Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 17, 250–268 (2010)

Published online 29 December 2009 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/cpp.665

Practitioner Is Mindfulness-Based
Report Therapy an Effective
Intervention for
Obsessive–Intrusive
Thoughts:
A Case Series
Megan Wilkinson-Tough,1* Laura Bocci,2
Kirsty Thorne3 and Jane Herlihy4
1
West of England Forensic Mental Health Service, Psychology Department
2
Gloucestershire Recovery in Psychosis
3
Southern Rehabilitation Institute
4
Centre for the Study of Emotion in Law, Trauma Clinic

Despite the efficacy of cognitive-behavioural interventions in improv-

ing the experience of obsessions and compulsions, some people do not
benefit from this approach. The present research uses a case series design
to establish whether mindfulness-based therapy could benefit those
experiencing obsessive–intrusive thoughts by targeting thought–action
fusion and thought suppression. Three participants received a relax-
ation control intervention followed by a six-session mindfulness-based
intervention which emphasized daily practice. Following therapy all
participants demonstrated reductions in Yale-Brown Obsessive–Com-
pulsive Scale scores to below clinical levels, with two participants main-
taining this at follow-up. Qualitative analysis of post-therapy feedback
suggested that mindfulness skills such as observation, awareness and
acceptance were seen as helpful in managing thought–action fusion and
suppression. Despite being limited by small participant numbers, these
results suggest that mindfulness may be beneficial to some people expe-
riencing intrusive unwanted thoughts and that further research could
establish the possible efficacy of this approach in larger samples. Copy-
right © 2009 John Wiley & Sons, Ltd.

Key Practitioner Message:

• Preliminary evidence is provided for the use of mindfulness-based
therapy with obsessive intrusive thoughts.
• Mindfulness processes may be useful in the management of thought-
action fusion and thought suppression.

Keywords: Mindfulness; Obsessive–Compulsive Disorder; Thought–

Action Fusion, Thought Suppression; Intrusive Thoughts

* Correspondence to: Megan Wilkinson-Tough, West England Forensic Mental Health Service, Fromeside, Blackberry Hill
Hospital, Stapleton, Bristol, BS16 1EG.
E-mail: Megan.Wilkinson-Tough@awp.nhs.uk

Copyright © 2009 John Wiley & Sons, Ltd.

Mindfulness-Based Therapy
INTRODUCTION
Characterized by intrusive obsessional thoughts
and compulsive ritualizations, obsessive–
compulsive disorder (OCD) has been found to
have a 6-month prevalence rate of 0.7–2.1% (Beb-
bington, 1998) and has been associated with signifi-
cant impairments in social functioning and quality
of life (Eisen et al., 2006; Grabe et al., 2000; Stengler-
Wenzke, Kroll, Matschinger, & Angermeyer, 2006).
Cognitive Behavioural Therapy (CBT) including
Exposure and Response Prevention (ERP) is the
most widely advocated intervention for OCD (e.g.,
NICE, 2004) but can be perceived as unacceptable
by clients, almost half of whom will not engage
or drop out at an early stage (Foa et al., 2005).
Equally, residual difficulties may remain post-
treatment (Foa, 1996) and some research sug-
gests that people experiencing particular types of
obsessive–intrusive thoughts are less likely to
benefit from ERP (Alonso et al., 2001; Christensen,
Hadzai-Pavlovic, Andrews & Mattick, 1987).
Considering the limitations of cognitive and
behavioural interventions for OCD, particularly
when treating people whose difficulties are charac-
terized primarily by distressing intrusive thoughts,
other approaches merit consideration. Therapies
incorporating a mindfulness component have been
developed in recent years to target difficulties
associated with a diagnosis of borderline person-
ality disorder (Linehan, 1993a; 1993b), recurrent
depression (Teasdale et al., 2000; Ma & Teasdale,
2004), chronic pain (Kabat-Zinn, 1982), psychosis
(Bach & Hayes, 2002) and anxiety (Miller, Fletcher
& Kabat-Zinn, 1995), to name a few. Bishop
et al. (2004) propose that the processes underlying
the positive effects of mindfulness are: the self-
regulation of attention and awareness, acceptance,
and openness to experience of the present moment.
In doing this, mindfulness facilitates an obser-
vational stance to internal experience, allowing
people to accept their thoughts as ‘just thoughts’,
rather than a literal reflection of reality (Baer, 2003;
Shapiro, Carlson, Astin & Freedman, 2006; Wells,
2006). Teasdale et al. (2000), Ma and Teasdale (2004)
and Shapiro et al. (2006) all highlight how the
increased objective awareness that is cultivated by
mindfulness practice can enhance people’s under-
standing of the patterns of automatic responding
that they may engage in, allowing them to disen-
gage from habitual or unhelpfully reactive behav-
iours. For example, Teasdale et al. (2000) and Ma
and Teasdale (2004) suggest that mindful aware-
ness cultivates insight into relapse processes in
Copyright © 2009 John Wiley & Sons, Ltd.
251
recurrent depression where an increase in rumi-
native thinking can be triggered by lowered mood.
Having gained this insight, those who may have
experienced a relapse in depression are potentially
freed from the automatic rumination spirals that
may previously have accompanied natural fluctua-
tions in mood (Ma & Teasdale, 2004; Teasdale et al.,
2000). Equally, Shapiro et al. (2006) describes how
‘reperceiving’ experience through the develop-
ment of mindfulness skills leads to self-regulation
of previously automatic responding in general.
Such mindfulness processes could be valuable in
enhancing therapies for OCD, where long-standing
habitual responses to anxiety-provoking intrusive
thoughts include thought suppression, neutraliza-
tion or compulsive behaviour.
Relevance of Mindfulness to Cognitive
Processes Underlying Obsessions
and Compulsions
Incorporating mindfulness into interventions for
OCD may help to target a number of processes
underlying the formation and maintenance of
obsessions and compulsions. Fairfax (2008) high-
lights how mindfulness may provide an alternative
way for people to relate to distressing intrusive
thoughts, normalising such thoughts and break-
ing the link to unhelpful automatic responding
(i.e., compulsive behaviours). As such, mindful-
ness could help people experiencing obsessions
and compulsions feel more in control of thinking
and behaving and could increase insight into the
metacognitive processes maintaining their diffi-
culties. Equally, Fairfax (2008) argues that using
a mindfulness-based approach which emphasizes
non-judgment may help to address self-censorship
due to fear of humiliation in therapy for OCD and
may subsequently increase the therapeutic alli-
ance. An additional benefit may be the fact that
mindfulness could help people to experience the
anxiety provoked by obsessive–intrusive thoughts
without judging it or trying to avoid the experi-
ence (Shapiro et al., 2006), thus supporting ERP
techniques (Fairfax, 2008).
The limited number of authors writing on the
use of mindfulness in OCD (e.g., Fairfax, 2008;
Hannan & Tolin, 2005; Orsillo, Romer, Block-
Lerner, Le Jerune, & Herbert, 2005) highlight the
value of mindfulness-based therapies in address-
ing two of the key processes thought to under-
lie the formation and maintenance of obsessions
and compulsions; namely, thought–action fusion
Clin. Psychol. Psychother. 17, 250–268 (2010)
DOI: 10.1002/cpp
252
(TAF) and thought suppression. A precursor to
the identification of these concepts in OCD was
Rachman and de Silva’s (1978) seminal work on
intrusive thoughts in a non-clinical population.
This research demonstrated that the content of
intrusive thoughts was similar in people with or
without OCD, with 80% of the non-clinical popu-
lation disclosing thoughts of contamination, aver-
sive sexual or harmful acts, and safety (Rachman &
de Silva, 1978). It was, therefore, proposed that the
way these thoughts are interpreted and managed
by the individual could result in the formation
of obsessive–intrusive thoughts (Rachman, 1997;
Rassin et al., 1999; Salkovski, 1985).
Thought–Action Fusion
One way by which normal unwanted or aversive
thoughts obtain inflated significance is through
TAF; a process whereby a person believes that
‘having an unwanted, unacceptable intrusive
thought increases the likelihood that a specific
adverse event will occur’ (TAF likelihood: Shafran
& Rachman, 2004, p. 87) or ‘that having an unaccept-
able intrusive thought is almost the moral equiva-
lent of carrying out that particular act’ (TAF moral:
Shafran & Rachman, 2004, p.88). The moderate sig-
nificant correlations between the Thought–Action
Fusion Scale (Shafran, Thordarson, & Rachman,
1996) and measures of OCD (e.g., Gwilliam, Wells,
& Cartwright-Hatton, 2004; Rassin, Merckelbach,
Muris, & Schmidt, 2001; Rassin, Muris, Schmidt, &
Merckelbach, 2000; Smari & Holmsteinsson, 2001)
suggest that despite being a component process of
obsessive–compulsive difficulties, TAF in isolation
cannot explain such problems. Additionally, TAF
may not be an OCD specific process, having been
linked to other anxiety disorders (Hazlett-Stevens,
Zucker, & Craske, 2002; Rassin, Diepstraten,
Mercklebach, & Muris, 2001). Although the litera-
ture suggests that TAF is neither specific to, nor
the sole determinant of OCD, clinical and non-
clinical research does implicate TAF processes
in obsessive–compulsive difficulties (Rassin,
Merckelbach, Muris, & Spaan, 1999).
If fusion with thoughts is a component process
in the development and maintenance of obsessive–
intrusive thoughts then the ability of mindfulness
techniques to cognitively decentre (Wells, 2006)
or de-fuse (Hayes, Strosahl, & Wilson, 1999) from
thoughts could be a valuable addition to interven-
tions for these difficulties (Fairfax, 2008; Hannan &
Tolin, 2005; Orsillio et al., 2005). This is highlighted
Copyright © 2009 John Wiley & Sons, Ltd.
M. Wilkinson-Tough et al.
in Shapiro et al.’s (2006) conception of Reperceiv-
ing as a central mindfulness mechanism, described
as a shift in perspective to a position of objective
witnessing of experience rather than immersion
in the content of personal narrative or thought.
Although cognitive approaches to therapy for
OCD discuss seeing thoughts as ‘just thoughts’,
arguably such interventions provide little direc-
tion or practice of how to apply this. Mindfulness-
based therapy could provide an experiential way
to help those with distressing intrusive thoughts to
non-judgementally experience these mental events,
without becoming fused with literal interpreta-
tions of the meaning of such thoughts (Hannan &
Tolin, 2005).
Thought Suppression
Alongside TAF, thought suppression has also been
highlighted as a component process that main-
tains obsessive–compulsive difficulties. Salkovs-
kis and Campbell (1994) propose that people
who are disturbed by the presence of unwanted
intrusive thoughts manage this by attempting to
push such intrusions from their minds. Wegner,
Schneider, Carter, and White (1987) demonstrated
that attempting to suppress a thought is difficult
and can have a paradoxical effect, instead enhanc-
ing the thought. In their meta-analysis of thought
suppression paradigms Abramowitz, Tolin, and
Street (2000) highlight that across studies sup-
pression produced a small to moderate thought
rebound effect and that longer suppression periods
were associated with greater enhancement of the
suppressed material. Wegner and Zanakos (1994)
found that self-reported tendency towards thought
suppression correlated with obsessional thinking
and Tolin, Abramowitz, Hamlin, Foa, and Synodi
(2002) found that compared to controls, those
with OCD were more likely to attribute suppres-
sion failures to negative internal attributes such as
psychological weakness.
Although cognitive-behavioural psycho-edu-
cation informs people with OCD of the role of
thought-suppression in initiating and perpetuat-
ing obsessions, it does not offer any alternative
strategies to manage such thoughts. Mindfulness
exercises develop skills in allowing thoughts to
pass through the mind without either rumination
or suppression. Instructions for these techniques
suggest ‘just noticing’ thoughts and allowing them
to naturally pass like clouds in the sky (Linehan,
1993b). Preliminary research with a non-clinical
Clin. Psychol. Psychother. 17, 250–268 (2010)
DOI: 10.1002/cpp
Mindfulness-Based Therapy
population (Clancy, unpublished data) suggests
that mindfulness may offer a valuable alternative
to thought suppression strategies. Arguably, prac-
tice with such exercises could arm people experi-
encing obsessive intrusions with skills to manage
distressing internal events in a way that will not
increase the frequency of such thoughts (Fairfax,
2008).
Previous Research
Despite the clear rationale for mindfulness-based
interventions for OCD, research in this area has
been very limited. Hanstead, Gidron, and Nyklícek
(2008) provide evidence that mindfulness medi-
tation is useful in reducing obsessive–compulsive
symptoms in a non-clinical student population.
Using participants with clinically significant dif-
ficulties Singh, Wahler, Winton, and Adkins (2004)
and Patel, Carmody, and Simpson (2007) provide
single participant case studies of successful
mindfulness-based interventions for OCD; how-
ever the use of A-B designs with one individual
in both studies limits the conclusions that can
be drawn. Schwartz and Begley (2002) describe
how mindfulness underpinned the conception
of the Four Steps approach. This is a cognitive-
behaviourally based self-help intervention which
suggests people: (1) ‘Relabel’ intrusive thoughts
as OCD; (2) ‘Reattribute’ these to a biochemical
imbalance in the brain; (3) ‘Refocus’ their attention
on a more constructive behaviour; (4) ‘Revalue’ the
intrusive thought rather than taking it at face value
(Schwartz & Beyette, 1997). However, published
treatment protocols for this approach (Schwartz &
Beyette, 1997; Schwartz, Stoessel, Baxter, Martin, &
Phelps, 1996) do not describe formal mindfulness
practice as central to this method and some aspects
of the approach appear to contradict the non-
judgemental stance of mindfulness (such as
describing intrusive thoughts as ‘toxic waste’ of the
brain). Fairfax (2008) describes the use of mindful-
ness as an adjunct to traditional cognitive-behav-
ioural techniques in a community-based group
intervention for OCD but does not provide outcome
data for this intervention. However, feedback data
is cited from group members receiving this inter-
vention who on average ranked their preference
for mindfulness as second out of fourteen differ-
ent techniques learnt in the group (Fairfax, 2008).
Finally, Twohig, Hayes, and Masuda’s (2006) four
participant multiple-baseline case series provides
a good preliminary demonstration of the efficacy
Copyright © 2009 John Wiley & Sons, Ltd.
253
of treating OCD with Acceptance and Commit-
ment Therapy (ACT), which incorporated mind-
fulness exercises in its protocol. However, as ACT
is a multi-component intervention it is difficult to
establish the specific value of using mindfulness
with OCD in this research.
Present Research
The present study provides a preliminary inves-
tigation of the usefulness of mindfulness with
obsessive–intrusive thoughts. The focus on intru-
sive thoughts was chosen because of the theoreti-
cal rationale suggesting that mindfulness could
be effective in addressing cognitive processes
underlying the interpretation and maintenance
of obsessive–intrusive thoughts, namely TAF and
thought suppression. Additionally, some litera-
ture suggests that people experiencing difficulties
characterized primarily by distressing obsessive–
intrusive thoughts may find approaches such as
ERP less beneficial than those presenting with
compulsive behaviours (Alonso et al., 2001;
Christensen et al., 1987).
The use of a three participant replication case
series design in the present study is in keeping with
previous research which has used this design to
pilot investigation of new therapeutic approaches
(Cooper, Todd, Turner, & Wells, 2007; Wells &
Papageorgiou, 2001; Wilson & White, 2006). Such
a design permits investigation of the intervention
response of each participant, acknowledging that
the suitability and benefits of such an approach may
vary across individuals. Additionally, in assessing
TAF and thought suppression, the present study
aims to elucidate the processes underlying any
clinical change in a way that is difficult for larger
efficacy studies.
Previous mindfulness research has primarily
used unspecified ‘treatment as usual’ as a control
condition (e.g., Ma & Teasdale, 2004; Teasdale
et al., 2000). This is unlikely to control for the non-
specific effects of attending therapy. Therefore, the
present research includes a control intervention
using relaxation sessions to account for the pos-
sibility that a positive outcome could be produced
by therapeutic non-specifics (e.g., the therapeutic
relationship). It is hypothesized that while partici-
pating in mindfulness-based therapy participants
with intrusive obsessive thoughts will demonstrate
reductions in daily ratings of TAF, thought sup-
pression and distress associated with obsessive
thoughts. In addition, it is hypothesized that these
Clin. Psychol. Psychother. 17, 250–268 (2010)
DOI: 10.1002/cpp
254
reductions should be associated with an increase in
mindfulness skills, a decrease in obsessive thinking
styles, and overall clinical improvement.
METHOD
Ethical Approval
Ethical review and approval was provided by a
local Research Ethics Committee.
Participants
Three participants completed the full research pro-
tocol following referral to a primary mental health
care service by their General Practitioner (GP). All
participants gave fully informed consent to partici-
pate in the research. Participants over the age of
18 with a Yale-Brown Obsessive–Compulsive Scale
(YBOCS: Goodman et al., 1989) total score greater
than 16 were recruited. In addition, having at least
a moderately severe level of obsessive–intrusive
thoughts, indicated by a sum of greater than six
on YBOCS questions one to three (time occupied
by obsessive–intrusive thoughts, and associated
interference and distress) was used as an inclu-
sion criterion. This criterion has not been used in
previous research but was needed to ensure partic-
ipants were experiencing difficulty with intrusive
thoughts rather than primarily being troubled by
habitual compulsions. However, no participants
were excluded on this basis as all participants
scoring greater the 16 on YBOCS total score had
a sum of greater than six on YBOCS items one
to three. Participants were excluded if they had
co-morbid psychosis or substance misuse, or were
receiving treatment with neuroleptic medication.
Table 1. Participant characteristics
Participant 2
Age 35
Gender Female
Ethnicity White British
Marital Status Divorced
Years of education 17
Years with OCD 20
Intrusive thought Harming her children
(main).
Multiple others.
Previous OCD CBT in secondary care
intervention
Current medication Cipralex (20mg)
Copyright © 2009 John Wiley & Sons, Ltd.
M. Wilkinson-Tough et al.
Participants on SSRI medication were included
providing they had been on their current dose
for over 2 months, although in practice the two
recruited participants taking medication had
received the same dose for over 6 months and this
dose remained stable throughout participation
in the present research. In total, seven potential
participants were assessed for trial suitability. Two
people did not demonstrate sufficiently high scores
on the YBOCS to be included. Five participants
commenced treatment but one withdrew after two
mindfulness sessions due to life events and finding
it difficult to engage with mindfulness concepts
and daily practise. A further male participant reluc-
tantly withdrew after the fifth mindfulness session
due to sudden employment relocation. Participant
characteristics are outlined in Table 1.
Measures
Yale-Brown Obsessive–Compulsive Scale
The Yale-Brown Obsessive–Compulsive Scale
(Goodman et al., 1989) is a 10 item measure admin-
istered by clinical interview. Five items assess
frequency, interference, distress, resistance and
control of obsessions and an additional five items
assess compulsions in the same way. Each item is
rated on a scale of 0-four; with higher scores reflect-
ing greater difficulty. Items are summed to provide
separate obsessions and compulsions subscales and
a total score. A combined obsessions and compul-
sions score of 16 or more is generally considered
to reflect clinically significant difficulties (Steke-
tee, 1999). The Y-BOCS has been demonstrated as
having acceptable inter-rater reliability, internal
consistency and convergent validity (Goodman
et al., 1989; Woody, Steketee, & Chambless, 1995).
Participant 2 Participant 3
30 48
Male Male
White British White British
Single Married
16 23
19 5
Harm coming to others Contamination of self by
(main). chemicals.
Multiple others
CBT self-help book CBT self-help book
None Fluoxetine (20mg)
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Mindfulness-Based Therapy
Obsessive Beliefs Questionnaire
The Obsessive Beliefs Questionnaire (Obses-
sive–Compulsive Cognitions Working Group
[OBQ], 1997; 2001; 2003; 2005) contains 44 self-
report items assessing enduring beliefs related to
the development and maintenance of OCD. Each
item is a statement of belief which participants rate
on a seven-point Likert-type scale as to the level
of their endorsement (one: disagree very much;
seven: agree very much). The OBQ has good
convergent and discriminant validity and factor
analysis has established three separate subscales
reflecting Responsibility/Threat Estimation, Per-
fectionism/Certainty, and Importance/Control of
Thoughts (OCCWG, 2005).
Kentucky Inventory of Mindfulness Skills
The Kentucky Inventory of Mindfulness Skills
(KIMS: Baer, Smith, & Allen, 2004) is a 39-item
self-report measure assessing level of mindful-
ness in daily life. Statements about behaviour or
experience are rated on a five-point Likert-type
scale (one: never or very rarely true; five: almost
always true). The KIMS has good internal con-
sistency and convergent and discriminant valid-
ity (Baer, Smith, Hopkins, Kritemeyer, & Toney,
2006). This measure was chosen above other mind-
fulness assessment tools (e.g., Freiburg Mindful-
ness Inventory (FMI): Buchheld, Grossman, &
Walach, 2001; Mindful Attention Awareness Scale
(MAAS): Brown & Ryan, 2003) as it can be used by
people who have no previous experience of mind-
fulness mediation and, in contrast to other uni-
dimensional mindfulness measures, it provides a
total score as well as assessment on four subscales
of Observing, Describing, Acting with Awareness
and Acting with Non-judgement. Using an assess-
ment tool that can demonstrate the development
of separate mindfulness sub-processes as well as
global skill may provide a more detailed under-
standing of the therapeutic processes most relevant
to mindfulness-based interventions for obsessive–
intrusive thoughts.
Daily Ratings of Thought–Action Fusion (TAF),
Thought Suppression and Distress
Participants rated TAF, thought suppression and
distress at intrusive thoughts on a scale of 0–100.
Ratings of TAF were adapted from a method used
by Masuda, Hayes, Sackett, and Twohig (2004)
which asks participants to rate how much they
believed the interpretation of their thought (0 =
did not believe this idea at all; 100 = completely
believed this idea). Wording of this scale was tai-
Copyright © 2009 John Wiley & Sons, Ltd.
255
lored to reflect each participant’s individual inter-
pretations of their intrusive thoughts. Participants
additionally rated the question: How much did
you try and suppress your obsessive thought and
push it completely from your mind? (0 = did not
attempt to suppress this thought at all; 100 = put
maximum effort into suppressing this thought).
Distress at the obsessive thought was rated on the
Subjective Units of Distress Scale (SUDS: Wolpe,
1969; 0 = no distress; 100 = extreme distress).
Post-Therapy Questionnaire
An open-ended questionnaire was used to gain
participant’s experiences of mindfulness-based
therapy. This consisted of two questions asking
participants: i) In what ways has learning mind-
fulness been helpful? And ii) In what ways has
learning mindfulness been unhelpful? Participants
were asked to write as fully as possible. They were
given half a side of A4 paper to provide a response
with instructions stating to continue on a separate
sheet if necessary.
Design
An A-B-C replication case series design was chosen
to pilot research into this new therapeutic proce-
dure. In phase A participants received no interven-
tion while monitoring their intrusive thoughts. In
phase B participants attended weekly individual
hour-long sessions where they spoke about their
current experience of OCD and completed a 10-
minute progressive muscle relaxation exercise in
session and at home on a daily basis. Relaxation
has been used in previous OCD outcome research
to control for non-specific effects of attending
therapy (e.g., Greist, Marks & Baer, 2002; Fals-
Stewart, Marks & Schafer, 1993). In Phase C
participants received six individual sessions of
mindfulness-based therapy and psycho-education
about TAF and thought suppression. The use of
peer-reviewed relaxation and mindfulness tapes
helped to standardize the treatment across par-
ticipants. The therapist also kept a reflective log
and attended regular supervision to ensure they
adhered to the therapy protocol. Three indepen-
dent variables were monitored by participants on a
daily basis: self-ratings of Thought–Action Fusion,
Thought Suppression, and Distress at Intrusive
Thoughts. Severity of OCD was measured with
the YBOCS at first assessment, immediately prior
to commencement of mindfulness-based therapy,
at the end of therapy, and at 2-month follow-up.
Obsessive–compulsive beliefs (measured with the
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256
OBQ) and mindfulness skill acquisition (measured
with the KIMS) were assessed at the same time
as the YBOCS was administered and at one addi-
tional time point mid-therapy (3 weeks).
Procedure
Potential participants, identified by their GP, were
invited to an initial assessment and informed of
their eligibility for the research at the end of this
session. They were phoned a week later by the
therapist to establish whether they would like to
participate. On providing informed consent, each
participant commenced phase A: monitoring of
their intrusive thoughts, lasting 2 weeks each. Fol-
lowing this, participants moved immediately into
phase B and remained in this phase until their TAF
ratings had stabilized (assessed by Young’s (1941)
C Statistic). As soon as ratings stabilized (3 weeks
for Participants 1 and 3, 2 weeks for Participant 2),
participants moved on to receive six 1-hour ses-
sions of mindfulness-based therapy. Ideally this
was delivered on a weekly basis, but on infrequent
occasions when participants were unable to attend
therapy due to illness they continued to practice the
current mindfulness exercise daily and complete
ratings for that week. Participants were followed
up via a single session at 2 months post-therapy.
Outline of Mindfulness-Based Intervention
The mindfulness intervention consisted of three
different 10 minute exercises drawn from Linehan
(1993b), introduced alongside a basic psycho-
education sheet about thought–action fusion and
thought suppression. The limited psycho-education
was purely provided as a framework around which
to base participant understanding of the benefit
of applying mindfulness to intrusive thoughts.
Mindfulness exercises were audio-recorded and
reviewed by therapists experienced in mindful-
ness practice to ensure the exercises demonstrated
face validity and did not differ in presentation
from the relaxation exercise. Although the mind-
fulness exercises were drawn from descriptions
within the DBT skills training manual (Linehan,
1993b) no other aspect of DBT was used within
the intervention to prevent the possibility that a
therapeutic strategy other than mindfulness could
have affected the outcome. The duration of the
exercises was kept to 10 minutes to maximize the
likelihood of daily use for 6 weeks. A grounding
mindfulness exercise was introduced first, requir-
ing participants to observe and describe bodily
sensations in the present moment. The following
Copyright © 2009 John Wiley & Sons, Ltd.
M. Wilkinson-Tough et al.
week participants completed a thought observa-
tion exercise, where they watched the ebb and flow
of thoughts. In the third week, a half-smile exercise
was used, requiring participants to observe their
current experience and approach their intrusive
thoughts with an accepting half-smile. In the fol-
lowing 3 weeks the exercises were repeated. The
content of the 1-hour weekly sessions focussed on
drawing out participants’ experience of mindful-
ness, its application to intrusive thoughts and use
in daily life in general. Difficulties with practice
were also problem-solved. These sessions were
conducted by a doctoral-level trainee clinical psy-
chologist in their final year of training who had
experience of using mindfulness in both DBT and
ACT interventions and who had been practising
mindfulness personally for 4 years.
RESULTS
Missing Data
Participant 3 had non-completed ratings for three
(out of 77) non-consecutive days. Statistical analysis
for this participant was conducted using replace-
ment values imputed by SPSS.
Analysis
Daily ratings were graphed and visually inspected.
Significant changes in the data series were ana-
lysed using Young’s (1941) C statistic (with two
tailed significance testing used throughout), as
described in Tryon (1982). This statistic is suitable
for use in the analysis of a series containing eight
or more data points (Young, 1941; Tryon, 1982).
A significant change in data from one experimen-
tal phase to another is demonstrated by: (1) ini-
tially testing the first phase (e.g., baseline) data
and establishing its stability (i.e., that there is no
significant trend in the data); (2) appending data
from the second phase (e.g., intervention) to data
from the previous phase and testing for signifi-
cance in this combined series. A significant result
demonstrates that a trend is present in the second
phase data. A significant C Statistic can reflect an
increase or decrease either in level or slope of the
data series and needs to be supported by visual
analysis to determine the nature of the significant
change. For this research analyses were carried out
to compare: (1) stabilized baseline ratings against
relaxation ratings and (2) stabilised ratings from
the last 2 weeks of relaxation with mindfulness
ratings.
Clin. Psychol. Psychother. 17, 250–268 (2010)
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Mindfulness-Based Therapy
Inductive thematic analysis following the process
outlined by Braun and Clarke (2006), identified
themes emerging from follow-up questionnaires.
These were completed by all three participants
who attended all therapy sessions (Participants 1
to 3) and one participant who withdrew for practi-
cal reasons one session before closing (Participant
4). All qualitative data was assessed by an inde-
pendent rater who initially read all data to verify
the identified themes. This same rater, then, recat-
egorized extracts to check inter-rater reliability.
Analysis using Cohen’s kappa (Cohen, 1960, 1968)
established a good level of agreement between
raters (κ = 0.759)
Participant 1
Daily Ratings
Daily ratings including means for each inde-
pendent variable across baseline, relaxation and
Figure 1. Daily ratings of thought–action fusion (TAF), thought suppression and distress for Participant 1
Copyright © 2009 John Wiley & Sons, Ltd.
257
mindfulness phases are presented in Figure 1 and
Table 2.
Clinical and Process Measures
The clinical and process measures for Participant
1 are shown in Table 3.
Integration of results for Participant 1
Participant 1 had previously received cognitive-
behavioural treatment in secondary care for OCD
but had not experienced substantial improvement
in her intrusive thoughts, reporting that ongoing
battles to rationalize her thoughts increased her
anxiety and the time she spent engaging with
these thoughts. The relaxation phase appeared to
produce some limited improvement in thought
suppression ratings alone; possibly reflecting the
non-specific effects of attending sessions and com-
pleting a daily exercise. After this initial improve-
ment, on commencing relaxation suppression
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258 M. Wilkinson-Tough et al.

Table 2. C Statistic comparisons of baseline, relaxation and mindfulness phases of daily ratings for Participant 1

Series C Stat Z Sig

Thought–Action Fusion Baseline 1
−0.102 −0.354 NS
Baseline/Relaxation comparison 0.138 0.793 NS
Last 2 weeks of relaxation1 −0.066 −0.231 NS
Relaxation/Mindfulness comparison 0.681* 5.003* 0.01
Thought Suppression Baseline1 0.179 0.624 NS
Baseline/Relaxation comparison 0.297* 1.708* 0.05
Last 2 weeks of relaxation1 0.290 1.013 NS
Relaxation/Mindfulness comparison 0.701 5.155* 0.01
Distress Baseline1 0.081 0.283 NS
Baseline/Relaxation comparison 0.093 0.537 NS
Last 2 weeks of relaxation1 0.006 0.0217 NS
Relaxation/Mindfulness comparison 0.728* 5.353* 0.01
* indicates significance at or exceeding the 0.05 level
1
indicates a test for stability in baseline and control measures. A non-significant result suggests stability.

Table 3. Clinical and process measures for Participant 1

1st assessment End of relaxation Mid-mindfulness End of mindfulness Follow up

YB-O 10 10 – 3 1
YB-C 6 10 – 5 8
OBQ R/T 60 66 46 55 52
OBQ P/C 40 46 40 35 40
OBQ TI/C 75 83 39 22 17
KIMS Obs. 20 25 34 35 32
KIMS Des. 25 23 24 35 32
KIMS Aw. 27 23 30 32 32
KIMS W/J 14 17 35 35 34
KIMS Total 86 88 123 137 130
* YB-O = YBOCS obsessions sub-scale; YB-C = YBOCS compulsions sub-scale (YBOCS reduction indicates symptom improvement).
OBQ R/T = Responsibility/Threat Estimation sub-scale; OBQ P/C = Perfectionism/Certainty sub-scale; OBQ TI/C = Importance/
Control of Thoughts sub-scale (OBQ reduction indicates improvement). KIMS Obs. = Observe sub-scale; KIMS Des. = Describe
sub-scale; KIMS Aw. = Act with Awareness sub-scale; KIMS W/J = Act Without Judgement sub-scale (an increase on the KIMS
reflects mindfulness skill acquisition).

ratings were found to have stabilized in the last
2 weeks of relaxation; therefore, the improvement
following introduction of mindfulness can be seen
to be a positive effect of mindfulness beyond the
non-specific effects of therapy. Results from the
mindfulness-based therapy showed a significant
decrease on all daily ratings compared to the relax-
ation control phase. Particularly notable in Table 2
was the increase in KIMS Act Without Judgement
sub-scale during and after mindfulness therapy
and the concurrent decrease in YBOCS Obsession
score and OBQ Importance/Control of Thoughts
score. Overall Participant 1 showed an increase of
49 points on the total KIMS score when compar-
ing post-relaxation assessment to scores at the end
of the mindfulness intervention, suggesting mind-
fulness skills had been developed with training.
These changes are maintained at follow-up when
Participant 1 was extremely positive about mind-
fulness-based therapy, reporting that the accep-
tance component had been particularly valuable
(see qualitative analysis of feedback for further
details). At the end of therapy and at follow-up,
for this participant the total YBOCS score fell
below 16, the cut-off level commonly accepted as
reflecting a clinically significant problem (Steketee,
1999), although this mostly represents improve-
ment in the obsessions scale, with compulsions less
effected.
Participant 2
Daily Ratings
Daily ratings including means for each indepen-
dent variable across baseline, relaxation and mind-
fulness phases are presented in Figure 2 while

Copyright © 2009 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 17, 250–268 (2010)
DOI: 10.1002/cpp
Mindfulness-Based Therapy
Figure 2. Daily ratings of thought–action fusion (TAF), thought suppression and distress for Participant 2
comparison of the daily ratings are presented in
Table 4.
Clinical and Process Measures
The clinical and process measures for Participant
2 are shown in Table 5.
Integration of Results for Participant 2
Participant 2 showed a significant decrease on all
daily ratings compared to baseline and relaxation
control phases. Although the relaxation control
did produce some improvement in the distress
ratings alone, this change stabilized before mind-
fulness was introduced, suggesting an additional
improvement with mindfulness beyond that
gained by non-specific effects of attending therapy
and completing daily exercises. The pronounced
change on the 8th day of mindfulness appears to
reflect a sudden shift in Participant 2’s attempts
Copyright © 2009 John Wiley & Sons, Ltd.
259
to suppress unwanted thoughts, with a continu-
ing gradual reduction following this. Overall Par-
ticipant 2 showed an increase of 19 points on the
total KIMS score when comparing post-relaxation
assessment to scores at the end of the mindful-
ness intervention, suggesting that some mindful-
ness skills had been developed with training. At
the end of therapy, combined YBOCS obsessions
and compulsions scores fell below clinical cut-
off and reduction across the three OBQ scales is
demonstrated. This improvement mostly repre-
sents change on the obsessions subscale and was
not maintained at follow-up, although Participant
2’s difficulties did not return to pre-therapy levels
of severity. At follow-up Participant 2 reported
that he had discontinued mindfulness post-therapy
and felt he had fallen back into habitual ways of
responding to thoughts. He restarted mindfulness
a few days prior to follow-up and reported this had
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260 M. Wilkinson-Tough et al.

Table 4. C Statistic comparisons of baseline, relaxation and mindfulness phases of daily ratings for Participant 2

Series C Stat Z Sig

1
Thought–Action Fusion Baseline 0.0121 0.041 NS
Baseline/Relaxation comparison 0.113 0.590 NS
Last 2 weeks of relaxation1 −0.158 −0.553 NS
Relaxation/Mindfulness comparison 0.243* 1.900* 0.05
Thought Suppression Baseline1 0.282 0.942 NS
Baseline/Relaxation comparison 0.241 1.254 NS
Last 2 weeks of relaxation1 −0.194 −0.768 NS
Relaxation/Mindfulness comparison 0.962 7.516 0.01
Distress Baseline1 −0.032 −0.109 NS
Baseline/Relaxation comparison 0.398* 2.071* 0.05
Last 2 weeks of relaxation1 0.145 0.506 NS
Relaxation/Mindfulness comparison 0.602 4.705 0.01
* indicates significance at or exceeding the 0.05 level.
1
indicates a test for stability in baseline and control measures. A non-significant result suggests stability.

Table 5. Clinical and process measures for Participant 2

1st assessment End of relaxation Mid-mindfulness End of mindfulness Follow up

YB-O 11 11 – 5 7
YB-C 10 9 – 8 9
OBQ R/T 94 91 85 79 78
OBQ P/C 85 84 84 73 77
OBQ TI/C 46 35 33 25 26
KIMS Obs. 44 41 42 49 49
KIMS Des. 26 30 29 31 31
KIMS Aw. 37 30 31 33 33
KIMS W/J 18 15 19 22 21
KIMS Total 125 116 121 135 134
* See Table 2 for key to scales.

been beneficial. However, he also felt that he would the final 5 weeks of mindfulness-based therapy
benefit from an ERP approach for the compulsions (when he had clarified the meaning of thought sup-
he experienced and was referred on for this. pression) his average daily rating was 10.9. (See
Figure 3 and Table 6.)

Participant 3 Clinical and Process Measures

Daily Ratings
Participant 3 misinterpreted rating of the
Thought Suppression question until 2 weeks into
mindfulness therapy. Therefore, thought suppres-
sion ratings are not presented in Figure 3, which
presents TAF and Distress ratings alone. This is
unfortunate as Participant 3 reported that thought
suppression was the aspect most improved by
therapy in session and in the follow-up question-
naire; for example: ‘The most essential part for
me was learning the ability of not controlling my
thoughts, which was counterproductive’. Although
this cannot be objectively verified through analy-
sis of daily thought suppression ratings, across
The clinical and process measures for Participant
3 are shown in Table 7.
Integration of Results for Participant 3
Examination of TAF and Distress ratings alone
would suggest that Participant 3 did not benefit
from mindfulness-based therapy. The relaxation
phase appeared to increase his TAF and Distress
and the mindfulness phase only served to bring
these ratings back to baseline levels. However,
verbally Participant 3 reported that both sup-
pression and frequency of his intrusive thoughts
improved dramatically with mindfulness-based
therapy, although on the increasingly less frequent

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DOI: 10.1002/cpp
Mindfulness-Based Therapy 261

Figure 3. Daily ratings of thought–action fusion (TAF) and distress for Participant 3

Table 6. C Statistic comparisons of baseline, relaxation and mindfulness phases of daily ratings for Participant 3

Series C Stat Z Sig.

1
Thought–Action Fusion Baseline 0.229 0.799 NS
Baseline/ Relaxation comparison 0.466 2.679 0.01
Last 2 weeks of relaxation1 0.453 1.582 NS
Relaxation/Mindfulness comparison 0.691 5.697 0.01
Distress Baseline1 0.314 1.095 NS
Baseline/Relaxation comparison 0.454 2.609 0.01
Last 2 weeks of relaxation1 0.128 0.448 NS
Relaxation/Mindfulness comparison 0.628 5.177 0.01
* indicates significance at or exceeding the 0.05 level.
1
indicates a test for stability in baseline and control measures. A non-significant result suggests stability.

Table 7. Clinical and process measures for Participant 3

1st assessment End of relaxation Mid-mindfulness End of mindfulness Follow up

YB-O 9 9 – 5 1
YB-C 9 6 – 6 0
OBQ R/T 71 76 76 56 56
OBQ P/C 65 68 42 26 40
OBQ TI/C 43 34 27 31 35
KIMS Obs. 42 37 28 34 38
KIMS Des. 29 35 38 39 35
KIMS Aw. 40 33 34 38 37
KIMS W/J 25 28 38 43 41
KIMS Total 136 134 147 154 151
* See Table 2 for key to scales.

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DOI: 10.1002/cpp
262
occasions when he did experience an intrusive
thought he found his interpretation of it to be just
as believable and subsequently just as distressing.
This may explain why TAF and Distress ratings
did not reduce below baseline levels. YBOCS
scores displayed in Table 4 support Participant 3’s
verbally reported improvement, with combined
obsessions and compulsions scores falling well
below the clinical cut-off of 16 at end of therapy
and follow-up. Overall Participant 3 showed an
increase of 20 points on the total KIMS score when
comparing post-relaxation assessment to scores at
the end of the mindfulness intervention, suggest-
ing that some mindfulness skills had been devel-
oped with training. This increase is particularly
attributable to changes on the KIMS Act Without
Judgement sub-scale. Participant 3 had avoided
ERP approaches in the past, feeling there was no
way he could engage with them. At the end of
therapy and follow-up he was exposing himself to
previously avoided triggers for intrusive thoughts,
without carrying out neutralising compulsions. He
reported that learning an alternative to suppress-
ing/over-controlling his thoughts had been most
useful (see qualitative analysis).
Post-Therapy Questionnaire: Participants 1–4
Themes derived from the analysis of the brief post-
therapy questionnaire are highlighted in italics.
Although three of the four participants provided
focussed answers, one participant talked much
more widely about their experiences (e.g., opinions
of books they had read outside of therapy). As this
data fell outside the scope of the current question
of helpful and unhelpful aspects of mindfulness-
based therapy it was separated into a miscellaneous
category which was included in second-rater veri-
fication but is not reported here.
Observation and Awareness
Two participants described how visualization
techniques used in mindfulness exercises facilitated
observation and awareness of thoughts, which in
turn helped them to manage these thoughts and let
distressing thoughts pass.
‘The thought watching has been useful as well,
trying to visualize them as passing objects. By
trying to let the thought pass I don’t hold on to it
and analyse it, and thereby make myself anxious
and upset’. (Participant 1)
Copyright © 2009 John Wiley & Sons, Ltd.
M. Wilkinson-Tough et al.
‘The concept of thoughts being like clouds passing
across the sky has also been beneficial to releasing
a thought that may otherwise have started up a
ritual’. (Participant 2)
Acceptance and Non-Suppression
Acceptance rather than judgement or unwilling-
ness to experience a thought or feeling was seen
as a helpful component developed by mindfulness
practice by three participants.
‘While tackling intrusive thoughts I have
found by accepting them, although not wanting
to think them, has helped a lot. Acceptance has
been a big help in getting rid of my thoughts’.
(Participant 1)
‘Looking at things with less judgement has
helped me (again, unfortunately I don’t apply it
all the time!) to pass over an unwanted thought/
feeling and helped me to move on’. (Participant
2)
‘Probably the biggest help, as far as the Half-smile
is concerned, has been to ‘accept’ the fact that I
may experience some anxiety’. (Participant 4)
At the same time as accepting thoughts and
feelings, three participants also described the
beneficial effects of not suppressing unwanted
experience.
‘Rather than trying to push the thoughts away
and increasing my anxiety levels, I just let them
stay, and they soon go’. (Participant 1)
‘I now appreciate that I can’t make [the thoughts]
go away completely or wish them away’. (Par-
ticipant 2)
‘The most essential part for me was learning the
ability of not controlling my thoughts, which was
counter-productive’. (Participant 3)
Managing Thought–Action Fusion
Two participants highlighted the role of
mindfulness-based therapy in reducing TAF.
‘Thought watching has helped me not to react to
thoughts that in my previous mind-set (before
learning the technique) I would have thought was
‘evil’ or ‘selfish’’. (Participant 4)
‘I can deflect [thoughts] or side-step them, by
recognising them for what they are, just thoughts’.
(Participant 2)
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Mindfulness-Based Therapy
Coping and Stress Management
When not discussing the benefits of specific
mindfulness processes such as observation and
acceptance, two participants framed mindful-
ness as a general coping and stress management
strategy.
‘As far as OCD is concerned, it has allowed
me to manage the thoughts and actions’.
(Participant 3)
‘Takes my mind away from stress and can really
relax me’. (Participant 2)
Normalization
Two participants described finding the normalis-
ing aspects of intrusive thought psycho-education
which accompanied the mindfulness as helpful.
‘The knowledge that ‘normal’ people also have
these thoughts (but just don’t react to them) has
helped me’. (Participant 4)
‘It was extremely reassuring to learn that other
“normal” people have bizarre thoughts as well’.
(Participant 2)
Unhelpful Aspects of Mindfulness-Based Therapy.
Three participants could not identify any unhelp-
ful effects of mindfulness. However, one partici-
pant found that developing mindful awareness
could create early difficulties.
‘Once I became mindfully aware of OCD and
carrying out thoughts and rituals it seemed I did
nothing but them. It was quite overwhelming,
initially, to see how big a part of my life OCD
is’. (Participant 2)
This participant also found that practical con-
straints could restrict mindfulness use.
‘Being quite detailed, it takes me awhile to get into
a grounding exercise and there sometimes just
isn’t time available’. (Participant 2)
DISCUSSION
The mindfulness-based therapy trialled in this
research aimed to improve participants’ experience
of obsessive–intrusive thoughts, with a reduction
in associated distress. All participants’ obsessions
scores on the YBOCS improved immediately post-
therapy, with total YBOCS scores ranging from 8
Copyright © 2009 John Wiley & Sons, Ltd.
263
to 13 and falling below clinical levels. One par-
ticipant did not maintain this full improvement
at 2 months, whereas the other two participants
maintained or improved these gains. Overall,
participants were positive about the mindful-
ness-based therapy in their feedback, highlight-
ing observation and awareness, acceptance and
non-suppression of thoughts, managing TAF, and
coping and stress management as valuable mind-
fulness components. Additionally, normalization
was identified as a helpful aspect of the psycho-
education included. However, a few unhelpful
aspects were reported by one participant.
These results are broadly comparable to a recent
study of a more time-intensive 17-session ERP
therapy for OCD as an adjunct to pharmacotherapy
where the mean YBOCS score at treatment comple-
tion was 14.2 (Simpson et al., 2008). However, it is
acknowledged that pre-treatment symptom sever-
ity as indicated by a mean score on the YBOCS
of 25.4 was greater in the Simpson et al. (2008)
study compared to the present research where par-
ticipant YBOCS total scores at initial assessment
ranged from 16 to 21. The present research did not
manage to demonstrate the magnitude of YBOCS
score improvement found in a trial of CBT for OCD
by Freeston et al. (1997), where the mean post-
therapy total YBOCS score was 7.2. However, in
the Freeston et al. (1997) research up to 40 sessions
of therapy were offered compared to the 6 sessions
of mindfulness-based intervention provided in
the present study. It is possible that participants
could have made further improvements if the
mindfulness-based intervention in the present
research had continued for longer.
It is difficult to comprehensively compare the
extent of mindfulness skill acquisition by par-
ticipants in the present research to those with
mindfulness experience in other studies as full
KIMS scores have been presented as outcome or
process measures in a limited number of published
papers. However, a recent mindfulness-based six-
session group intervention for insomnia produce
an average two point increase in KIMS scores
(Ong, Shapiro, & Manber, 2008) compared to an
increase of 49, 19 and 20 points for Participants
1–3, respectively. In the present study participant’s
KIMS total scores following mindfulness interven-
tion were found to be 15 to 23 points greater than
KIMS total scores reported by Thai Theravada
Buddhist monks with over 14 years average daily
mindfulness meditation experience (Christopher
& Gilbert, 2007). However, in the Christopher and
Gilbert (2007) study mindfulness-naive students
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264
scored higher on both the KIMS and the MAAS
(Brown & Ryan, 2003) than the monks, suggest-
ing that these two Western measures may not
be assessing mindfulness as practiced in Eastern
Buddist traditions.
The processes underpinning YBOCS measured
clinical improvement appeared to vary across par-
ticipants in this research. For participants1 and 2,
as hypothesized, significant improvements from
baseline and control intervention levels of TAF,
thought-suppression and distress daily ratings
were demonstrated alongside clinical improve-
ment in the YBOCS. However, despite showing
substantial clinical improvement on the YBOCS,
Participant 3 did not improve beyond baseline
levels of TAF and distress ratings. However, he did
verbally report reductions in thought suppression
and frequency stating that by the end of therapy he
experienced barely any intrusive thoughts, but that
when these infrequently occurred they remained
believable and distressing. Anecdotally he attrib-
uted the reduction in intrusive thought frequency
to using mindfulness as an alternative to a thought
suppression strategy.
The fact that the processes underlying clinical
improvement demonstrated in the daily ratings
measures appeared to differ for Participant 3 com-
pared to Participants 1 and 2 may not be surprising
when considering the frequently noted heteroge-
neity of OCD (Mataix-Cols, Rosario-Campos &
Leckman, 2005). Research has attempted to rec-
oncile this by identifying subtypes relating to
different clinical presentations; for example, sym-
metry/hoarding, contamination/cleaning and
pure obsessions subgroups (Baer, 1994). However,
variability in the subgroup organizations identi-
fied across different studies (e.g., Summerfeldt,
Richter, Anthony, & Swinson, 1999; Mataix-Cols,
Rauch, Manzo, Jenike, & Baer, 1999) possibly sug-
gests that symptom-based categorizations do not
adequately account for observed heterogeneity
in those receiving a diagnosis of OCD. The vari-
ability in the processes that appear to relate to
clinical improvement in the present research pos-
sibly suggests that a formulation-based approach
to intrusive thoughts may be a more useful way
of understanding the heterogeneity seen in OCD.
Such an approach could attempt to understand the
relevance of processes such as TAF and thought
suppression in the maintenance of each indivi-
dual’s difficulties.
If the processes underlying each individual’s
experience of OCD may vary then the suitability
of mindfulness and the emphasis placed on sepa-
Copyright © 2009 John Wiley & Sons, Ltd.
M. Wilkinson-Tough et al.
rate components of mindfulness for each individ-
ual may also need to differ. Qualitative feedback
from the present research suggests that different
participants valued different components of mind-
fulness. Equally, the drop-out of one of the five
recruited participants early in mindfulness train-
ing may suggest that such an approach did not
suit this individual. Teasdale, Segal, and Williams
(2003) emphasize the importance of formulation
when applying mindfulness, rather than using
it as a generic approach to coping with distress.
Therefore, when considering the future potential
of mindfulness training for people experiencing
obsessions and compulsions it may be important
to develop ways to assess who may or may not
benefit from such an approach and what processes
should be targeted for each individual. Moreover,
this suggests that a creative approach to future
research in this area will be needed as designs that
do not reflect the potential individual variability in
the processes underlying obsessions and compul-
sions may be less likely to produce valid or clini-
cally useful results.
As the present research focuses on obsessive–
intrusive thoughts, the possibility of mindfulness
being an effective intervention for compulsive
behaviours has not been fully explored. Although,
Participant 1 demonstrated improvements in
YBOCS measured compulsions, Participants 2
and 3 did not show substantial improvement of
such behaviours post-therapy. Shapiro, Carlson,
Astin, and Freedman (2006) suggests that mind-
fulness develops self-regulation through purpose-
fully directed non-judgemental attention, reducing
automatic responding to avoid unwanted expe-
riences such as anxiety. As such, mindfulness
training could enhance awareness of compulsive
neutralization of anxiety and provide a way to sit
with uncomfortable internal experiences rather
than avoid them (Fairfax, 2008). It may be that
increased attention to compulsive behaviours in
mindfulness-based therapy could produce clini-
cal improvements similar to that demonstrated by
Twohig et al.’s (2006) ACT intervention for OCD,
which incorparated mindfulness alongside other
techniques and used self-rated compulsive behav-
iours as a primary outcome measure.
The present research has several clear meth-
odological limitations. Although results suggest
that a mindfulness-based approach to obsessive–
intrusive thoughts may be valuable, with such
small participant numbers and a relatively short
follow-up period few claims can be made about
the generalizability and long term benefits of this
Clin. Psychol. Psychother. 17, 250–268 (2010)
DOI: 10.1002/cpp
Mindfulness-Based Therapy
intervention. The daily ratings scales used may be
limited as they rely on single item measures of
internal events. One of these measures (the thought
suppression measure) was created specifically for
the research and, in the case of one participant, was
clearly invalid and discarded; as such, suppression
ratings should be interpreted very tentatively for
the other two participants.
It is possible that using alternative measures
could have yielded different results in the present
study. Although participants mindfulness skills
appeared to increase with the mindfulness inter-
vention, as measured by the KIMS, assessment
using an alternative mindfulness measure may
have provided a different picture. The KIMS has
the advantage of measuring four different compo-
nents of mindfulness, compared to measures that
provide a uni-dimensional score such as the MAAS
(Brown & Ryan, 2003) and the FMI (Buchheld et al.,
2001). However, there is little research to demon-
strate how KIMS scores are affected by meditation
experience having been developed with a student
sample. Equally, the KIMS has been criticized for
not representing all facets of mindfulness (Walach,
Buchheld, Buttenmuller, Kleinknecht, & Schmidt,
2006). It is possible that by using either the MAAS
or the FMI changes in mindfulness skill may have
been more or less evident.
It is possible that investigation of additional pro-
cesses potentially underlying therapeutic outcome
may have enhanced understanding of this new
intervention further. For example, use of therapeu-
tic alliance measures could have tested Fairfax’s
(2008) proposal that the non-judgemental stance
of mindfulness could increase self-disclosure
and enhance the therapeutic relationship. Equally,
acceptance was highlighted as an important
component of the mindfulness-based intervention
by the qualitative analysis of participant feedback
yet was measured in a very limited way through
the KIMS Non-Judgement subscale. Future
research into the use of mindfulness with obses-
sive–intrusive thoughts could consider using the
Acceptance and Action Questionnaire (AAQ;
Hayes et al., 2004) to further explore this concept.
Although the majority of the research interven-
tion consisted of mindfulness practice, a small
amount of psycho-education was also used. There-
fore, the relative contributions of mindfulness and
psycho-education to the clinical improvements
seen cannot necessarily be disentangled. However,
it could be argued that improvements attributable
to psycho-education are likely to be reflected in
a sharp change in daily ratings on gaining this
Copyright © 2009 John Wiley & Sons, Ltd.
265
information in the first mindfulness-based therapy
session. Instead of this, daily ratings graphs gener-
ally reflected the more gradual decrease that you
would expect to see with more measured mindful-
ness skill acquisition.
The present study benefits from the use of a
relaxation control condition. However, the order of
presentation of mindfulness and relaxation could
not be counterbalanced as participants would
not be able to unlearn knowledge of mindfulness.
Additionally, for practical and ethical reasons, par-
ticipants did not receive the control intervention
for as long as the mindfulness training, although
participants’ daily ratings did stabilize during the
relaxation phase before progressing, suggesting
that any gains made beyond those observed in the
control intervention were attributable to the spe-
cific effects of mindfulness. However, the possibil-
ity still remains that the significant improvements
demonstrated during mindfulness compared to
the relaxation control were attributable to length
and order of presentation of the two interventions.
Finally, the therapist could not be blinded as to
which intervention was intended to be ‘active’ and
which was a control; however, the daily practice
audio-recordings, which formed a large part of
the intervention, were reviewed independently to
ensure no preference for the mindfulness exercises
above the relaxation control was conveyed.
In conclusion, despite methodological limita-
tions, results of the present research provide some
restricted preliminary quantitative and qualita-
tive evidence that a mindfulness-based approach
may be valuable for people experiencing intru-
sive obsessive thoughts. Interestingly, the use of
simple, brief daily practice of 10 minutes and a
limited number of therapy sessions enabled all
participants to reduce their obsessions and com-
pulsions to below clinical levels. Future research
could further explore what, on first investigation,
appears to be a promising approach. Such research
could consider group delivery or further delinea-
tion of the processes underlying clinical change.
In any future research it may be important to con-
sider the possibility that, due to the heterogeneity
of OCD, the factors producing clinical change may
vary across different individuals.
ACKNOWLEDGEMENTS:
The authors would like to thank Iain Davidson,
Kate Gleeson, Jo Timms, Hannah Frith and Reg
Morris for their contributions to this research.
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DOI: 10.1002/cpp
266
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