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Cognitive Therapy and Research
ISSN 0147-5916
Cogn Ther Res
DOI 10.1007/s10608-012-9503-2
Managing Obsessive Thoughts During
Brief Exposure: An Experimental Study
Comparing Mindfulness-Based Strategies
and Distraction in Obsessive–Compulsive
Disorder
Karina Wahl, Jan O.Huelle, Bartosz
Zurowski & Andreas Kordon
1 23
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ORIGINAL ARTICLE
Managing Obsessive Thoughts During Brief Exposure:
An Experimental Study Comparing Mindfulness-Based Strategies
and Distraction in Obsessive–Compulsive Disorder
Karina Wahl •Jan O. Huelle •Bartosz Zurowski •
Andreas Kordon
Springer Science+Business Media New York 2012
Abstract In mindful meditation, negative thoughts such
as obsessive thoughts are observed simply as mental events
that come and go, rather than as accurate reflections of
reality. This experimental study tested the efficacy of a
mindfulness-based instruction compared to distraction
during brief exposure to obsessive thoughts in obsessive–
compulsive patients. Thirty patients diagnosed with
obsessive–compulsive disorder were asked to listen to their
own obsessive thoughts through headphones during three
time phases: at baseline, during an experimental condition
and during a return to baseline. During the experimental
condition, they were instructed to deal with their obsessive
thoughts using either a mindfulness-based strategy or a
distraction strategy (random allocation). Results showed
that a mindfulness-based strategy reduced anxiety and urge
to neutralize from first to second baseline, whereas a dis-
traction strategy did not. Data offer initial evidence that
using mindfulness-based metaphors during brief exposure
with obsessive thoughts may be a useful alternative to
distraction.
Keywords Obsessive–compulsive disorder Exposure
Mindfulness Distraction Experimental study
Introduction
Exposure with obsessive thoughts using a recorded version
of the thought (‘‘loop tape exposure’’, Salkovskis 1983;
Salkovskis and Westbrook 1989) is the recommended
treatment for patients with obsessive–compulsive disorder
(OCD; Freeston et al. 1997). It can be combined with
in vivo exposure to specific situations if necessary
(Ladouceur et al. 1993; Freeston et al. 1997). Typically, it
is carried out under certain conditions (e.g., with the
instruction not to neutralize, lasting until the anxiety
decreases noticeably) in order to maximize habituation and
incorporation of correcting information (Foa and Kozak
1986), which are supposed to underlie the reduction of
anxiety during exposure.
Data from case and uncontrolled studies (e.g., Abra-
mowitz 2002; Hoogduin et al. 1987) and from a controlled
trial (Freeston et al. 1997) show that particularly patients
without overt compulsions (‘pure obsessionals’) are likely
to benefit from a combined treatment of loop-tape exposure
and cognitive restructuring. However, drop-out rates were
19–22 % in the Hoogduin and Ladouceur studies and the
authors argued that these might be accounted for by the
demanding processes of (loop tape) exposure. This raises
the question whether the conditions of exposure can be
varied so that it becomes more tolerable for patients and
maximizes the chances of anxiety reduction at the same
time.
Variations of exposure and their effects have been
studied in patients diagnosed with overt compulsive rituals
such as compulsive washing or checking. For example, Foa
et al. (1984) found that exposure without deliberate
blocking of rituals reduces anxiety but not the frequency of
compulsive rituals. Grayson et al. (1982,1986) compared
distraction and focused attention during exposure and
K. Wahl (&)
Department of Psychology, University of Hamburg,
Von-Melle-Park 5, 20146 Hamburg, Germany
e-mail: karina.wahl@uni-hamburg.de
J. O. Huelle
Universitaetsklinikum Eppendorf, Martinistr. 52,
20246 Hamburg, Germany
B. Zurowski A. Kordon
Department of Psychiatry and Psychotherapy,
Medical University of Luebeck, Ratzeburger Allee 160,
23538 Lu
¨beck, Germany
123
Cogn Ther Res
DOI 10.1007/s10608-012-9503-2
Author's personal copy
found that both conditions resulted in reduced subjective
and physiological anxiety during one exposure session.
However, habituation under distraction conditions did not
generalize to between session habituation. To our knowl-
edge, variations of loop tape exposure and their effects on
efficacy and tolerability have not been studied systemati-
cally yet.
Recently, it has been suggested that patients diagnosed
with OCD might benefit from mindful awareness during
exposure (Didonna 2009; Fairfax 2008; Hannan and Tolin
2005), thus making exposure less stressful and possibly
decreasing drop-out rates. Kabat-Zinn (1990) described
mindfulness as paying attention in a particular way: on
purpose, in the present moment, and nonjudgmentally. A
mindfulness mode of processing thus involves a nonjudg-
mental, accepting observation of an ongoing stream of
internal and external stimuli as they arise. Stimuli include
personal thoughts, also upsetting ones, which are perceived
simply as temporary mental events that come and go, rather
than as accurate reflections of reality. Empirical evidence
from case studies (Patel et al. 2007; Singh et al. 2004;
Wilkinson-Tough et al. 2010), from an analogue study
(Hanstede et al. 2008) and from a controlled trial (Twohig
et al. 2010) shows that mindfulness based interventions can
be effective in individuals bothered by intrusive thoughts
and patients diagnosed with OCD. These studies have
discussed and applied different aspects and interventions of
mindfulness during various stages of therapy.
In our view, a mindfulness-based strategy seems par-
ticularly suitable for the management of obsessive
thoughts during brief exposure. First, bringing deliberate
attention towards the obsessive thoughts might enhance
habituation processes, prolong their effects and generalize
to between session habituation (Grayson et al. 1982,
1986). Second, observing and describing thoughts in a
mindful way might stop individuals from giving in
automatically to thought suppression or neutralization,
thus fostering habituation processes further, as suggested
by Najmi et al. (2009). Third, metaphorical ‘letting go
experiences’ (Hanstede et al. 2008) such as imaging the
obsessive thought pass by like clouds in the sky might
change the short term meaning of the content of the
obsessive thoughts, as less threatening. This could initiate
an accepting attitude. Finally, in the long run, patients
diagnosed with OCD might develop a new relationship to
their obsessive thoughts, relating to them as transient
mental events and not as facts. This seems particularly
important in OCD, since cognitive theories of clinical
obsessions (e.g., Clark and Purdon 1993; Freeston and
Ladouceur 1997; Rachman 1997; Salkovskis 1985) posit
that the ways in which intrusive thoughts are interpreted
differentiates normal intrusions from obsessions. It seems
plausible to assume that the dysfunctional significance of
intrusions could be reduced by mindfulness through
continued practice (Baer 2003).
Mindfulness is a multidimensional construct and has
been integrated into Western clinical psychology with
varying operationalizations and degrees of complexity
(Brown et al. 2007). For this study the mindfulness
instruction was adapted from the ‘thoughts are not facts’
module of the mindfulness-based cognitive therapy for
depression (MBCT; Segal et al. 2002). Participants are
encouraged to view their thoughts as transient mental events
by bringing deliberate awareness towards them and
reminding themselves that thoughts are just thoughts and not
facts. Additionally, participants are instructed to use meta-
phors such as observing their thoughts like clouds moving
across the sky. The study is in line with other research
investigating the effects of an experimentally induced
mindful self-focus on emotional and cognitive processes
(e.g., Broderick 2005; Huffziger and Kuehner 2009; Marcks
and Woods 2005). In contrast to intensive mindfulness
intervention programs, the experimental manipulation of the
study presented here included a short induction period of
selected mindfulness elements only (e.g., an observing,
nonjudgmental state of mind). Importantly, this study does
not claim to capture the complex processes involved in
therapeutic mindfulness interventions.
Two recent studies have examined the effects of varying
strategies (thought suppression, acceptance, and focused
distraction) in the management of naturally occurring
obsessive thoughts. Najmi et al. (2009) investigated the
relative effectiveness of thought suppression, focused dis-
traction and acceptance on distress and frequency associ-
ated with obsessive thoughts in patients diagnosed with
OCD. While an acceptance based strategy reduced distress
significantly, thought suppression resulted in an increase in
distress. No significant changes were found for the focused
distraction strategy. Marcks and Woods (2005) demon-
strated that, in non-clinical individuals, an acceptance-
based strategy in response to personally relevant intrusive
thoughts resulted in a decrease in anxiety levels, whereas
thought suppression did not. Both studies monitored the
occurrence and distress of naturally occurring obsessive
thoughts. Our study extends these results by comparing a
mindfulness-based and a distraction strategy not in response
to naturally occurring obsessive thoughts, but during brief
exposure with obsessive thoughts via headphones. Our main
variables were anxiety and urge to neutralize.
The time of assessing the mindfulness effects is an
important issue. Since mindful awareness encourages
patients diagnosed with OCD to deliberately pay attention
to their obsessive thoughts and associated feelings, it seems
plausible that an immediate rise in anxiety occurs. How-
ever, the rise in anxiety should be followed by a decline at
a later time, when individuals let the thought pass by
Cogn Ther Res
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without appraising it or reacting upon it. If mindfulness
works by enhancing habituation, then a reduction in anxi-
ety should not only be observed within an exposure session
but also during a further exposure session (Grayson et al.
1982,1986). Therefore we chose a delayed time period of
renewed exposure after a short break to assess the main
effects.
The aim of the present experimental study was to
investigate the efficacy of a mindfulness-based strategy
compared to distraction during brief exposure to obsessive
thoughts. It was hypothesized that patients diagnosed with
OCD who had previously engaged in a mindfulness-based
strategy while listening to their own obsessive thoughts
would be less anxious and report a lower urge to neutralize
than those who had previously engaged in distraction.
Secondly, it was expected that the immediate effect of the
mindfulness-based instruction would be a rise in anxiety, as
opposed to a reduction in anxiety in the distraction
condition.
Materials and Methods
Overview
Thirty patients diagnosed with OCD were asked to listen to
their own obsessive thoughts through headphones during
three phases: at baseline, during an experimental condition
and during a return to baseline. During the experimental
condition, they were instructed to deal with their obsessive
thoughts using either a mindfulness-based strategy or a
distraction strategy (random allocation). Dependent vari-
ables were anxiety and urge to neutralize, which were
assessed on visual analog scales at three times points
within the three phases.
Participants
Thirty-six patients diagnosed with OCD were recruited at
an inpatient clinic specialized in cognitive behavioral
treatment of OCD. Patients were assessed by experienced
clinicians using the structured clinical interview for DSM-
IV axis i disorders (SCID-I; First and Gibbon 2004) and
were included if they met the following criteria: (1) primary
diagnosis of OCD, defined by DSM-IV (American Psychi-
atric Association 1994), (2) aged 18–65, (3) could report an
identifiable obsessive thought, (4) confirmed that listening
to their own intrusive thoughts through headphones in the
laboratory would cause them discomfort, (5) were not
acutely suicidal, (6) had no history of substance dependency
or psychotic symptoms, (7) had not already started with
exposure and response prevention interventions and, (8) did
not use any form of counting as a neutralizing ritual. Four of
the recruited patients did not meet inclusion criteria and two
patients (one of each condition) did not complete the
experimental procedure satisfactorily. As became evident
during the course of the experiment, one patient was suf-
fering from a specific animal phobia, which was activated
during the animal movie between assessment phases. The
second participant did not give any reasons for dropping out
of the experiment. Participants were randomly allocated to
the experimental (mindfulness-based coping) or control
(distraction) condition using sampling without replacement.
Table 1presents demographic characteristics and psycho-
pathology measures of the participants who completed the
experiment successfully. There were no significant differ-
ences in any of the participants’ characteristics (all
ps[.05) between the experimental and control condition
group. Additionally, initial anxiety levels (STAI-State;
Spielberger et al. 1983) did not differ between groups. In
each group, seven participants (46.7 %) were acutely
diagnosed with comorbid psychiatric disorders (mindful-
ness condition: five [33.3 %] patients with major depression
and two [13.3 %] patients with anxiety disorders; distrac-
tion condition: six patients [40 %] with major depression,
one [6.7 %] of whom was also suffering from three
additional anxiety disorders, and one patient [6.7 %]
with tic-disorder). Thirteen patients (86.7 %) were taking
Table 1 Characteristics of participants in the two experimental
groups
Measure Mindfulness
(N=15)
Distraction
(N=15)
M(%) SD M (%) SD
Age 30.67 10.93 39.73 13.36
Female (%) 60 40
Y-BOCS total 22.93 4.76 24.33 4.27
Y-BOCS compulsions 10.67 2.50 11.73 1.94
Y-BOCS obsessions 12.27 2.71 12.60 2.87
STAI-S 40.40 5.70 39.73 6.15
STAI-T 49.80 5.59 50.26 6.89
BDI 18.78 12.52 20.60 11.90
BAI 27.96 19.34 31.92 16.29
OCI-R total 27.47 11.86 30.86 12.89
OCI washing 4.53 4.87 5.93 4.93
OCI checking 5.73 4.11 6.73 4.13
OCI ordering 3.40 2.77 4.13 3.68
OCI obsession 7.53 3.54 8.40 3.58
OCI neutralising 3.67 3.81 2.80 3.00
OCI hoarding 2.60 2.87 2.86 3.22
Y-BOCS Yale–Brown Obsessive–Compulsive Scale, STAI-Sstate-
trait anxiety inventory, state, STAI-Tstate-trait anxiety inventory,
trait, BDI Beck depression inventory, BAI Beck Anxiety inventory,
OCI-Robsessive–compulsive inventory, revised
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anti-depressant medication in the mindfulness group and 14
(93.3 %) in the distraction group.
Measures
Standardized Questionnaires
A German version of the Yale–Brown Obsessive–
Compulsive Scale (Y-BOCS; Goodman et al. 1989; Hand
and Buettner-Westphal 1991) was used to assess OC
symptom severity. The Y-BOCS is a widely used semi-
structured clinician interview that includes a symptom
checklist and a 10-item symptom severity scale. After the
patient’s main obsessions and compulsions are identified
with the symptom checklist, the clinician rates the severity
of obsessions (items 1–5) and compulsions (items 6–10) on
a 5-point scale from 0 (no symptoms) to 4 (extreme) based
on the past week. The Y-BOCS has satisfactory psycho-
metric properties (Goodman et al. 1989; Storch et al. 2005)
and is considered the gold standard measure of obsessive–
compulsive symptoms.
The obsessive–compulsive inventory, revised (OCI-R;
Foa et al. 2002;Go
¨nner et al. 2008) is an 18-item self-
rating questionnaire of obsessive–compulsive symptom
severity in six domains: cleaning and washing, checking,
obsessions, neutralizing, hoarding and symmetry and order,
with good validity and reliability in the German version
(Go
¨nner et al. 2008).
The Beck depression inventory (BDI-II; Beck et al.
1996; Hautzinger et al. 1995) is a 21-item self-report
instrument intended to assess the severity of depressive
symptoms according to DSM-IV (APA 1994). For the
German version of the BDI-II (Hautzinger et al. 1995),
good internal consistency and test–retest reliability as well
as convergent and discriminant validity have been dem-
onstrated (Ku
¨hner et al. 2007).
The Beck anxiety inventory (BAI; Beck et al. 1988;
Margraf and Ehlers 2003) assesses somatic and cognitive
aspects of anxiety in a 21-item self-report questionnaire.
The German version showed good internal consistency and
temporal stability as well as convergent and discriminant
validity (Margraf and Ehlers 2003).
The state-trait anxiety inventory (STAI; Spielberger,
et al. 1983; Laux et al. 1981) is comprised of two scales,
with 20 items each, measuring trait anxiety and state
anxiety. The German versions of both scales demonstrated
high internal consistency, satisfactory test–retest reliability
and validity (Laux et al. 1981).
Visual Analog Scales (VAS)
Two 0–100 VAS were used to assess the dependent vari-
ables. Anxiety was rated on a 0–100 scale with 0 labeled
‘no anxiety at all’ and 100 labeled ‘the most anxious I have
ever felt’. Urge to neutralize was rated on a 0–100 scale
with 0 labeled ‘no urge to neutralize at all’ and 100 labeled
‘extreme urge to neutralize’.
Manipulation Check
Compliance with instructions and perceived helpfulness of
the coping strategies were assessed on 0–4 Likert scales. At
the end of the experiment, participants were asked to rate
(1) to what extent they managed to comply with the
instructions (0 =not at all and 4 =very much so) and
(2) how helpful they found the coping strategy in dealing
with the obsessive thoughts (0 =not at all and 4 =very
much so) during the baseline and separately for each of the
three instructions during the experimental condition, thus
resulting in four ratings per question. Percentage spent
neutralizing was assessed on a 0–100 scale separately for
each of the three phases (baseline, experimental condition
and return to baseline).
Procedure
Diagnostic evaluation (SCID-I and Y-BOCS) took place
within the first 2 weeks of the CBT inpatient treatment.
Participants were informed about the purpose of the study
(‘to investigate the effects of different coping strategies in
response to obsessive thoughts’) and written informed
consent was obtained from all participants prior to partic-
ipation. The study had been approved by the local ethics
committee of the University of Luebeck. Participants were
tested separately in a single experimental session in the
presence of the investigator. The experimental session
started with the identification of the most troublesome
obsessive thought. If necessary, the investigator and par-
ticipant elaborated on the obsessive thought so that it lasted
for about 10–15 s when spoken out loud. It was written
down on a form devised for this purpose. The average
duration of the intrusive thoughts did not differ between
experimental groups. Finally, participants read aloud the
written version of the intrusion verbatim onto an Apple
Macintosh Computer. Then they were asked to fill in the
STAI-State subscale. Before the experiment started, par-
ticipants were told that ratings of anxiety and urge to
neutralize would be taken at several points during the
experiment, and all participants were given practice in
rating the three verbal analog scales. Afterwards, partici-
pants were asked to put on the headphones and a power
point presentation was started. With the first slide, partic-
ipants were given the following instruction:
During the experiment, you will be listening to your
obsessive thoughts through the headphones. At the
Cogn Ther Res
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same time, you will be given written instructions on
the screen on how to respond to these thoughts. Once
in a while, I will ask you to rate how anxious you are
and how much you want to neutralize at this partic-
ular time.
Once these instructions had been given, the investigator
ensured that the participant fully understood what was
required of him or her, and the experiment continued.
During the subsequent baseline (5 min), the obsessive
thought was presented through headphones every 30 s,
while the participants were given the following written
instructions on a slide:
During the next 5 min, you may think about anything
you like.
Ratings of anxiety and urge to neutralize were taken at
three time points after 45 s, 2.45 and 4.45 min. A 5-min
interval followed in which an animal movie was presented
in order to prevent further cognitive processing of the
obsessive intrusion or instruction. The animal movie was
followed by the experimental phase (6 min) in which
repeated audio-presentation of the obsessive intrusion was
accompanied by either a mindfulness-coping instruction or
distraction. Ratings of anxiety and urge to neutralize were
taken 15 s before the next slide was presented, i.e., at the
three time points after 45 s, 2.45 and 5.45 min. Then the
animal movie continued for another 5 min and was fol-
lowed by a return to baseline phase (5 min) that was
identical to the first baseline. Once the power point pre-
sentation was finished, participants removed the head-
phones and were asked to complete ratings of compliance
and perceived helpfulness. Finally, participants filled in the
set of standardized questionnaires. They were then
debriefed and the experiment ended.
Mindfulness-Based Coping
The mindfulness-based coping and the distraction instruc-
tion were presented on three power-point slides each, with
a presentation time of 1 min for the first slide, 2 min for the
second slide and 3 min for the third slide. The instructions
for the mindfulness-coping strategy were adapted from the
module ‘Thoughts are not facts’ used in MBCT (Segal
et al. 2002). The instruction focused on deliberate non-
judgmental awareness of thoughts and a metaphorical
‘letting go’ experience. The three statements were as
follows (1) ‘Thoughts are thoughts and not facts.’
(2) ‘Become aware of your thoughts at this moment’
(3) ‘Let your thoughts pass by like clouds in the sky.’
These three instructions had been rated most helpful in
pilot studies. Content validity of the mindfulness-based
coping strategy was determined by expert ratings.
Distraction
The three distraction instructions were as follows (1) ‘At
this moment your thoughts are causing you distress.’
(2) ‘Distract yourself from your thoughts.’ (3) Silently count
backwards in sevens from 700, i.e., 700, 693, 686 …’.
Results
Experimental Condition
In order to get more reliable measures of anxiety and urge
to neutralize, data were averaged for the three time points
during each phase. A 3 92 mixed-model ANOVA with
phase (baseline, experimental condition, return to baseline)
as the within-subject factor and experimental condition
(mindfulness vs. distraction) as the between subject factor
was conducted on anxiety and urge to neutralize. Alpha
was set at a=.05. To explore significant interactions,
results were followed up with ttests for dependent vari-
ables. Descriptive statistics of the original scores by phase,
time point and experimental condition are shown in
Tables 2and 3. For anxiety, there was a main effect of
phase, F(2, 56) =20.68, p\.001, modified by a signifi-
cant interaction of phase and experimental condition,
F(2, 56) =6.77, p\.01. For individuals in the mindful-
ness condition, anxiety declined significantly from baseline
(M=57.78, SD =16.41) to return to baseline (M=
28.67, SD =17.81), t(14) =7.25, p\.001, and from
experimental condition (M=47.78, SD =25.19) to return
to baseline, t(14) =6.67, p\.001. For individuals in the
distraction condition, reduction in anxiety between baseline
(M=50.23, SD =25.65) and return to baseline (M=
42.22, SD =27.45) and between experimental condition
Table 2 Means and standard deviations for anxiety (0–100) by
phase, time point and experimental condition
Descriptives/
time (min)
Mindfulness-
based
instruction
Distraction
MSDMSD
Baseline (5 min) 0.45 56.67 21.27 47.33 27.64
2.45 61.33 15.06 52.00 27.83
4.45 55.33 22.00 51.33 26.69
Experimental
condition
(6 min)
0.45 44.67 23.56 46.67 26.90
2.45 54.00 27.98 48.67 26.42
5.45 44.67 27.48 46.00 30.43
Return to
baseline
(5 min)
0.45 33.33 21.93 42.00 27.05
2.45 28.67 18.07 44.00 28.23
4.45 24.00 16.39 40.67 28.65
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(M=47.11, SD =26.33) and return to baseline were
smaller and not significant, t(14) =0.93, and t(14) =
1.22, ns, respectively. For urge to neutralize, there was a
similar pattern of results: a significant effect of phase, F(2,
56) =10.22, p\.001, was modified by a significant
interaction of phase and experimental condition, F(2,
56) =3.24, p\.05. Specifically, individuals who used the
mindfulness strategy experienced a decrease in urge to
neutralize from baseline (M=47.11, SD =23.80) to
return to baseline (M=26.00, SD =17.92), t(14) =3.62,
p\.01, and from experimental condition (M=
43.78, SD =27.02) to return to baseline, t(14) =4.39,
p\.01. In contrast, individuals who used the distraction
strategy, did not experience a significant decline in urge to
neutralize, neither from baseline (M=46.00, SD =30.56)
to return to baseline (M=39.78, SD =31.33), t(14)
=.41, ns, nor from experimental condition (M=44.22,
SD =31.61) to return to baseline, t(14) =1.63, ns. Fig-
ures 1and 2shows the means and 95 % confidence inter-
vals for self-reported anxiety and urge to neutralize by
phase and experimental condition.
Manipulation Check
Ttests for independent samples were calculated to analyze
differences in compliance with instructions and perceived
helpfulness of the instructions. There were no significant
differences between the two experimental conditions in any
of the compliance variables (all ps[.05). Additionally,
instructions were seen as equally helpful in both experi-
mental conditions (ps[.05), except for the first slides of
the experimental phase (‘Thoughts are thoughts and not
facts.’ vs. ‘At this moment your thoughts are causing you
distress.’). Participants in the mindfulness-based instruc-
tion (M=2.87, SD =1.36) found the sentence more
helpful than those in the distraction condition (M=.93,
SD =.96), t(22) =-4.51, p\.001. Finally, percentage
of time spent neutralizing the obsessive thought during
each time phase did not demonstrate any significant dif-
ferences between experimental and control group
(ps[.05). The average time percentage spent neutralizing
was low in both groups (M=22.22, SD =11.97 for the
mindfulness condition, M=36.94, SD =11.9 for the
distraction condition).
Additional Analyses
To test whether there was an initial increase in anxiety
levels in the mindfulness condition as opposed to a
reduction in anxiety levels in the distraction condition, a
392 mixed-model ANOVA for the three time points
within the experimental condition was conducted on anx-
iety, with time points (0.45, 2.45, and 5.45) as the within-
subject factor and experimental condition (mindfulness vs.
Table 3 Means and standard deviations for urge to neutralize
(0–100) by phase, time point and experimental condition
Descriptives/
time (min)
Mindfulness-
based
instruction
Distraction
MSDMSD
Baseline (5 min) 0.45 45.33 26.96 46.00 31.58
2.45 48.67 25.03 46.67 32.22
4.45 47.33 26.58 45.33 32.92
Experimental
condition (6 min)
0.45 41.33 23.26 46.00 30.43
2.45 49.33 32.40 44.67 32.48
5.45 40.67 28.40 42.00 35.70
Return to baseline
(5 min)
0.45 30.00 21.04 40.00 33.17
2.45 25.33 18.07 40.67 31.50
4.45 22.67 17.51 38.67 30.91
Fig. 1 Mean anxiety and 95 % confidence intervals across phases by
experimental condition
Fig. 2 Mean urge to neutralize and 95 % confidence intervals across
phases by experimental condition
Cogn Ther Res
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distraction) as the between subject factor. If predictions
were correct, anxiety should have increased during the
presentation of the second slide in the mindfulness condi-
tion (‘Become aware of your thoughts at this moment.’)
and declined during the presentation of the second slide in
the distraction condition (‘Distract yourself from your
thoughts.’). This would lead to a significant interaction of
time point and experimental condition. Table Two shows
the means and standard deviations per time point and
condition. Although the means show a marked rise in
anxiety at time two in the mindfulness condition relative to
the control group, no significant interactions or significant
main effects were evident (all ns. at a=.05). To assess the
possibility that we had inadequate power to detect a 3 92
interaction—given our sample size, a medium effect size,
and an a=.05—we found that power was .63. Thus, we
may have had insufficient power to detect a medium-sized
effect.
Discussion
The aim of this study was to investigate the efficacy of a
mindfulness-based strategy compared to distraction during
brief exposure to obsessive thoughts. As predicted, par-
ticipants experienced a greater decline in anxiety and urge
to neutralize after having engaged in a mindfulness-based
strategy than those who had engaged in distraction. Thus, it
appears that deliberately focusing on one’s obsessive
thoughts and then imagining these passing by like clouds in
the sky, is an effective way of dealing with the accompa-
nying anxiety and urge to neutralize when these thoughts
are presented a short time later without any explicit
instructions as to how to deal with them.
Results are unlikely to be accounted for by different
levels of compliance with the instructions between groups,
since there were no significant differences between groups
regarding compliance measures. Additionally, participants
rated the instructions as being equally helpful in both
groups, with the exception of one introductory instruction,
which was found to be more helpful in the mindfulness
group than in the distraction group. However, an additional
analysis demonstrated that there were no differences
between the groups in either anxiety or urge to neutralize
immediately after presenting this particular introductory
slide in the experimental condition [anxiety: t(28) =.21,
ns, urge to neutralize: t(28) =.47, ns]. Therefore, it
appears unlikely that differences in perceived helpfulness
of the introductory slide in the experimental period caused
the differences between groups at return to baseline
The mechanisms of change through which a mindful-
ness-based strategy reduces anxiety and urge to neutralize
during brief exposure can only be speculated upon. It is
possible that focused attention towards the obsessive
thoughts was the moderating factor and facilitated habit-
uation processes. We hypothesized that focused attention
towards the obsessive thoughts in the mindfulness group
would result in an initial rise in anxiety, followed by a
reduction. This prediction was not confirmed. However,
the study may have had insufficient power to detect
medium size effects and conclusions about the course of
anxiety would be premature. In the present study, group
differences in anxiety reduction are unlikely to be
accounted for by different levels of neutralizing, since
percentage time spent neutralizing during any phase of the
experiment did not differ significantly between groups.
One additional mechanism of change remains increased
‘letting go capacity’ in the mindfulness group through the
use of metaphors (Hanstede et al. 2008). ‘Letting go’
might have decreased the risk of attaching significance to
the thought, increasing its acceptance. It remains to be
seen in future studies if certain aspects of mindfulness-
based strategies (e.g., focused attention, accepting obser-
vation, particular metaphors) are associated with particular
mechanisms of change and which are most useful during
brief exposure.
Data are consistent with results by Grayson et al. (1982,
1986), who showed that focused attention but not distrac-
tion during exposure generalized to between session
habituation. Data are also in line with previous research
showing that exposure alone (without explicitly blocking
compulsive rituals) leads to a reduction in anxiety (Foa
et al. 1984). Our data replicate and extend findings by
Marcks and Woods (2005) and Najmi et al. (2009), who
investigated the management of naturally occurring intru-
sive thoughts in the laboratory. In both studies, the use of a
mindfulness-based strategy had an immediate beneficial
effect (reduction in anxiety) in healthy individuals (Marcks
and Woods 2005) and also in patients diagnosed with OCD
(Najmi et al. 2009). Our results extend these findings by
showing that individuals also profit from a mindfulness-
based strategy when applied during brief exposure to
obsessive thoughts.
Clinical implications of these findings include consid-
erations of how mindfulness-based strategies can be best
integrated into empirically validated therapy for patients
diagnosed with OCD. The study suggests that conditions of
loop tape exposure can be varied in such a way that
mindfulness elements are added and the explicit instruction
to prevent neutralizing can be omitted. If our results were
replicated and found to have a lasting effect, they might be
incorporated into other exposure interventions, particularly
for patients without overt compulsions, in order to reduce
drop-out rates. Additionally, it can be discussed whether
patients might use mindfulness-based strategies in response
to their naturally occurring thoughts, or as a supplementary
Cogn Ther Res
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strategy for relapse prevention when obsessive thoughts
re-occur.
Limitations of the current study should be taken into
consideration. Pilot work and previous studies (Grayson
et al. 1982,1986; Salkovskis et al. 2003) have demon-
strated that distraction during exposure is a powerful
mechanism that results in short term anxiety reduction. It
could be argued that applying metaphors such as clouds in
the sky simply act as distraction from the immediate dis-
tress of the thoughts. Therefore, we chose a counting
backward task as an appropriate control, since it is a cog-
nitively demanding task that distracts the person to roughly
the same degree as a mindfulness-based strategy would.
However, if the mindfulness instruction did not distract
participants, they performed more exposure to their
obsessional thoughts than participants in the distraction
condition. In this case the study was not designed to answer
questions about the efficacy of mindfulness. Any conclu-
sions about the efficacy of mindfulness could be explained
in terms of the effects of exposure. Whether a mindfulness-
based instruction is better than brief exposure alone can
only be answered in future studies including a third control
condition with exposure only. Second, only short term
effects of the mindfulness-based instruction were assessed,
whether these last cannot be concluded. Future studies with
three groups (mindfulness, distraction and listening to the
thought without any instructions) and a later assessment of
the effects (e.g., 1 day later) are needed in order answer
these questions. Further methodological weaknesses
include the exclusive reliance on subjective reports of
anxiety and urge to neutralize on VAS. Although the use of
such ratings is typical in experimental studies investigating
psychopathological processes, future research should
incorporate ratings that possess good psychometric prop-
erties. The sample size was small and might compromise
generalizability of results.
Finally, it should be emphasized again that implement-
ing brief aspects of mindfulness in experimental studies is
not representative of the complex multi-facetted construct
of mindfulness, which is typically integrated into an
intensive training, including mindful meditation practice
over several weeks. We think that—if at all—mindful
meditation is only an alternative to cognitive restructuring
for changing faulty appraisals of obsessive thoughts in case
it could be achieved through continued intensive practice.
Data offer initial evidence to support the idea that a
mindfulness based strategy during brief exposure might be
advantageous compared to a distraction strategy. Results
are in line with studies finding preliminary evidence of the
effectiveness of mindfulness and acceptance-based inter-
ventions in the reduction of OC symptoms (Hanstede et al.
2008; Patel et al. 2007; Singh et al. 2004; Twohig
et al. 2010; Wilkinson-Tough et al. 2010) and a recent
meta-analysis on the effects of mindfulness-based therapy
on anxiety and depression (Hofmann et al. 2010). Ulti-
mately, it is hoped that knowledge provided from this study
and future research may result in significant clinical
implications relevant to cognitive behavioral therapy.
Acknowledgments We are grateful to Johanna Schriefer and
Dr. Bernhard Osen for their help with data collection.
Conflict of interest None.
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