such that arising experiences are experienced for what they are—thoughts are thoughts, no matter how disturbing, they need not be neutralized; emotions and sensations are transient and not harmful; compulsive urges are simply urges—they need not to compel action; and rituals are rituals—they neither afford much protection, nor, in actuality, is protection generally needed. Patients can perhaps thereby learn to be with the arising symptoms of OCD in a new, non-perpetuating way, breaking the maladaptive spiral.

Overall, the results of this pilot study suggest that MBCT for OCD could be a promising therapeutic option, whether as an adjunctive to CBT when residual symptoms are present, or as a stand-alone treatment. The results of this study, however, should be interpreted with caution as it utilized a small underpowered sample size, did not include a control group, and failed to control for extraneous alternative treatment effects (e.g., medications, ERP-based self-directed exposures) that may have contributed to improved outcomes. Future research with sufficiently powered RCT designs is now required. Quantitative and qualitative studies of direct comparisons between CBT and MBCT might help to elucidate overlapping and differential treatment mechanisms and aspects of health economics.

Footnotes

  1. 1.

    Of 37 participants, the following demographic information was missing: education (n = 3), ethnicity (n = 1), marital status (n = 1), and occupation (n = 1)

Notes

Acknowledgements

The authors would like to thank Dr. Danielle Katz for her editorial assistance.

Funding Information

This research was supported by internal funds from the Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre.

Compliance with Ethical Standards

All aspects of the clinical protocol were approved by the Sunnybrook Health Sciences Centre (SHSC) Research Ethics Board.

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Copyright information

© International Association of Cognitive Psychotherapy 2018

Authors and Affiliations

  • Steven Selchen
    • 1
    • 2
  • Lance L. Hawley
    • 1
    • 2
  • Rotem Regev
    • 1
  • Peggy Richter
    • 1
    • 2
  • Neil A. Rector
    • 1
    • 2
    • 3
  1. 1.Department of PsychiatrySunnybrook Health Sciences CentreTorontoCanada
  2. 2.Department of PsychiatryUniversity of TorontoTorontoCanada
  3. 3.Sunnybrook Research InstituteSunnybrook Health Sciences CentreTorontoCanada

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