Why ACT and Other Mindfulness-Based Interventions are Not the Solution to ‘Pure O’

I’m sure this article will elicit some harsh responses from people who use ACT to treat ‘Pure O.’  I did not write this article to cause a stir.  I wrote it because I feel compelled to speak out against an approach that I believe hurts patients. Please read with this in mind, and feel free to reach out to me with any constructive feedback, questions, or other input.  If I have misunderstood or mischaracterized any aspect of ACT, this was unintentional and I would appreciate being disabused of my mistaken understanding.  With that being said…

Mindfulness and mindfulness-based interventions such as ACT are often presented as a treatment for ‘intrusive thoughts.’  As will be discussed in this article, I believe that as an intervention for this issue, mindfulness and ACT are at best unnecessary and at worst quite harmful.

Mindful Rumination

Before getting into the problems inherent in these approaches, it bears discussing a separate problem that often coincides and interacts with them.  This problem is the failure to distinguish between a thought that occurs to you, or a question that exists — neither of which is controllable — and any form of engagement with that thought or question (i.e., compulsive rumination) — which not only can be controlled, but absolutely must be controlled as part of treatment.

When patients with ‘intrusive thoughts’ are encouraged to use mindfulness, but aren’t fully clear on the above distinction, they typically end up mindfully ruminating.  In other words, they try to notice and accept the thoughts that comprise their compulsive rumination.  Here’s what this might look like:

“I notice a memory coming up of feeling something towards that guy… I notice the thought that I might be gay because I thought that guy was attractive… I notice the thought that I probably am not gay because I enjoy being intimate with women… I notice that memory coming up of the time I noticed how cute my teacher was… I notice the thought coming up that people have always said I’m sensitive…”

Mindful rumination is just as harmful as regular rumination.  It is the functional equivalent of someone mindfully washing their hands over and over.  Thus, teaching a patient about acceptance, defusion, mindfulness, letting thoughts be there, pink elephants, white bears, etc. before teaching them to identify and eliminate compulsive rumination is extremely harmful.  It is an accidental endorsement of compulsion.  It is iatrogenic.  It is a humongous problem.

But let’s imagine that this problem were out of the way, even though it is not out of the way in the real world.  Let’s assume the clinician has drawn a razor sharp distinction between the thought that occurs to you and any engagement with it.  Does mindfulness work then?

An Overall Problem with the Overall Approach

An overarching problem with using mindfulness, in any way, for intrusive thoughts is that it reinforces the following misguided beliefs:

(1) That you have to DO something in order to stop ruminating, when in reality you have to NOT DO something.  Instead of looking for an antidote, just stop eating poison.

(2) That rumination is an external force that needs to somehow be held at bay, rather than something the person themselves is doing and can stop doing.

Not ruminating, when done correctly, is effortless.  All that is required is the clear decision to stop doing it.  No trick or strategy can ever replace that decision, nor is any trick or strategy necessary.

Specific Problems with Specific Approaches

In addition to this overarching problem, there are specific additional problems with specific mindfulness-based interventions.  What follows is a list of several mindfulness-based interventions for compulsive rumination, and the problems with each one:

“When you find yourself ruminating, just come back to the present moment.”

1. The main problem with this strategy is that you can’t be mindful all the time, but you do need to stay out of rumination all the time.  Therefore telling someone to use mindfulness to stop ruminating isn’t going to solve the problem, even if it works for a moment at a time.
2. Whether it’s intended to or not, this approach makes people think that the opposite of rumination is mindfulness, which is both wrong and confusing.  A person can be completely lost in other thoughts without being engaged in compulsive rumination.
3. Even though it sounds fancier, using mindfulness this way is functionally tantamount to distraction, which has the potential to backfire when used the wrong way.  For further discussion, see here.

Defusion; “It’s just a thought.”

1. This smacks of self-reassurance.  It’s basically a way of telling yourself that the thought doesn’t matter, isn’t real, doesn’t represent a real threat.
2. As anyone with OCD can tell you, it’s not just a thought.  It’s a feeling, an urge, an impulse, a complete visceral certainty that your worst fear is true.  
3. The person with OCD is not concerned about that thought or feeling or impulse, itself.  They are concerned with the question that it represents, and the terrifying, real-world implications and consequences of that question.  The idea that ‘it’s just a thought’ misses the mark in terms of what the experience of OCD is really about.

Mindful awareness; “Paying attention with openness, curiosity, flexibility and kindness.” -Dr. Russ Harris

The problem with this approach is that it encourages directing attention toward the thought, and directing attention toward the thought is a form of engagement with it that keeps a person aware of it.  For a more nuanced discussion of this issue, see here.

Some Additional Thoughts

What do people without OCD do when they have an uncomfortable thought that reminds them of an disturbing question that they don’t want to think about?  Do they come back to the present moment?  Do they direct playfulness and curiosity toward the thought or question?  Do they tell themselves it’s just a thought?  No.  You know what they do?  Nothing.  And that’s what people with OCD need to learn to do.

But despite all of the mindfulness-bashing above, I do actually think that mindfulness could be applied in a helpful way.  Here’s what that might look like:

“When a thought or question that concerns us arises in our consciousness, we feel the urge to engage with it, to solve it, to make it go away.  We can’t force the thought to leave our consciousness, but we can choose not to engage with it.  If we passively allow it to remain in consciousness (i.e., if we do nothing), without directing our attention toward it (i.e., if we do nothing), it will bother us far less, and eventually leave our consciousness.”

If this is how someone is using mindfulness, I’m on board.  But I would propose that using the word mindfulness is unnecessary to teach the above approach, and that using the term risks confusing patients who have inevitably come across some of the other mindfulness-based approaches discussed in this article, and will think we are encouraging them to use these.

If you are someone who has used a mindfulness-based intervention to treat your OCD and feel it has worked for you, I would love to hear from you.  But to be clear, ‘worked for you’ means you feel better, not that you’ve learned to accept feeling bad. If you’ve been told that learning to live with regular OCD symptoms is what effective treatment looks like, you may want to consider a different approach.