Jon Hershfield - Applying Mindfulness to Traditional CBT Tools How to Enhance What Works in Terms...

Jon Hershfield, LMFTKimberley Quinlan, LMFT

International OCD Foundation 23rd Annual Conference 2016Chicago, IL

Applying Mindfulness to Traditional CBT Tools: How to Enhance What Works in

Terms Your Clients Understand

Why pay attention to mindfulness?

• Mindfulness is used in ACT, DBT, MBSR, and a la carte

• Varied definitions of the word “mindfulness”• Need specifics for when and how to apply

to OCD treatment without losing the effectiveness of CBT

Mindfulness• Paying attention to the present

moment• Non-judgmental observation of

internal experiences• Letting go of resistance to

discomforting thoughts, feelings, and sensations

Core Elements of CBT• Psycho-education on the disorder and

its treatment conceptualization• Cognitive restructuring – challenging

distorted thought processes• Behavioral therapy – exposure with

response prevention (ERP)

Psychoeducation and Mindfulness

• Why do I think this way?• Do other people have these

thoughts?• What if these thoughts mean

something important?

The spotlight

Hershfield, J and Corboy, T. (2013) The Mindfulness Workbook For OCD: A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioral Therapy. New Harbinger Publications: Oakland, CA

The spotlight

Hershfield, J and Corboy, T. (2013) The Mindfulness Workbook For OCD: A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioral Therapy. New Harbinger Publications: Oakland, CA

Thoughts as mental events

• Thoughts are thoughts, not threats (not “JUST a thought” – which implies value)

• Value is unknown, not intrinsic• To be acknowledged, observed• Be curious about them, not avoidant

Feelings as raw data• Feelings are feelings, not facts• Not evidence, significance is unknown• Appraisals of physical sensations• To be experienced in the moment, not sought

after or checked for• Pain (a present experience) vs. suffering (same

experience plus resistance)

Physical sensations as nerves firing

• Not mandates to act• Also not evidence, personal significance

uncertain (i.e. groinal response as fear or arousal)

• Cause unknown• To be experienced, not explained unless

medically impairing

Mindfulness and cognitive restructuring

• Changing what-if to what-IS (attention to presence of thought, not content appraisal)

• Not neutralizing or reassuring• Aim to discourage compulsions, not

get certainty

Common distortions and reframes

• Black-and-white• I am dirty• I am uncomfortable because my

finger touched something and I don’t know what was on it

Common distortions and reframes

• Catastrophizing• I’m might get AIDS and die• This is a typical thought for me when

I see a cut. I can’t predict the future.

Common distortions and reframes

• Emotional reasoning• I feel gay, I must be in denial• Things I obsess about make my heart

rate go up and when I check my groin I notice sensations

Common distortions and reframes• Mind reading• The conference attendees think I’m

an idiot• I don’t know what they’re thinking. I

often assume people are thinking negative things about me.

Other distortions• Disqualifying the positive• Magical thinking• Selective abstraction• Personalizing• Should/must statements• Magnifying

Mindfulness and ERP• Exposure with Response Prevention (ERP)• Gradually making contact with feared stimuli

while resisting urges to compulsively neutralize or reassure

• Mindfulness = ERP to being in the presence of unwanted thoughts/feelings without engaging in rituals

ERP Goals• Bring the unwanted thought or feeling into the

present moment• Stay with the discomfort associated with

uncertainty about the thought/feeling• Resist the urge to avoid or change this discomfort• Willingness to cope with all possible outcomes

because there’s no other choice

Meditation and OCD• Asking an OCD sufferer to clear their mind is

counterproductive – do not clear, notice busy• 10,000 hands pulling you away from your anchor –

meditation may seem impossible, empathize• Performance evaluation, more effort = less success• The point is to exercise the muscle that allows you to

come back from an obsession, from the “what IF” to the “what IS”, not to relax

Mindful Meditation Goals• Allow unwanted thoughts and

feelings to be present when they occur

• Acknowledge the associated discomfort

• Observe (not react to) urges to avoid or change the discomfort

Basic meditation (the “practice” of mindfulness)

• Optional entering the meditation: few deep breaths, then closing the eyes and breathing “normally”

• Checking in: “Here I am in this space.” The weight of the body. Touch: Feet on the floor, legs on the seat, hands on the lap, air on the face. Tastes, smells. Sounds: Opening up the ears to sounds close and far away. Mood: Howzitgoin right now?

• Body scan: Printing out a mental picture paying attention to the body and how it appears from the inside, starting with the head and ending with the feet.

Basic meditation (the “practice” of mindfulness)• Noticing the in-breath.

• Noticing the out-breath. “Following” the breath.• Counting if helpful (1 in, 2 out, 3 in, 4 out. Up to

10, starting over when distracted) or noting “in” and “out”

• Noting when wandered off. That’s thinking. That’s feeling.

• Attempting to return the focus to the breath. Gently attempting, not succeeding or failing. Engaging this wander/return activity for the remainder of the meditation (anywhere from a minute to 20 or more).

Basic meditation (the “practice” of mindfulness)

• Letting the mind do whatever it wants. Releasing any efforts to note or return.

• Optional exiting: Noticing the sounds, the hands, the legs, the feet.

• Opening the eyes. • Doing nothing. (not evaluating the success or failure

of the meditation)• Doing something.

Why Meditation Can Help

• Adds an additional tool to the tool box (but beware of using meditation as escape from pain)

• Reinforces the concept of homework completion and discipline in overcoming OCD.

• Built-in ERP to fears of inadequacy, unwanted thoughts/feelings, and fear of wasting time.

• Allows for the question, “What would I do in this moment if this trigger occurred while I was meditating?”

• Makes the assessment of “thoughts as thoughts” more habitual/instinctual, less prone to ritualizing, taking the bait, or self-reassuring.

Why Meditation Can Help

When Mindfulness Attacks

• Thoughts are “just” thoughts is a judgment• “It’s not me, it’s my OCD” vs. “It is me and so

be it.” – the problem with relabeling/reattributing

• Perfectionism and the solving ritual• Checking the present• Meditation as a compulsion

Encouraging Mindful Self-Talk

• “Hey, look at that…”• “Duly noted…”• “Good one, OCD!”• Accepting the presence of the typical

“...aaand right on schedule”• “That’s just how I think.”

contact

• Jon Hershfield – jon@ocdbaltimore.com

• Kimberley Quinlan –kimberley@kimberleyquinlan-lmft.com