Clinical Handbook of Mindfulness (57 page)

use of this memory could neutralize the doubt activation, but these patients

are not able to validate this information.

To validate
one’s own perceptive experience means that one considers it

as real and objective: the awareness of the perceptive experience is hierarchi-

cally superordinate in the activation of the emotions and the behavior of an

individual. For example, if after leaving their home, people wonder whether

they have switched off the light or not, they may immediately recover the

memory of the visual experience of seeing a dark room or recall a vision of a

finger as it presses down on the light switch. Although the image may not be

perfectly clear, such a recollection is usually sufficient in itself to prevent the

activation of doubt. In obsessive patients as well, and especially in those with

good insight, we may presume that a clear memory of sensory experiences

(visual, auditive, tactile, etc.) is present in the episodic memory store, the

awareness and use of which would allow them to see their recurrent doubts

as groundless. However, these patients are unable to validate the information

available to them. The patient’s experience would thus in fact eventually be

relegated to a secondary position with respect to the obsessive doubt. The

patient may for example say, “I know I turned off the tap. I remember doing

it, but I am not absolutely certain that I did and I really need to be sure!” This

type of phenomenon only occurs when the patient has to face a situation that

can be associated in some way with the feared event. Moreover, its occur-

rence is facilitated by a dysfunctional evaluation of the
gravity
of the event,

rather than its likelihood. Consequently, an event can be evaluated by the

subject as being so “serious” (even if highly unlikely) that even the slightest

risk of its occurrence is unacceptable. This lack of confidence in one’s senso-

rial experience is hypothesized to be linked to a fear found in OCD patients –

should a personal error actually occur – of being excluded, marginalized, and

humiliated by their social group
(Guidano & Liotti, 1983;
Didonna, 2003,

2005).
A mindfulness-based treatment would thus have an important influ-

ence on the capacity of obsessive patients to validate the recollection and

awareness of their perceptual experience moment by moment. In this way,

the practice of mindfulness would serve as an antidote to the activation of

obsessive ideation, thereby managing to neutralize pathological doubts.

One of the problems in OCD sufferers is that in anxiety-evoking situations

and during obsessive crises, they may very well enter in a different state of

mind. Insight into the unreasonable or senseless nature of a person’s obses-

sions is situation bound
(Kozak & Foa, 1994;
Steketee & Shapiro
,
1995).
In fact, in clinical practice it has often been observed that the level of insight

is lowest in OCD patients during critical situations compared with “normal,”

nonthreatening conditions. For this reason these patients might benefit from

cultivating a regular mindfulness practice, which has the effect, among the

others, of stabilizing and normalizing one’s states of mind and metacognitive

processes (see also Chapter 4 of this book).

204

Fabrizio Didonna

A Mindfulness-Based Technique: The Perceptive

Experience Validation Technique (PEV)

Trust is intimately connected to the correspondence between our perceptions

and reality.

–
Matthieu Ricard

The hypothesis illustrated in the previous section forms the
rationale
of

a therapeutic technique called the Perceptive Experience Validation (PEV).

This technique is aimed at training OCD patients, in particular checkers,

to pay attention mindfully to their own perceptive experience and to
val-

idate
as much as possible the memory and consciousness of it, using them

as an “antidote” against the activation of obsessive ideation. As was stated

above, during obsessive crises, patients’ information processing skills can

be compromised. They often experience significant difficulties in believing

their own memory of the perceptual experiences they have had. Normally,

OCD patients who don’t have a totally incapacitating disorder and who have

good insight also have good awareness of their decision making processes,

successfully making decisions numerous times each day in situations uncon-

nected with the disorder. To accomplish this, they must be fully aware of the

perceptual information that informed those decisions. The problem arises in

situations that evoke anxiety. In such situations, OCD patients are not able to

validate (or are not used to validating) their perceptions and cannot, there-

fore, fight the doubt, which eventually takes over.

Based on this hypothesis, the author
(Didonna, 2003, 2005)
developed a

procedure whose goal is to help patients to validate their perceptual experi-

ence during critical situations in order to credit this memory as objective and

real, and consequently, to minimize the importance of the doubt. The basic

idea, supported by clinical experience with dozens of clinical cases, is that

helping and training patients to pay attention to the ongoing stream of their

own experience in a mindful way and to validate it continuously can func-

tion as an
antidote
to the doubt. This initially takes place during the session

and the patient learns to develop a continuous and persistent habit to do the

same in vivo, first in normal (non-anxiety inducing) and then in critical situ-

ations. This activity may favor a reduction in or elimination of the deficit in

working memory and the
self-invalidating
cognitive bias. It is hypothesized

that a regular practice of a mindful, sustained attention to ordinary stimuli

during daily life, and actively giving those perceptions a clear and intentional

validation, can also create an improvement in the self-regulation of attention.

The technique is a process involving several different steps (see

Figure 11.2). The first one is to have the patients write a precise description

of an intrusive thought (doubt, obsession, image) they would like to work

on, and indicate how convinced they are (%) that the feared event will hap-

pen, has happened, how serious it is, or that they could be responsible for

it, and the level of discomfort or anxiety they experience thinking of it (0–

100). The patients are then asked to divide the paper into two columns. On

the left, they are to write down all of the information they remember about

their perceptive experience in a given situation that are incompatible or con-

flicting with the obsessive doubt (e.g., I
saw
that the window was closed).

On the right side of the paper, the patients are to write down anything and

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

205

everything that keeps the obsessive doubt active (inferences, suppositions,

hypotheses, selective reasoning, etc.) and that are not in any way based on

their experience (e.g., “I could have done it without realizing it”). It is impor-

tant that the patient understand that they are not to write on the left-hand

side anything that comes from external reassurances or any rituals that would

just be reinforced by being placed there. The next step has two aspects: On

the one hand, there must be an intervention of
validation of the percep-

tive experience
of the patients (the left-hand side). The therapist confirms

through verbal and non-verbal behavior that he/she believes that what the

patient claims he/she has perceived is real, objective and indisputable. On

the other hand, the therapist has to try to help the patients learn to observe

the experience in a mindful way and to
self-validate
the experience, not only

during a session, but more importantly, outside as well. This will automati-

cally, and often immediately, lead the patients to place less importance on the

elements that “feed” the doubt. One sentence often used with OCD patients

in order to help them in this process is “Your senses don’t lie.”

Indeed, following a series of exercises, these elements (on the right side

of the paper) will tend to be less and less present. It is important that the

patients understand that they shouldn’t put too many perceptive elements

on the left-hand side of the page since this would lead to useless ruminating

and be counterproductive. A single element related to the perceptual experi-

ence should be considered enough with most people to neutralize the doubt

and put an end to the obsessive ritual. They need to be aware that this is

what they actually do in situations not related to the obsessive problem. For

example, one of the following recollections can be considered necessary and

enough: “I did not
hear
a crash,” “I
saw
that the room was dark when I left

the house,” “I didn’t
hear
any sounds of a newborn coming from that rub-

bish heap,” and so forth. At the end of the exercise, the patients are asked to

identify again the degree to which they are convinced that the thought they

are having in that moment related to the feared event is true and realistic,

and compare the initial level, of discomfort to the present level.

In a single case study
(Didonna, 2003)
(see Figure 11.2), a 28-year-old

patient was obsessed with the idea that when she had been driving her car

she might have hit another vehicle –
without realizing it
– and that the

ensuing damage would have later subsequently cause the death of the other

driver. Analyzing the patient’s recollection of her actual experience during

the feared event, it was discovered during a treatment session that she pos-

sessed a very clear memory of her sensory experience which would have

neutralized and prevented any obsessive doubt (e.g., “I didn’t hear the sound

of an impact” or “I didn’t feel that I was losing control of the vehicle”). What

the patient was incapable of doing was to simply validate and utilize those

sensory experiences during her obsessive crisis. The therapist helped the

patient validate the recollection, which was quite clear, of her actual expe-

rience, giving increased credibility to here experience (column on the left).

This led the patient to automatically place less importance on the subjective

elements that had previously fed her obsessive doubt (right-hand column).

At the end of the exercise, both her level of conviction with respect to the

obsessive thought and her level of discomfort decreased. The patient stated:

“Today I understood that continuously seeking all of the elements that feed

my doubts and obsessions (right-hand column) only leads to new doubts and

206

Fabrizio Didonna

Intrusive thought:
“I’m afraid I hit a truck that was behind me when I was driving out of my parking
space.”

Level of conviction:
75%

Level of anxiety/distress (0-100):
80

Information not coming from my

Information coming from my own
own perceptive experience

perceptive experience

(What did I
see, hear, smell, feel, touch,

(What am I
worried
about? What do I
think

taste
in that situation?)

happened?)

•
I didn’t hear any noise on my car
•
I think I moved backwards

•
When I looked in the rear view mirror I

•
The driver might not have realised

saw that the truck was far enough

I hit him

away not to cause me any problems

•

•
I think I was at the right angle to have hit

When I left I heard a noise, but it

it

wasn’t the typical noise you hear

when you hit a car it

•
I saw that the bumper wasn’t damaged

•
I saw the truck pull out into the

road without any problem

Level of conviction at the end of the exercise:
10%

Level of anxiety/distress (0-100):
20

Figure. 11.2.
Example of the use of the perceptive experience validation (PEV)

technique.

obsessions; from now on I want to place more importance on my actual

experience.”

This procedure was repeated during other sessions and by the end, the

patient only needed one “objective” element in the left-hand column to neu-

tralize the obsessive doubts on the other side of the paper. The patient was

also asked to conduct the same procedure at home each time obsessive

ideations occurred and to try and maintain a mindful and validating attitude

toward her own experience throughout the day even when she wasn’t in

an anxiety-evoking situation. Treatment gains were maintained at 3-month