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Jon Hershfield, LMFT
Kimberley Quinlan, LMFT
International OCD Foundation 23rd Annual Conference 2016
Chicago, IL
Applying Mindfulness to
Traditional CBTTools: How to
Enhance WhatWorks in
TermsYour 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 MindfulnessWorkbook For OCD: A Guide toOvercomingObsessions and Compulsions
Using Mindfulness and Cognitive BehavioralTherapy. New Harbinger Publications:Oakland,CA
The spotlight
Hershfield, J and Corboy,T. (2013)The MindfulnessWorkbook For OCD: A Guide toOvercomingObsessions and Compulsions
Using Mindfulness and Cognitive BehavioralTherapy. 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
• KimberleyQuinlan –
kimberley@kimberleyquinlan-lmft.com

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Jon Hershfield - Applying Mindfulness to Traditional CBT Tools How to Enhance What Works in Terms Your Clients Understand

  • 1. Jon Hershfield, LMFT Kimberley Quinlan, LMFT International OCD Foundation 23rd Annual Conference 2016 Chicago, IL Applying Mindfulness to Traditional CBTTools: How to Enhance WhatWorks in TermsYour Clients Understand
  • 2. 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
  • 3. Mindfulness • Paying attention to the present moment • Non-judgmental observation of internal experiences • Letting go of resistance to discomforting thoughts, feelings, and sensations
  • 4. 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)
  • 5. Psychoeducation and Mindfulness • Why do I think this way? • Do other people have these thoughts? • What if these thoughts mean something important?
  • 6. The spotlight Hershfield, J and Corboy,T. (2013)The MindfulnessWorkbook For OCD: A Guide toOvercomingObsessions and Compulsions Using Mindfulness and Cognitive BehavioralTherapy. New Harbinger Publications:Oakland,CA
  • 7. The spotlight Hershfield, J and Corboy,T. (2013)The MindfulnessWorkbook For OCD: A Guide toOvercomingObsessions and Compulsions Using Mindfulness and Cognitive BehavioralTherapy. New Harbinger Publications:Oakland,CA
  • 8. 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
  • 9. 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)
  • 10. 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
  • 11. 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
  • 12. 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
  • 13. 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.
  • 14. 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
  • 15. 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.
  • 16. Other distortions • Disqualifying the positive • Magical thinking • Selective abstraction • Personalizing • Should/must statements • Magnifying
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. 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
  • 21. 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.
  • 22. 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).
  • 23. 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.
  • 24. 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.
  • 25. • 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
  • 26. 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
  • 27. 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.”
  • 28. contact • Jon Hershfield – jon@ocdbaltimore.com • KimberleyQuinlan – kimberley@kimberleyquinlan-lmft.com