Clinical Handbook of Mindfulness (55 page)

account for reductions in depressive and anxious symptoms (see also Chap-

ter 5 of this volume for more details).

To conclude, mindfulness training may be an effective intervention to pre-

vent or neutralize the tendencies to ruminate that obsessive individuals have,

allowing them to learn to stay in touch with their intrusive (normal) thoughts

without reacting to them in dysfunctional and counterproductive ways.

Inflated Responsibility and Mindfulness

Move, but don’t move the way fear moves you.

Rumi

In the last few decades, many authors
(Salkovskis, 1985;
Salkovskis,

Shafran, Rachman & Freeston,
1999; Rachman & Shafran, 1998,
Obsessive Compulsive Cognitions Working Group-OCCWG,
1997)
have highlighted the

problem of an inflated sense of responsibility in OCD patients.
Salkovskis

196

Fabrizio Didonna

(1985)
considers an exaggerated sense of responsibility to be a cardinal feature of the disorder. It is particularly common among patients whose main

problem is checking and it tends to generate intense guilt. Inflated responsi-

bility is defined by
OCCWG (1997)
as the “belief that one is especially powerful in producing and preventing personally important negative outcomes.

These outcomes are perceived as essential to prevent. They may be actual

problems, or perceived moral dilemmas. Such beliefs may pertain to respon-

sibility for doing something to prevent or undo harm, and responsibility for

errors of omission and commission.” An example of this kind of belief is: “If

I don’t act when I foresee danger, I am to blame for any bad consequences.”

OCD patients tend to misinterpret the meaning of responsibility, because

for them, this concept can only suggest “duty” or “rules.” They then mind-

lessly impose these rules upon themselves, most likely because they have

been told that this is the “right” and “proper” way to live or because some

particular experiences (in certain cases even traumatic ones) gave them

an inflated sense of responsibility. However, authentic responsibility means

being
aware
of the impact of our actions and being willing to
feel
how our

behavior
really
affects ourselves and others. Responsibility means “
response-

ability
” – the ability to be present in each moment and respond appro-

priately to each event we are confronted with
(Trobe, T. & Trobe, G. D.,

2005);
this is, in fact, a definition of mindfulness. When people are accountable in this way, they are able to more deeply respect and trust themselves

(
mindful self-validation
). This is because in a mindful state (paying atten-

tion to the present moment without judgement), patients are more able

to clearly understand their own real involvement in the problematic situa-

tion. Therefore, mindfulness-based therapy may intervene in order to give

patients a more functional and realistic meaning of the sense of respon-

sibility, which is so seriously distorted in people suffering from obsessive

problems.

Attentional Bias and Mindfulness

There is good evidence that OCD patients show disorder-specific attentional

bias for threat
(Lavey, van Oppen, & van den Hout, 1994;
Foa, Ilai, McCarthy, Shoyer, & Murdock,
1993).
This problem seems to involve both a general inability to inhibit processing of irrelevant information as well as distraction by threat relevant cues
(Amir & Kozak, 2002).
These individuals may be paying particular attention to threatening information relevant to their

current concerns. Furthermore, because of their attentional biases, OCD

patients are not able to attend to information that would disconfirm their

fears
(Didonna, 2003).
OCD sufferers also show both deficits in orienting attention (how attention is placed) and conflict attention (the process of

inhibiting an automatic response to attend to a less automatic response; Fan,

McCandliss, Sommer, Raz, & Posner,
2002).
These biases in information processing might be also conceptualized as
mindfulness deficits
. In fact, by def-

inition, mindfulness is a state of mind in which individuals pay
attention
in a

particular way: to the present moment, on purpose and without judgement

(Kabat-Zinn, 1994).
This definition can easily allow us to understand how mindfulness training and practice may intervene to change the way in which

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

197

OCD patients pay attention to their internal and external experience because

mindfulness is a practice in which individuals learn and train themselves to

direct attention in a wholesome, productive and efficient manner.

A group of leading authors
(Bishop et al., 2004)
in the field of mindfulness highlighted that the first component of mindfulness involves the
self-

regulation of attention
so that it is focuses on the immediate experience,

thereby allowing for increased recognition of mental events in the present

moment. Mindfulness begins by bringing awareness to current experience –

observing and attending to the ongoing stream of thoughts, feelings, and sen-

sations from moment to moment – by regulating the focus of attention. This

leads to a feeling of being very alert to what is occurring in the here-and-

now
(Bishop et al., 2004).
It is hypothesized that self-regulation of attention involves two specific skills and components:
sustained attention
and
skills

in switching
.
Skills in sustained attention
refer to the ability to maintain a

state of vigilance over prolonged periods of time
(Parasuraman, 1998;
Posner & Rothbart,
1992)
as is required to maintain an awareness of current experience.
Skills in switching
allow the patient to bring attention back

to a mindful focus (e.g., the breath) once an internal experience has been

acknowledged.
Switching
involves flexibility of attention so that one can shift

the focus from one object to another
(Posner, 1980).
Patients with OCD lack both these abilities, and in fact, have a selective attention to threatening stimuli. But they are not really aware of the current experience and are unable to

switch attention to another focus.

The self-regulation of attention also creates a non-elaborative awareness of

private experience as it arises. Rather than getting caught up in ruminative,

elaborative thought streams about one’s experience and its origins, implica-

tions, and associations, mindfulness involves a direct experience of events in

the mind and body
(Teasdale, Segal, Williams, & Mark, 1995).
This could be considered the opposite of what OCD patients normally do.

Clinical observation suggests that normally checking compulsions are

mindless behaviors in which attention is paid to the checking actions rather

than to the real perceptions and outcomes derived from the rituals or to what

the individual learns through the behavior. Therefore, OCD sufferers are not

able to bring mindful attention to their inner experience and then to the

rituals, which are aimed at changing or avoiding that experience. The devel-

opment of mindfulness can be associated with improvements in sustained

attention and switching, which can be objectively measured using standard

vigilance tests (e.g.,
Klee & Garfinkel, 1983)
and tasks that require the subject to shift mind-set
(Rogers & Monsell, 1995).

Recent studies (Zylowska, Ackerman, Yang, et al., 2008; Jha, Krompinger

& Baime,
2007)
which investigated the effects of a mindfulness meditation approach for Attention Deficit Hyperactivity Disorder (ADHD) and

also for non-clinical samples showed that this kind of training can lead

to significant cognitive changes, in particular those related to a reduc-

tion in various measures of attentional processes including alerting, ori-

enting, conflict attention and attentional set-shifting (see Chapter 17 of

this volume). These early findings suggest that mindfulness training might

be effective to improve attentional deficits in OCD too, in which these

biases may be relevant activating and maintenance factors for obsessive

symptoms.

198

Fabrizio Didonna

Thought-Action Fusion, Level of Insight and Mindfulness

Thought-action fusion
is a cognitive bias, often found in OCD, in which a

fusion or confusion between thought and action arises
(Rachman, 1993).
It may take two forms: (1) probability bias, in which the individual believes that

having an unwanted thought concerning harm increases the risk of actual

harm occurring to someone, and (2) morality bias, in which the person

believes that having the unwanted intrusive thought is morally equivalent

to carrying out the repugnant act
(Rachman & Shafran, 1998).
In this mental process, individuals tend to create a sort of identification with an aspect of

their own private experience. In some way they say: “This thought is me,”

or “I am this thought,” or “This thought is something real,” creating a sort of

reification of cognitive experience.

In mindfulness practice the thinking mind is considered similar to one of

the five senses that registers (but does not cause) visual, auditory, and other

incoming stimuli. Negative thoughts are similarly registered and noticed as

transient “thought stimuli” that occur in the mind. As such, negative thoughts

are not overpersonalized and do not serve as dictators of subsequent feelings

and activities (e.g., rituals, neutralizations). Cognitions are accepted as the

natural and normal behavior of the mind, but not as inherently defining the

self
(Marlatt & Kristeller, 1999;
Epstein, 1996).

The mindfulness practice of
self monitoring
thoughts and other men-

tal events trains individuals to become less identified with their own pri-

vate experience (“thoughts without a thinker” – see
Epstein, 1996),
no

matter how upsetting or entertaining they may be. Through meditation,

individuals can learn to develop a sense of equanimity or balance without

being absorbed into their own mental processes. This process has been

called “mental disidentification”
(Marlatt & Kristeller, 1999).
As
Goleman

(1988)
suggests, “The first realization in meditation is that the phenomena contemplated are distinct from the mind contemplating them.” When individuals enter into this process of disidentification from mental states, they

begin to see that these thoughts and feelings are not them. They happen acci-

dentally and are neither an organic part of the patients nor are they obliged

to follow them
(Snelling, 1991.
p. 55).

It has been ascertained that mindfulness training leads to a significant shift

in perspective
(Shapiro, Carlson, Astin, & Freedman, 2006;
see also the Chapter 5 of this volume) and several concepts have been coined over the past

few years to define these metacognitive processes in which patients learn

to become a non-attaching and non-reacting observer and witness of their

own inner states:
decentering
(Safran & Segal, 1990),
deautomatization

(Deikman, 1982;
Safran & Segal, 1990),
reperceiving
(Shapiro et al., 2006)

and
detachment
(Bohart
,
1983).
Safran and Segal (1990)
define
decentering
(also called distancing) as the ability to “step outside of one’s immediate

experience, thereby changing the very nature of that experience” (p. 117).

Decentering is also defined as the ability to observe one’s thoughts and feel-

ings as temporary events in the mind rather than reflections of the self that

are necessarily true (see also Baer et al., Chapter 9 of this volume; Fresco

et al., 2007). Decentering involves awareness of experiences without iden-

tifying with them or being carried away by them, and includes taking a

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

199

present-focused, non-judgemental stance toward thoughts and feelings,

accepting them as they are
(Fresco, Segal, Buis, & Kennedy, 2007).
As

Segal et al. (2002)
have suggested, mindfulness-based interventions, such as Mindfulness-Based Cognitive Therapy, may lead to clinical change not so

much through the alteration of thought content, as through “decentering,”

by which individuals learn to switch from a perspective that thoughts rep-

resent reality to a perspective in which their thoughts are viewed as only

an internal event. Deikman describes
deautomatization
as “an undoing of

the automatic processes that control perception and cognition” (p. 137).

Reperceiving
(Shapiro et al., 2006)
is conceptualized as a
metamechanism
in which individuals are able to disidentify from the contents of consciousness (thoughts, emotions, and body sensations) as they arise, and simply be

with them instead of being defined (i.e., controlled, conditioned, or deter-