J Cogn Ther

https://doi.org/10.1007/s41811-018-0003-3

Mindfulness-Based Cognitive Therapy for OCD:

Stand-Alone and Post-CBT Augmentation Approaches

Steven Selchen 1,2 & Lance L. Hawley 1,2 &

Rotem Regev 1 & Peggy Richter 1,2 & Neil A. Rector 1,2,3

# International Association of Cognitive Psychotherapy 2018

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 complet-
ed 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–com-
pulsive 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

* Neil A. Rector
neil.rector@sunnybrook.ca

1
Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
2
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
3
Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto,
Ontario M4N 3M5, Canada
 J Cogn Ther

Mindfulness can be defined as Bthe 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 reduc-
ing 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 spec-
trum, 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 combi-
nation (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 allevi-
ate 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 dysfunc-
tional obsessive beliefs through which patients misinterpret the significance of
intrusive, ego-dystonic thoughts and images (Clark 2004). Although CBT treat-
ment 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 demon-
strated 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.
J Cogn Ther

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, exam-
ining a three-participant case series in which participants achieved considerable symp-
tom 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 partic-
ipants 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 im-
provements 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.
 J Cogn Ther

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 BMindfulness Based Cognitive Therapy for Depression—Second
Table 1 Overview of MBCT treatment sessions and modifications
Session and theme Agenda
Pre-class participant
interview
1. Awareness and Mindful eating (raisin exercise)
Automatic Pilot Discussion of Bautomatic pilot^
Body scan and inquiry
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
3. Gathering the Scattered Mindfulness of Seeing
Mind Sitting with Breath, body
Home practice review
Mindful Stretching and Movement
3-minute Breathing Space
4. Recognizing Aversion Sitting meditation—Awareness of Breath, This modified content focuses on thoughts, beliefs, or Guided sitting meditation
Body, Sound, Thought, and Open
Awareness
Modified content Home practice
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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 intru-
sions endorsed by general population demonstrat-
ing 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 re-
actions to each component of experience (intrusion,
emotion, urge, etc.) fuel the OCD cycle and how
relating differently to each component can interrupt
the cycle
Revisited MBCT model of OCD in session and Body scan (daily)
handout with themes as above; inquiry throughout BEveryday mindfulness^—awareness of a routine daily activity
session involved contextualizing content based on Mindful eating
OCD symptomatology.
Minimal adaptation, primarily involving Body scan (daily)
contextualizing content based on OCD Mindfulness of breathing
symptomatology. Awareness of a routine daily activity
Pleasant Events Calendar
The Unpleasant Events Calendar was modified, with Mindful movement
the context of improving awareness of specific 3-minute Breathing Space OCD
OCD-related thoughts, emotions, physical experiences diary
symptoms, rituals, and urges to ritualize.
appraisals that can arise in reaction to intrusive Mindful movement
thoughts or images, inviting mindful awareness of Mindful Walking
Table 1 (continued)

Session and theme Agenda Modified content Home practice

Home practice review these reactions and the opportunity to cultivate an Regular breathing space
Automatic thoughts in OCD alternate relationship to these thoughts, rather than Additional breathing space
3-minute Breathing Space relating to them as a narrative of reality. (when you notice unpleasant experiences)
Mindful Walking
5. Allowing/Letting Be Sitting meditation, including noticing Minimal adaptation, primarily involving inquiry and Working with difficulty meditation
reactions and introducing a difficulty discussion of specific OCD content Breathing spaces (regular)
Home practice review Breathing spaces (additional/responsive)
Breathing space—extra guidance
6. Thoughts Are Not Facts Sitting meditation In-session and home practice worksheet was adapted Worksheet: working wisely with OCD
Home practice review to increase awareness of the components of the At least 40 min per day of selected meditation(s).
Thoughts are not facts—discussion OCD cycle and how it is maintained. Breathing spaces (regular)
Working wisely with OCD worksheet Breathing spaces (additional/responsive)
7. Responding Wisely to Sitting meditation Substantial departure from the MBCT for depression Worksheet: Responding wisely to OCD meditation practice
OCD Home practice review protocol which focuses on BHow can I best take select a pattern of practice intended to be used regularly
Responding wisely to OCD, including care of myself?^; instead, the focus here is on going forward
befriending OCD various ways of responding mindfully and more Breathing spaces (regular)
adaptively to OCD, including Bbefriending^ OCD Breathing spaces (additional/responsive)
(with material adapted from Siegel (2010),
BMindsight^)
8. Maintaining and Body scan A BHome Practice Plan^ is developed in order to Develop and implement a BHome Practice Plan^
Extending New Homework review develop a specific plan for relating differently to
Learning Home practice plan OCD, in order to maintain and extend progress.
What I value closing practice
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J Cogn Ther

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 BDefining 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 BThoughts 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 experi-
ences may ultimately maintain the OCD cycle.

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 Bgold
standard^ reliability status (Grove et al. 1981). Diagnoses were coded indepen-
dently, and 100% agreement was required between the interviewers before
trainees conducted interviews independently. Trainees continued to receive on-
going 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 proper-
ties, including acceptable to good internal consistency in meditating and non-
meditating samples (Baer et al. 2008).
 J Cogn Ther

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). Re-
spondents 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.

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.

1
Of 37 participants, the following demographic information was missing: education (n = 3), ethnicity (n = 1),
marital status (n = 1), and occupation (n = 1)
Table 2 Demographic breakdown by condition

Pre-CBT MBCT (n = 19) Post-CBT MBCT (n = 18) Total (N = 37) Statistical analyses Significance
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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)
Table 2 (continued)

Pre-CBT MBCT (n = 19) Post-CBT MBCT (n = 18) Total (N = 37) Statistical analyses Significance

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)
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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 symp-
tom (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.

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. BJennifer^ is a single Caucasian woman who is 50 years old. She
listed Bmusician 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 Bcontaminated^ 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 Bcontaminated^ clothing, and using various strong cleaning
agents on household items in order to avoid personal contamination as well as
potentially Bspreading^ 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 Bthe
hospital floor is dirty,^ and the associated Bovergeneralized threat^ appraisal would
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
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Fig. 1 YBOCS symptom ratings at baseline and post-treatment for MBCT groups

lead her to believe that this is a high-risk scenario that will likely cause her to become
seriously ill. Further, she experienced the Binflated 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 Bspread the
contamination^ to others, leading them to become sick as a result of her Birresponsible
behavior.^ As a result, she experienced significant emotional distress involving in-
creased 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
 J Cogn Ther

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 Bdecentering^ or Btaking a step back^ from thoughts, observing an obses-
sive thought as a mental event. As individuals become more aware of habitual patterns
of thinking, feeling, and behaving, Bthe 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 BAutomatic 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 Bunpleasant^ 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 Beveryday^ 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 Bdo 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
Beveryday^ mindfulness practice involving a routine activity, and eat at least one meal
Bmindfully.^
The theme for session 2 involved BDealing with Barriers.^ Mindfulness
practices include the body scan and the Bmindfulness 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 Binteresting to be curious
about the emotion^ she experienced, particularly since she typically believes that
anger is Bnegative and unhelpful,^ and therefore should be avoided. During the
homework review, she reported that she had found the Bmindful 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 Bbarriers^ 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 Bcontaminated^ floor during the
J Cogn Ther

body scan, she was experiencing more intense emotion (anger and irritation), and
she was particularly concerned that her mind Bwandered 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 BGathering the Scattered Mind.^ Mindful-
ness practices included the Bmindfulness 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 Bsomewhat more tolerant^ of these experiences over time. During the
discussion of the BPleasant 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 Bextremely 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 Ballowed [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 Bmore interesting and authentic^ as a result of
her mindful approach.
The theme for session 4 involved BRecognizing 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 Bcompelled^ to engage in compulsive hand washing
behaviors, feeling as if she Bhas no choice.^ Further, she reported that she noticed that
there were several occasions in which she was able to Bnotice 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
Boverestimated 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
BCode Brown^ environmental spill in the hospital. She stated that, several years ago,
she would have likely Bturned 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 Binflated responsibility^ appraisal, in which she is often concerned that
she would be an Birresponsible 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 BAllowing 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
Binviting in a difficult experience^ to the practice. During the homework review,
 J Cogn Ther

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 Bturn towards^ several painful experi-
ences involving recent interactions with a friend who was experiencing signifi-
cant medical difficulties. Initially, she was concerned that this event would elicit
distressing obsessive thoughts involving contamination themes, resulting in
Boverwhelming, unmanageable emotion.^ However, she also recognized that
she had Btaken 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 Bdoes 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 Binviting in a difficult experience^ to the practice. Following the sitting meditation
practice, Jennifer indicated that it was not difficult for her to Binvite a difficulty^ into the
exercise, since over the last several months she has been forced to confront many
challenging (personal and professional) events Bhead 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 Bnotice 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 Bwelcome the difficult events in^ and Btolerate these experiences without
becoming emotionally overwhelmed.^ During the discussion of BWorking 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 Bslow things down,^ and engage in fewer compul-
sions, in comparison to when she is Bon autopilot.^ She provided an example of
recognizing that she is having the thought BI am going to lose everyone (due to illness)^
and then choose how she will respond to the thought using her Bwise mind.^ This
facilitated a compassionate group conversation regarding OCD-related beliefs involving
Binflated responsibility,^ and group members commented on her compassionate ability
to support others autonomy without Btrying to fix^ them.
The theme for session 7 involved BHow 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 Binviting in a difficult
experience^ to the practice. Jennifer reported that she found the sitting meditation
practice to be Btolerable^ and that there were moments in which she Bappreciated [her]
life.^ She indicated that she has become able to develop an Baccepting 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 Bon [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.
J Cogn Ther

The theme for session 8 involved BUsing 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 Bmost
important point^ of these practices involves Bhaving more options^ when she experi-
ences 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 Bcentered and
grounded,^ allowing her to choose how she will work with a difficult situation
when it occurs. In general, she reported Bhaving 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 Banchor^
herself. She further indicated that the MBCT treatment had helped her become
Bless reactive^ to triggering situations, thereby allowing her to better function at
home and in public settings.

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

Fig. 2 Case example—patient’s

YBOCS scores during MBCT
treatment
 J Cogn Ther

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 deter-
mined 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 difficul-
ties 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 com-
pare 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
J Cogn Ther

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 demon-
strated 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 Bapproach^ instead of
Bavoid^ 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 diffi-
culty 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 difficul-
ties. 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 symp-
toms 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 contrib-
uted 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.

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.
 J Cogn Ther

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