Clinical Handbook of Mindfulness (56 page)

mined) by them. Through reperceiving patients realize: “this pain is not me,”

“this depression is not me,” “these thoughts are not me,” as a result of being

able to observe them from a meta-perspective
(Shapiro et al., 2006).
Another related cognitive process, in which the focus is on changing individual’s relationship to thought rather than attempting to alter the content of thought

itself, is the concept of
cognitive defusion
(Hayes, Strosahl, and Wilson’s,

1999). The authors noted that the ability to pay attention to private experi-

ence and becoming a detached observer of it is often associated with a
shift

in the self-sense
. Through defusion, which is considered a change in per-

spective, identity begins to shift from the contents of awareness to awareness

itself.
Hayes et al. (1999)
define this process as the shift from “self as content”

(that which can be observed as an object in consciousness) to “self as con-

text” (that which is observing consciousness itself). Individuals may develop

a sense of the “self” as an ever-changing system of constructs, concepts, sen-

sations, images and beliefs that are eventually seen to be as impermanent and

transient conditions rather than a stable entity. One final related concept is

the process of
detachment
(Bohart, 1983),
which “encompasses the interrelated processes of gaining distance, adopting a phenomenological attitude,

and the expansion of attentional space”
(Martin, 1997).

As has been well stated by
Schwartz & Beyette (1997),
“there is an observing aspect of the mind that can really maintain its independence even though

the contents of the consciousness are being flayed around by the disease pro-

cess. We are really training the mind to not identify with those experiences

but to see ourselves as separable from those experiences.”

All the metacognitive processes illustrated above, developed through the

practice of mindfulness, can have a significant clinical relevance for obses-

sive pathology. The problem in OCD is that individuals often tend to
reify

their rapport with cognitions and consider thoughts as something real, as a

true and permanent representation of reality or
self
(in particular in patients

with poorer insight). Such “real” thoughts are then given inflated importance

(OCCWG, 1997).
When obsessive sufferers realize the impermanence of all

mental states, they are more able to relate to private experience with a sense

of
non-attachment
, developing a higher level of tolerance for unpleasant

inner states and disengaging themselves from the automatic behavioral pat-

terns (neutralizations, compulsions, reassurance seeking) which maintain the

obsessive syndrome. Thus it can be assumed that for OCD patients, these

mechanisms may lead to an improvement and increase in the level of insight

200

Fabrizio Didonna

and ego-dystonicity (referred to the degree that the content of the obsession

is contrary to or inconsistent with a person’s sense of self as reflected in

his or her core values, ideals, and moral attributes,
(Purdon, 2001;
Purdon

& Clark,
1999).
This, in turn, may decrease both the tendencies to judge and to react (with compulsive behavior) to the cognitive, emotional and sensory experience and to activate thought-action fusion bias. Furthermore, in

mindfulness- and acceptance-based interventions, the therapist often makes

use of metaphors or guided visualization exercises (see Chapter 7) that have

the purpose of allowing patients to internalize and indirectly incorporate

various elements of outer reality (connected in some way with mindfulness

principles – e.g.,
lake meditation
, see Appendix A), which may be subse-

quently be transformed into powerful resources. Metaphor is also proposed

as a therapeutic tool to develop and improve decentering, detachment and

defusion processes.

Acceptance and OCD

A core problem for obsessive individuals is
acceptance
. For them it is very

difficult, or often impossible, to accept several experiences connected with

their problem: intrusive or obsessive thoughts, imagined and feared conse-

quences of not preventing harm or doing things in a wrong way, negative

emotions (anxiety, guilty, shame, disgust), physical sensations. Therefore,

OCD individuals are not able to accept potentially normal and nonthreat-

ening experiences (see also the section on problem formulation and Fig-

ure 11.3).

As it is well illustrated in other chapters of this book, acceptance is one

of the main components of mindfulness-based approaches and it is defined

as a moment by moment process by which one moves away from viewing

thoughts and feelings as reality or things that need to be changed, and toward

embracing them simply as internal events that do not need to be altered with-

out unnecessary attempts to change their frequency or form, especially when

doing so would cause psychological harm
(Hayes et al., 1999).
Through

acceptance, individuals can notice internal events they experience while

simultaneously renouncing any effort to avoid or change these events and

responding to the facts which actually occurred rather than the inner expe-

rience elicited by such events
(Hayes et al., 1996).
The use of acceptance for OCD patients implies a conscious abandonment of behavior that functions

as experiential avoidance and a willingness to experience one’s emotions

and cognitions as they arise, without any secondary elaborative processing

(judgement, interpretation, appraisal, meta-evaluation).

Mindfulness is a training process through which patients learn to calmly

observe their inner experience with a feeling of clarity and without respond-

ing to it (Schwartz & Beyette,1997). The process of observing in and of

itself helps people increasingly come to the realization that they can change

their responses to those thoughts in very adaptive ways. In order to help

OCD individuals to observe and analyze their level of acceptance toward

private experience, in particular thoughts, and to develop and cultivate

this attitude, it may be useful to give patients a task to carry out on their

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

201

Thoughts,

Am I trying to

Was I able to allow and

COMMENTS

Emotions,

cultivate

accept this state

How do I feel now if I

Sensations

acceptance

(Emotion, sensation,

was able to accept?

now towards

thought) and stay in

How do I feel now if I

these internal

touch to it, without

was not able to

experiences?

react?

accept?

(Yes/No)

If not why?

What are the

consequences?

Figure. 11.1.
Homework table of acceptance.

own (see Figure 11.1) in which they are asked to fill in a form as nega-

tive internal experiences arise, noticing the private experience (emotions,

sensations, thoughts) during critical situations and whether or not they are

willing accept that state, if they are able to cultivate acceptance toward it,

and if not why, and what the consequences of doing or not doing this are.

This exercise can improve the metacognitive awareness of patients’ attitude

toward private experience and allow them to realize what the consequences

of this attitude are on their cognitive and emotional experience and dis-

ease.

Obsessive Doubt and Self-Invalidation of the

Perceptive-Sensorial Dimension

We do not see things as they are, we see them as we are.

The Talmud

Several studies have found that OCD patients, in particular checkers, lack

confidence
in their memory
(Sher, Frost, & Otto, 1983;
McNally & Kohlbeck
,

1993)
and are less satisfied with the vividness of their memories (Constans, Foa, Franklin, & Matthews,
1995).
Empirical observation and some studies have suggested that this lack of confidence is only related to OCD-related

stimuli
(Foa et al., 1997)
and threatening situations, and is significantly lower or often absent in normal or safe conditions (e.g., during a psychotherapy

session).

More specifically,
Hermans, Martens, De Cort, Pieters, & Eelen (2003)

showed that this low cognitive confidence in OCD patients is present on at

least three different levels: low confidence in their memory for actions, low

confidence in their ability to discriminate actions from imaginations, and low

confidence in their ability of keeping attention undistracted.

202

Fabrizio Didonna

According with the already discussed attentional bias hypothesis (Lavey

et al.,
1994;
Amir & Kozak, 2002),
Hermans et al. (2003),
in order to explain this lack of confidence, suggested that individuals suffering from

OCD would mistrust the accuracy or completeness of previous avoidance

behavior (checking, washing) because important elements of this behavior

might have been missed due to distraction or moments of lessened attention.

It has also been suggested
(Didonna, 2003, 2005)
that this low confi-

dence in cognitive experience in patients suffering from OCD – and “check-

ers” in particular – may depend on a cognitive bias in processing and/or

using relevant sensory information regarding situations that tend to generate

obsessive cognitions. This bias can be conceptualized as a
self-invalidation

of perceptive experience
. It is hypothesized that this problem may play a

decisive role in the activation of pathological doubt and in the relationship

between the patient’s conscious perceptive experience and the obsessive

phenomenology.

Clinical observation
(Didonna, 2005)
suggests that, during psychotherapy sessions, obsessive patients are usually able to recall the perceptive experience they felt during the anxiety-evoking events that activated obsessions.

Nevertheless, we also find that during an obsessive crisis they experience

considerable difficulty in voluntarily recovering and trusting their own sen-

sorial information relating to that event. They then become unsure of their

own experience. If this information were used instead of being discounted,

it might, neutralize obsessive doubt. On account of the vicious-cycle phe-

nomenon in which the patient becomes ensnared (cf. Figure 11.2), this ini-

tial validation deficit consequently leads to an over-evaluation of the doubt,

which tends to
invalidate
and/or increasingly “scotomizes” (to cover or

exclude some elements in the perceptual and experiential field) and obscure

the objectivity of their own perceptive experience. As was stated by Pema

Chodron
(2002),
an American buddhist nun, “Whether we experience what

happens to us as an obstacle and enemy or as teacher and friend depends

entirely on our perception of reality. It depends on our relationship with

ourselves.”

In the following case example, a 23-year-old man performed “checking rit-

uals” consisting in returning home up to 15–20 times to check whether he

had closed the Venetian blinds of his apartment on the eight floor of the

condominium where he lived. He feared that a burglar might break into the

apartment while he was out and steal all of his possessions. During ther-

apy, the patient was able to recall a visual memory of the blinds fully closed

and the darkened rooms; he could visualize his hands moving as he manip-

ulated the strap beside the window to roll down the shutters and he had

an auditory memory of the noise that it made. Both the visual and auditory

memories were related precisely and with considerable detail. The problem

was that during the obsessive crisis, the patient did not use these memories

at all.

To comprehend the underlying cause of the development of the obsessive

phenomenon it may be useful to ask a seemingly obvious question: why do

most people
not
present obsessive symptoms? The hypothesis proposed by

the author – also useful in terms of the process of
normalization
of the

obsessive phenomenon with patients – is that in people who do not have

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

203

OCD symptoms, an obsessive doubt concerning actions or events is not acti-

vated because they automatically use, and simultaneously
self-validate
their

own experience in the various situations they encounter, rendering such

consciousness salient and affording it due priority. Even obsessive patients

(in particular those with good insight) would have, in their
episodic memory

store
, a substantially clear memory of sensorial experiences. Awareness or