Clinical Handbook of Mindfulness (54 page)

at a “radical” and
hierarchically superordinate
level in the process of acti-

vation and maintenance of the disorder. If we take into consideration the

problem-formulation models of the cognitive theories, we see that mindful-

ness can intervene at the point of transition between activating factors and

an individual’s metacognitive processes (cf. Figure 11.3). Thus, the mindful

state can be considered a
pre-metacognitive attitude
or
mode
that prevents

patients from falling into the specific evaluations, judgments, and biases that

maintain and/or overactivate the psychopathological problems. More specif-

ically, the practice of mindfulness allows patients to acquire and develop

the capacity to consciously recognize and accept undesired thoughts and

emotions as an alternative to the activation of habitual, automatic and pre-

programmed modes that tend to perpetuate difficulties. Moreover, it teaches

patients how to “observe” their experience without entering into the mode

of meta-evaluation.

The fact that disturbing cognitions in OCD are generally accompanied by

insight
(i.e., the recognition that one’s symptoms are excessive and inap-

propriate) renders the disorder particularly amenable to mindfulness-based

methods. In fact, the symptoms themselves can be easily made natural sub-

jects of observation on the part of the patient, who is induced to view them

with greater clarity and awareness (mindfulness) and initiate a process of

decentering
and
disidentification
from inner states.

OCD Phenomenology and Mindfulness Dimensions

There are two ways to slide easily through life:

To believe everything or to doubt everything.

Both ways save us from thinking.

Alfred Korzybski (1879–1950)

The core features and the source of distress of OCD are recurrent cog-

nitive intrusions (obsessions) that create an awareness of alarm or threat

(e.g., “Have I accidentally run over someone with my car? Did I lock the

door?”). Individuals with OCD typically engage in some safety seeking behav-

iors (avoidance or escape response) in reaction to the obsessive threat.

Obsessive thoughts normally take the form of either a perceived threat of

physical damage to oneself or others or, in some cases, more of a moral or

spiritual threat to oneself, others, or a divinity.

Considering the enormous heterogeneity and phenomenological differ-

ences that can be found in individuals suffering from OCD, clinical obser-

vation and several studies on information processing
(Amir & Kozak, 2002)

and obsessive belief domains
(OCCWG, 1997)
suggest that OCD patients may have a general problem of mistrust and lack of confidence in their private

experience that leads them to continuously do something in order to pre-

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

193

vent the feared outcomes. This particular way of relating to internal states

might also be conceptualized, using a mindfulness-based perspective, as a

deficit of mindfulness.

In a recent exploratory study
(Didonna & Bosio,
manuscript in preparation) with a sample of 21 OCD patients (mean total severity score at the

Yale-Brown Obsessive-Compulsive Scale was 22 – moderate symptoms), the

authors investigated the relationships between obsessive-compulsive phe-

nomenology and mindfulness components and skills, using several clinical

scales and a multifactorial mindfulness scale called the Five-Facets Mindful-

ness Questionnaire (FFMQ, see Baer et al., Chapter 9 of this volume; Baer,

Smith, Hopkins, Krietemeyer, & Toney,
2006).
The FFMQ measures a trait-like general tendency to be mindful in daily life, which is defined through five

factors:
observing, describing, acting with awareness, nonjudging of inner

experience
, and
nonreactivity to inner experience
. Preliminary data show

that OCD patients scored significantly lower (
p <
0, 001) than the control

group, a non-clinical sample, in three of the five factors plus the total score.

These three dimensions found in OCD sample were
acting with awareness,

nonreactivity to inner experience, and nonjudging of inner experience.

Acting with awareness
includes attending to the activities of the moment. It

contrasts with automatic pilot, behaving mechanically without awareness of

one’s actions (cf. rituals and neutralizations in OCD).
Nonreactivity to inner

experience
is the tendency to allow thoughts and feelings to come and go,

without getting carried away by them or caught up in them (cf. ruminations

and neutralizations in OCD).
Nonjudging of inner experience
refers to tak-

ing a non-evaluative stance toward private experience (cf. cognitive biases

and belief domains and assumptions in OCD). Furthermore, with respect to

this latter factor, a negative correlation between Y-BOCS scores and
Nonjudg-

ing
sub-scale scores was found: the more the obsessive symptoms increase,

the greater the tendency to judge the inner experience becomes. Further

investigation is needed to confirm these relationships, but this data suggests

that OCD may be associated with deficits in mindfulness skills which are

clearly connected with some clinical features of OCD.

In what follows, the relationships and effects of mindfulness training and

practice with respect to some typical OCD phenomenological features will

be analyzed.

Rumination and Mindfulness

To believe with certainty we must begin with doubting

– Stanislaw Leszczynski (1677–1766)

As has been observed by several authors
(De Silva
,
2000;
Salkovskis, Richards, & Forrester,
2000b),
the term
obsessional rumination
has been used in the literature indiscriminately to describe both obsessions and mental

neutralizing. Interestingly, however, with respect to the contents and scope

of this chapter and book, the meaning of the word “rumination” given by

the
Oxford English Dictionary
(1989) is paradoxically
meditation
. Since

“to ruminate” is defined as “to revolve, to turn over and over again in the

mind,” it is not a passive experience, and for this reason obsession cannot

be a rumination
(de Silva, 2003).
Following the definition of
de Silva (2003)

194

Fabrizio Didonna

“an obsessional rumination is (more likely) a compulsive cognitive activity

that is carried out in response to an obsessional thought. The content of the

intruding thought determines the question or the theme that the person will

ruminate about.” Some examples of rumination are “Am I a homosexual?,”

“Will I go to hell?,” and “Am I going mad?”

Mindfulness training may affect processes common to many disorders

(Teasdale, Segal, & Williams, 2003).
Rumination is a mental behavior that characterizes several mental diseases, among them Generalized Anxiety Disorder, Social Anxiety Disorder, Depression, and OCD. Although the contents

and behavioral and emotional consequences of rumination may be quite dif-

ferent depending on the disorder, the starting point or the trigger of the pro-

cess and the clinical mechanisms of it are similar. There is a lot of agreement

that rumination is a normal and adaptive process at least to some degree (in

creativity, problem-solving, as a response to stress, etc.), but if this cognitive

process fails to reach a natural closure, it can be maladaptive (Field, St-Leger

& Davey,
2000).
Rumination in both normal and clinical samples is used as a problem-solving strategy in order to decrease the discrepancy between actual

state and desired state – the “doing mode”
(Segal, Williams, Teasdale, 2002).

For obsessive individuals, rumination is an attempt to pass from a feeling of

discomfort or anxiety to calmness, or from an inflated sense of responsibil-

ity to feeling free from it. Since this strategy is related to self-states, in OCD

patients, as is the case for other disorders, it is disastrously counterproduc-

tive because it maintains the undesired state (see Figure 11.3).

Several factors have been associated with iterative thinking and rumina-

tion, among them:
mood
(low mood influences cognitive perseveration;

Schwarz & Bless, 1991);
perfectionism
(Bouchard, Rh´

eaume & Ladouceur,

1999)
and
inflated responsibility
(Rh´

eaume, Ladouceur, Freeston & Letarte,

1994;
Wells & Papageorgiu, 1998).
In general, what above indicates that rumination is a reactive metacognitive process. Mindfulness-based interventions

are a form of
mental training
aimed at reducing cognitive vulnerability to

reactive modes of mind
(e.g., rumination), which can intensify an individ-

ual’s level of stress and emotional malaise or which can perpetuate the disor-

der (maintenance factors)
(Segal et al., 2002).
Mindfulness training (such as MBCT or MBSR) is an anti-ruminative intervention because it trains patients

to shift from a “doing mode” (motivated to reduce discrepancies between

actual and desired states) to a “being mode” (characterized by direct, imme-

diate, intimate experience of the present, non-goal oriented, accepting and

allowing what is)
(Segal et al., 2002).
In a mindful state, patients learn to have a direct experience of inner states by directly
living
the thoughts, emotions and sensations, rather than
thinking about
the experience. The anti-

ruminative effect of mindfulness has been well described by Jon Kabat-Zinn

(1990) in his illustration of the effects of his MBSR programme, which is also

a definition of the cognitive process of
decentering
:

It is remarkable how liberating it feels to be able to see that your thoughts

are just thoughts and they are not “you” or “reality
. . .
” For instance, if you

have the thought that you have to get a certain number of things done today

and you don’t recognize it as a thought but act as if it’s “the truth,” then you

have created a reality in that moment in which you really believe that those

things must all be done today .
. . .
On the other hand, when such a thought

comes up, if you are able to step back from it and see it clearly, then you will

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

195

be able to prioritize things and make sensible decisions about what really

does need doing. You will know when to call it quits during the day. So the

simple act of recognizing your thoughts as thoughts can free you from the

distorted reality they often create and allow for more clear sightedness and a

greater sense of manageability in your life. (pp. 69–70).

Mindfulness practice is training that can help prevent ruminative processes

because it uses intentional control of attention to establish a type of alter-

native information processing or cognitive mode that is incompatible with

the factors that maintain the disorder (see Figure 11.3). During mindfulness

practice patients are invited to intentionally maintain awareness of a partic-

ular object of attention, such as the physical sensations in the body while

breathing, moment by moment
(Teasdale, 1999).
Whenever the mind wan-

ders (and this is a normal condition) to thoughts, emotions, sounds or other

physical sensations, the contents of awareness are noted. One then raises the

intention to gently, but firmly bring awareness back to the original focus of

attention. This focus, which is normally an internal experience that is always

available, such as breathing, can be a clear and firm “anchor” for patients

that brings their awareness back to the present moment limiting the extent to

which they become lost in the reality created by the thought streams they are

so often immersed in (rumination)
(Teasdale, 1999).
This process is repeated continuously on a regular basis through several moments of daily practice of

mindfulness. This practice provides repeated experiences in which the abil-

ity to relate to thoughts as passing and impermanent events in the mind is

facilitated by choosing a non-cognitive (frequently bodily) primary focus of

attention, against which the experience of thoughts can be registered as sim-

ply another event in awareness rather than as the primary “stuff” of the mind

or the self
(Teasdale, 1999),
which is a common mode of processing for OCD

sufferers. As patients observe the content of thoughts as they arise and then

to let go of them and return to the original focus of attention, they learn to

develop a
decentered
and
detached
perspective with respect to every kind

of cognitions. Several studies
(Jain et al., 2007;
Kocovski, Fleming, & Rector,
2007)
carried out with non-clinical and clinical samples (social anxiety, depression) have showed that mindfulness- and acceptance-based interventions lead to decreases in rumination and that these decreases in rumination