A Mindful Practice: Can Enhanced Access to Internal States Reduce Reliance on Proxies and Obsessive-Compulsive Tendencies? A Controlled Trial
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The Gershon H. Gordon Faculty of Social Science
The School of Psychological Sciences
M.A Clinical Psychology Program
A Mindful Practice:
Can Enhanced Access to Internal States Reduce Reliance
on Proxies and Obsessive-Compulsive Tendencies?
A Controlled Trial
by
Eliad Zehavi
Thesis supervisor: Prof. Reuven Dar
M.A dissertation, submitted in fulfillment of the requirements for the M.A
Clinical Psychology Program, The Faculty of Social Science, The School of
Psychological Sciences, Tel Aviv University
June, 2020 תש"פ,א' בתמוזThe Gershon H. Gordon Faculty of Social Science
The School of Psychological Sciences
M.A Clinical Psychology Program
A Mindful Practice:
Can Enhanced Access to Internal States Reduce Reliance
on Proxies and Obsessive-Compulsive Tendencies?
A Controlled Trial
by
Eliad Zehavi
Thesis supervisor: Prof. Reuven Dar
M.A dissertation, submitted in fulfillment of the requirements for the M.A
Clinical Psychology Program, The Faculty of Social Science, The School of
Psychological Sciences, Tel Aviv University
June, 2020 תש"פ,א' בתמוזAuthors Note
I would like to thank several individuals – without their significant contribution the
current work could not have been completed: Our dedicated lab assistant Noa Avrahami, which
devoted time, patience and curiosity in recruiting the participants, managing the study database,
and examining our methodology and working process. Prof. Nava Levit-Binnun from the
Interdisciplinary center in Herzliya, which for the study's purposes, generously gave us access
to the mindfulness courses in Muda center, and provided professional consultation regarding
the mindfulness measures we applied. Michal Edelman, our contact for collaboration in Muda
center. With care and kindness, Michal has made her assistance available to us regularly, for
many months, and helped us recruit the participants (and recruit the MBSR instructors in our
side), manage frequent practical issues which arose, and come up with the idea for the pool of
the control group. Yarin Shechter, a dear friend which provided his professional abilities and
insight in the English proof of this work. Finally, I would like to thank the thesis supervisor
prof. Reuven Dar. With his experience and generous supervision and comments, he enabled
this research process to be productive and educating, and enabled me to explore new areas of
knowledge and research expertise.Table of Contents
INTRODUCTION ............................................................................................................ 5
2T 2T
First-Line Psychotherapies for Obsessive-Compulsive Disorder .............................. 6
2T 2T
The Seeking Proxies for Internal States Model ......................................................... 6
2T 2T
Mindfulness Meditation as a Possible Enhancer for Accessing Internal States ........ 9
2T 2T
METHOD ....................................................................................................................... 11
2T 2T
Participants............................................................................................................... 12
2T 2T
Materials .................................................................................................................. 13
2T 2T
Depression and Anxiety Scale (DASS-21 two sub-scales) .............................. 13
2T 2T
Multidimensional Assessment of Interoceptive Awareness............................. 14
2T 2T
Seeking Proxies for Internal States Inventory (SPISI) ..................................... 14
2T 2T
Obsessive-Compulsive Inventory-Revised (OCI-R) ........................................ 15
2T 2T
Mindfulness-based stress reduction (MBSR) Program .................................... 15
2T 2T
Procedure ................................................................................................................. 16
2T 2T
RESULTS ....................................................................................................................... 17
2T 2T
Manipulation check.................................................................................................. 17
2T 2T
The effect of Mindfulness training on SPISI and OSI-R scores .............................. 20
2T 2T
Examining the Mediation Hypothesis of the SPIS model ....................................... 22
2T 2T
DISCUSSION ................................................................................................................ 24
2T 2T
REFERENCES ............................................................................................................... 28
2T 2T
Appendix A ................................................................................................................ 36
2T 2T
Appendix B ................................................................................................................ 37
2T 2T
Appendix C ................................................................................................................ 38
2T 2T
Appendix D ................................................................................................................ 39
2T 2T
Abstract in Hebrew ......................................................................................................... 40
2T 2TCan Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
Can Enhanced Access to Internal States Reduce Reliance on Proxies and Obsessive-
Compulsive Tendencies?
ABSTRACT
Obsessive-compulsive disorder (OCD) is associated with a significant impairment in
functioning and reduced quality of life. Most of the first-line therapies for OCD focus on
detaching the association of the obsessions with the compulsions, while individuals with OCD
were found to display various other common features. Consequently, while the majority of
OCD patients achieve improvement with these first-line treatments, a substantial portion
continues to experience considerable OC symptoms. Based on recent findings that support the
Seeking Proxies for Internal States (SPIS) comprehensive model of OCD, in the current paper
we report a preliminary investigation for the clinical applications of the SPIS model. In a
controlled non-randomized study (N intervention = 57, N control = 21), we found that individuals who
R R R R
participated an eight-weeks Mindfulness-based Stress Reduction (MBSR) program
demonstrated enhanced interoceptive awareness, reduced tendency to seek and rely on proxies
and reduced OC tendencies, while participants of an empty control group, chosen out of the
same population poll, did not show similar changes. Our findings also suggest a possible
mediating role of proxy seeking in the reduction of OC tendencies. Possible interpretations and
implications of the results are discussed, while addressing several important limitations of the
current study.
Keywords: SPIS, mindfulness, MBSR, OCD, interoceptive awareness
4Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
Introduction
Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder, characterized by
the presence of obsessions and compulsions. Obsessions are defined as recurrent and persistent
thoughts, urges or images that are experienced as intrusive and inappropriate, and elicit marked
anxiety or distress. The individual's attempts to ignore or suppress the obsessions, or to
neutralize them with some other thought or action, constitute the compulsions, which are
defined as repetitive behaviors or mental acts that the person feels driven to perform in response
to the obsession, or according to rules that must be applied rigidly (American Psychiatric
Association, 2013). OCD is associated with a significant impairment in functioning and
reduced quality of life (Macy et al., 2013). It affects nearly 2.3% of the population at some
point in their lives, and the prevalence during a given year is about 1.2% worldwide (Ruscio,
Stein, Chiu, & Kessler. 2010). Subthreshold obsessive-compulsive symptoms are even more
common, with a mean prevalence of up to 13% (Fullana et al., 2010). The initial phase of OCD
often occurs in adolescence or early adulthood, and without treatment it tends to have a chronic
course (Eisen et al., 2006). Therefore, clinical attempts to understand and manage OCD are of
great significance to the public and to psychological literature.
The current study focuses on a key aspect of OCD - its postulated association with the
ability to access one's internal states, and is aimed to advance literature in three ways; first, we
present a preliminary experimental investigation for the clinical applications of the Seeking
Proxies for Internal States model (SPIS; Lazarov, Dar, Oded, & Liberman, 2010; Liberman &
Dar, 2009) in assisting obsessive-compulsive (OC) individuals. Second, we report an additional
preliminary examination for the effect of a Mindfulness-based Stress Reduction (MBSR;
Kabat-Zinn, 1990) program on OC tendencies, and the tendency to seek and rely on proxies.
Third, we wish to validate and expand the theoretical construct of the SPIS model named
"access to internal states", through its interface with the mindfulness theoretical framework.
5Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
First-Line Psychotherapies for Obsessive-Compulsive Disorder
A systematic review of randomized controlled studies has shown that the first-line
psychological treatment offered to OCD patients is cognitive behavioral therapy (CBT), based
on exposure and response prevention (ERP) or on cognitive restructuring (CR) (Pozza &
Dèttore, 2017). Even though the majority of OCD patients achieve improvement with these
treatments, a substantial portion continues to experience considerable OC symptoms (Franklin
& Foa, 2008). For example, Fisher and Wells (2005) found that among patients that completed
the CBT program, only 60% were considered recovered, and merely 25% were symptoms-free.
These efficiency rates are worrisome, since the lasting symptoms of individuals who achieve
only partial relief, continue to impair their quality of life (Fontenelle et al., 2010), and those
individuals are less likely to maintain their treatment gains (Simpson et al., 2004).
Nevertheless, these first-line therapies focus largely on detaching the association of the
obsessions with the compulsions (Rector, Richter, Katz, & Leybman, 2019), while individuals
with OCD were found to display various other common features, aside from the obsessions and
compulsions. These features include their tendency to intensively monitor their thoughts and
actions (Riesel, Endrass, Auerbach, & Kathmann, 2015; Yoris et al., 2017), their experience of
'chronic' doubt (Dar, 2004; Samuels et al., 2017), their struggle with decision-making (Frost &
Shows, 1992; Sarig, Dar, & Liberman, 2012) and their reduced sense of agency (Oren,
Friedmann, & Dar, 2016). The partial efficiency of first-line treatments, and their disregard of
additional core OCD features, highlight the need for further development of the theoretical
understanding of OCD and its clinical applications.
The Seeking Proxies for Internal States Model
A recent comprehensive model of OCD which provides a possible psychological
mechanism for the complex phenomenology of OCD, is the Seeking Proxies for Internal States
model (SPIS; Lazarov et al., 2010; Liberman & Dar, 2009). The SPIS model suggests that the
6Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
core feature of the disorder is attenuated access to one's internal states, including emotions,
bodily states and sensations, as well as preferences. According to the model, in order to
compensate for their attenuated access to internal states, OC individuals are driven to seek and
rely on more easily discernible indices - “proxies” - for their actual internal states. These
proxies may include rules, behaviors, or environmental stimuli (Lazarov, Liberman, Hermesh,
& Dar, 2014; Liberman & Dar, 2009). The continuous search and reliance on these proxies, is
presumed to constitute the compulsive part in OCD. For example, individuals with OCD might
find it difficult to evaluate their love for a romantic partner (due to their attenuated access to
internal states), and might use the amount of daily text messages sent to the partner as an index
(proxy) for their feelings; similarly, OC person may also review how long he or she has slept
in order to infer how tired they are. In this manner, the SPIS model postulates that the
attenuation of access to internal states in OCD can account for the complex phenomenology of
the disorder, including prevailing doubts, repetitive checking, behavior governed by rules and
rituals, and a distortion in the sense of agency (Liberman & Dar, 2018).
Previous correlative studies and controlled experiments have yielded support for the
different parts of the mechanism described by the SPIS model. First, several studies
demonstrated that individuals with high OC tendencies have reduced access to various internal
states, including relaxation level (Lazarov et al., 2010), muscle tension (Lazarov, Dar,
Liberman, & Oded, 2012a,b, Zhang et al., 2017; Lazarov et al., 2014 in OCD patients), time
perception (Gilaie-Dotan, Ashkenazi, & Dar, 2016), sense of understanding (Dar, Eden,
Dongen, Hauschildt, & Liberman, 2019), movement initiation (Ezrati, Sherman, & Dar, 2018)
and emotions (Dar, Lazarov, & Liberman, 2016).
Corresponding to the second component in the mechanism described by the SPIS
model, several studies implemented tasks involving a few of the afore-mentioned internal
states; it was shown that high OC participants as well as OCD patients that demonstrated
7Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
attenuated access to these states, were more disposed to seek and rely on external proxies for
them, and were more exposed to the effects of false feedback. An elegant demonstration of
these effects came from studies that used proprioception (a neural system that obtains
information about the state of internal organs; Sherrington, 1906) as the internal state: Lazarov
et al. (2014) demonstrated that OCD patients had larger errors when asked to reproduce a
specific degree of muscle tension, as compared with non-clinical and anxiety control
participants; This difference was eliminated when participants were provided with
biofeedback, as an external proxy for this internal state. In another study (Lazarov et al.,
2012b), high and low OC participants were instructed to relax their forearm muscles while
viewing false preprogrammed “feedback” on their muscle tension. Each participant underwent
two successive phases of putative feedback, one indicating a gradual increase in muscle tension
and one indicating a gradual decrease in muscle tension. Following each phase, participants
rated their perceived level of muscle tension. As predicted, the ratings of the high OC
participants indicated that they relied more on the false biofeedback proxy in judging their own
level of muscle tension. Furthermore, in an additional study, by introducing a manipulation that
undermined participants' confidence in their internal states, a results pattern resembling to that
of high-OC individuals was produced (for biofeedback-aided relaxation see Lazarov et al.,
2012b; for biofeedback-aided muscle tensing see Lazarov et al., 2012a; for emotions
assessment see Dar et al., 2016, Study 3).
Additional support for the hypothesis that compulsive behaviors can be explained by
reliance on proxies for internal states, was provided by developing the Seeking Proxies for
Internal States Inventory (SPISI; Liberman, & Dar, 2018) and examining its correlations with
OC symptoms. In two large samples (Ncombined=1486), the correlation between the scale and
the Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002) was high and
significant (r = .56, p < .001 in both sample) and remained significant and moderate to high in
8Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
size after controlling for anxiety, depression and stress (r = .42 in sample 1, r = .51 in sample
2).
Together, these findings provide strong support for the SPIS model, and suggest it may
yield clinical applications that would benefit OCD patients, through attending some of the root
features of OCD which have not yet been the target of therapeutic efforts. Is it possible that by
improving individuals' ability to access their internal states, their need to seek and rely on
proxies will be reduced, along with their OC tendencies? If so, what sort of intervention would
be suitable for this purpose?
Mindfulness Meditation as a Possible Enhancer for Accessing Internal States
While the biofeedback procedures described above were suitable for a preliminary lab
demonstration of the causal effects hypothesized by the SPIS model, the theoretical construct
of internal states is broader and more clinically significant than is captured in these studies,
encompassing a rich variety of behaviors, sensations, emotions and preferences (Liberman &
Dar, 2018). Therefore, an intervention intended to reduce OC tendencies by enhancing patients'
ability to be in direct contact with their internal states, may have the capacity to be generalized
into a broad spectrum of internal states (and thereby makes the need to adjust a specific practice
for every internal state redundant).
One possible intervention that could prove to be be especially suitable for this purpose
is mindfulness practice; mindfulness can be defined in its broadest meaning as a mental process
of intentionally bringing one's awareness and attention to the internal experiences occurring in
the present moment, in a non-judgmental manner (Baer, 2003). The quality of mindfulness is
presumed to be developed through the practice of meditation, originating in eastern meditation
practices (Kabat-Zinn, 2003). It is simple to notice, that the core principle of mindfulness holds
9Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
large resemblance to the "access to internal states" construct postulated by the SPIS model.
This suggests mindfulness practice as a way for reducing proxy seeking tendencies.
The notion by which increased access to internal states is a central outcome of
mindfulness practice, is supported by findings from brain imaging studies; a recent systematic
review of seven FMRI studies, that followed participants of eight-weeks mindfulness-based
interventions, have indicated that the most consistent longitudinal effect observed was
increased insular cortex activity (Young et al., 2018), which is strongly related to bodily
awareness (including awareness of interoceptive experiences), and emotional processing (Farb,
Segal, & Anderson, 2013; Lutz, Brefczynski-Lewis, Johnstone, & Davidson, 2008). The
consistent effects of mindfulness on insular cortex activity were also found in a recent meta-
analysis that included 21 FMRI studies (Falcone, & Jerram 2018).
Several mindfulness-based therapies were developed in the recent two decades, the
most prominent are the Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, &
Teasdale, 2002), and the Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, &
Wilson, 1999). A number of authors have suggested different effective mechanisms for these
therapies: Bishop et al. (2004) suggested that the effective mechanisms are increased
attentional control and increased awareness and acceptance of the present moment. Baer (2003)
suggested that by bringing awareness to the experience, people can learn to recognize the
transient nature of experience and to question the factual accuracy of their thoughts. Teasdale
et al. (2000) suggested that through becoming aware of habitual patterns of thinking, feeling
and behaving, people earn the opportunity to make non-automatic choices regarding their
behavior. Studies have shown support for MBCT and ACT efficiency in reducing OC
symptoms (e.g., for MBCT see Külz et al., 2019; for ACT see Twohig, Morrison, & Bluett,
2014), even though postulating different action mechanisms than that of the current paper.
10Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
However, the most widespread method of mindfulness training available to the general
public is the Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990) program. MBSR
is an outpatient program that was developed for populations with a wide range of chronic pain
and stress-related disorders. MBSR's primary goal is to help participants integrate mindfulness
qualities into their everyday lives. The program consists of eight to ten weekly group sessions.
During each session, a discussion of one of the mindfulness milestones is held, with address to
stress, coping and homework assignment issues. Then, the MBSR instructor leads a guided
mindfulness meditation, intended to foster the ability to come into direct contact with, and
monitor one’s current body sensations, mental images, emotions, and thoughts. (Baer, 2003).
Surprisingly, while the efficiency of MBSR for a range of mental disorders such as
depression and anxiety, is supported by a growing number of studies (e.g., Marchand, 2012),
no empirical work has been made to examine MBSR efficiency for reducing OC tendencies.
Only a single case report was published on this matter, with a supporting conclusion (Patel,
Carmody, & Simpson, 2007). Thus, the current study is the first to empirically examine the
effect of MBSR on OC tendencies. Based on the SPIS theoretical framework and its supporting
findings, our hypotheses were: Compared to participants in the control group, participants who
have undergone a mindfulness intervention will display: (A) Enhanced interoceptive awareness
(as indicator for enhanced access to internal states), (B) Reduced tendency to seek and rely on
proxies for internal states, and (C) Reduced level of OC tendencies. An additional hypothesis
(D) was that the change in interoceptive awareness will predict the reduction in OC tendencies,
and that this reduction will be mediated by the reduction in the need to seek and rely on proxies.
Method
In a preliminary controlled study, we examined the effects of MBSR program on
interoceptive awareness, reliance on proxies in everyday life and OC tendencies. The study
11Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
was conducted in collaboration with the Muda Center for Mindfulness Science and Society - a
major Israeli education center for mindfulness training.
Participants
A statistical power analysis was performed for sample size estimation, based on data
from a pilot study we conducted (N=27) comparing OC tendencies of participants before and
after taking an eight-weeks MBSR course. The results of the pilot were significant, with
Cohen’s d = .48, considered to be moderate [(M = -2.89, SD = 6.07), t(26) = -2.48, p = .02].
Under the expectations for no change of OC tendencies within the control group in the current
study, the projected sample size required to find a difference between groups, with α = .05 and
power = .80, was approximately N=138, with 69 participants in each group. For the
intervention group, we invited students of an eight-weeks MBSR program to participate in the
study. Overall, we approached students of six MBSR courses, that took place in Israel, from
October 2019 to March 2020. For the control group, we approached individuals that were
interested in participating in the same MBSR courses, but eventually did not sign up.
Due to the Coronavirus pandemic of 2019, which broke out in Israel a few months after
the beginning of the current study, the afore-mentioned mindfulness courses were suspended,
and we were unable to complete the sample recruitment. Throughout the time the study was
conducted, the intervention and control samples maintained a 1: 3 ratio in size in favor of the
intervention sample, as a result of different agreement and completion rates between groups.
Thus, the ultimate sample consisted of 78 participants (N intervention = 57, N control = 21); Out of
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about 100 MBSR students we approached, 87 agreed to participate in the study, and 65 of them
completed all of the study measures (75%). As reflected in the uneven ratio of sample sizes,
recruiting participants for the control group proved to be harder than we expected; overall, we
approached 148 potential control participants, and managed to personally contact 127
individuals, of which 26 reported to practice mindfulness on a regular basis, and so did not
12Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
continue to the study participation. Eventually 53 individuals agreed to participate in the study
for the control group, of which 23 completed the study measures (43%). Participants of both
groups who turned out after the study completion to conduct a previous mindfulness practice
routine, were excluded from the analysis (MBSR = 8, control = 2). All the participants were
Hebrew speaking Israelis from the local general population (54 women, 24 men), ranging from
23 to 77 years of age (M = 46.86, SD = 17.73). All the participants were entered in a raffle for
ten gift cards, each worth approximately $71 in local currency, as compensation for their
participation. The MBSR and control groups did not differ significantly in any of the
background variables (age, gender, education, family status & religiosity), nor in the baseline
measure of depression and anxiety symptoms [(M = 8.74, SD = 6.63), t(76) = -1.60, p = .11].
Materials
1
Depression and Anxiety Scale (DASS-21 two sub-scales).
Depression and anxiety symptoms were assessed using two sub-scales out of the 21-
item DASS (Lovibond & Lovibond, 1995) translation to Hebrew. The DASS-21 is a self-report
questionnaire yielding three sub-scales, assessing dimensional components of depression
(seven items), Anxiety (seven items) and psychological stress (which was not included in the
current study). Each statement reflects a negative emotional symptom and is followed by a
four-point scale ranging from 0 (The item does not apply to me at all) to 3 (The item applies to
me very much or most of the time), on which participants indicated the extent to which the
statement applied to their experience over the past week. In the current sample, while
Cronbach’s alpha was good for the depression items (time 1 = .87, time 2 = .88), it was
questionable for the anxiety items (time 1 = .69, time 2 = .73). Thus, summary scores were
computed for all 14 items of both sub-scales together, such that higher scores indicate greater
anxiety and depression symptoms. Cronbach’s alpha was good for the unified scale (time 1 =
.86, time 2 = .87).
13Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
Multidimensional Assessment of Interoceptive Awareness (MAIA) – three sub-scales.2
The MAIA (Mehling et al., 2012) is a self-report measure of interoceptive awareness
that comprises eight interrelated sub-scales, with each sub-scale assessing a different facet of
interoceptive awareness. All participants completed three sub-scales which were deemed most
relevant to the theoretical construct of Access to Internal States: ‘noticing’, 'emotional
awareness' and 'body listening' sub-scales. The ‘noticing’ sub-scale consists of four items, and
was selected because it measures the subjective perception of the ability to perceive and focus
on bodily sensations (e.g., ‘When I am tense, I notice where the tension is located in my body’).
Emotional awareness sub-scale consists of five items, and measures the awareness of the
connection between body signals and emotional states (e.g., "I notice how my body changes
when I am angry"). The body listening sub-scale consists of three items, and measures the
tendency to actively listen to the body for insight (e.g., "I listen for information from my body
about my emotional state"). Answers for all three sub-scales are given on a six-point Likert
scale, ranging from ‘never’ to ‘always’. The score for each scale is calculated by the mean of
its individual items. The MAIA is found to have acceptable internal consistency, and good
convergent and discriminant validity of all scales (Mehling et al., 2012). In the current sample,
Cronbach’s alphas were good for the noticing scale (time 1 = .82, time 2 = .83) and the
emotional awareness scale (time 1 = .86, time 2 = .88), and excellent for the body listening
scale (time 1 = .91, time 2 = .90). Mean scores for all items of the three sub-scales together
were also computed, with excellent Cronbach’s alpha (time 1 = .92, time 2 = .93).
Seeking Proxies for Internal States Inventory (SPISI). 3
Tendency to seek and rely on proxies for internal states was assessed by the 15-items
SPIS Inventory (SPISI, Liberman & Dar, 2018). Participants rated the extent to which each
item was descriptive of their feelings and behaviors in their daily life, on a five-point scale
ranging from 1 (Not at all) to 5 (Very much). Examples of items are “To know if I have
14Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
understood what I've read, I check to see if I remember parts of it by heart;” I know how close
I am to someone by how often we interact;” Sometimes I need to infer what I am feeling from
my actions;” To know how hungry I am, I consider what and when I've eaten today”.
Cronbach’s alpha was excellent (time 1 = .91, time 2 = .91). Summary scores were calculated
for the scale, such that higher scores indicate greater tendency to seek and rely on proxies.
Obsessive-Compulsive Inventory-Revised (OCI-R). 4
OC tendencies were measured by the OCI-R (Foa et al., 2002). The OCI-R lists 18
characteristic symptoms of OCD, divided among six subscales which are based on symptom
categories that are commonly found in OCD (washing, obsessing, hoarding, ordering, checking
and neutralizing). Each symptom is followed by a five-point Likert scale ranging from 0 (Not
at all) to 4 (Extremely), on which participants indicated its prevalence during the past month.
Cronbach’s alpha for all items was good (time 1 = .85, time 2 = .87). Summary scores were
computed for the scale, such that higher score indicates greater OC tendencies.
Mindfulness-based stress reduction (MBSR) Program
For enhancing participants' level of access to internal states, participants of the
intervention group went through a MBSR program, formerly known as the Stress Reduction
and Relaxation Program (SRRP; Kabat-Zinn, 1982). The MBSR primary goal is to help
participants integrate mindfulness qualities into their everyday lives. The program consisted of
10 group sessions (with about 22 participants in a group) of 2.5 hours each, and approximately
30-45 minutes of daily home practice. An all-day (seven-eight hours) intensive mindfulness
session was held around the sixth week. During each group session, a discussion of one of the
mindfulness practice milestones was held, with address to stress, coping and homework
assignments issues. Then, the MBSR instructor led a guided mindfulness meditation, intended
to foster the ability to come into direct contact with, and monitor one’s current bodily
sensations, mental images, emotions, and thoughts. For example, in sitting meditation,
15Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
participants were instructed to sit in a relaxed and wakeful posture with eyes closed, and to
direct attention to the sensations of breathing; in the body scan exercise, attention was directed
sequentially to numerous areas of the body, while the participant was lying with eyes closed.
Sensations in each area were carefully observed. Participants also practiced mindfulness during
ordinary activities like walking, standing, and eating (Kabat-Zinn, 1990).
The Participants in the MBSR were instructed to practice these skills outside group
meetings for at least 30-45 min per day, six days per week. Audiotapes were used early in
program, but participants were encouraged to practice without tapes after a few weeks. For all
mindfulness exercises, participants were instructed to focus attention on the target of
observation (e.g., breathing or walking) and to be aware of it in each moment. When emotions,
sensations, or cognitions rose, participants were guided to observe them nonjudgmentally.
When participants noticed that the mind has wandered into thoughts, memories, or fantasies,
the nature or content of them was briefly noted, if possible, and then attention was directed
back to the present moment. Thus, participants were instructed to notice their thoughts and
feelings but not to become absorbed in their content (Kabat-Zinn, 1982).
Procedure
A few days before the beginning of the MBSR course, participants of both the
intervention and control groups received an email from the experimenter. The email notified
them that they will be approached and offered the opportunity to participate in a study, in the
first session of the course (intervention group), or by a telephone call in the next few days
(control group). As a cover story, participants were told that the study examines the relations
of experiential practice with behavioral tendencies. As notified by the email, the experimenter
arrived to the first session of the MBSR course, and before the first mindfulness practice,
offered the students to participate in a study involving 10-15 minutes of completing several
questionnaires in two time points: In the current session (at the time of the approach), and eight
16Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
weeks later. The approach to the potential control participants was made via a telephone call
by the experimenter, with the same content delivered. Following their consent, paper
questionnaires were handed out to participants (intervention group) or sent to their email
address via a web-based survey platform (Qualtrics). Firstly, participants completed a short
demographic questionnaire, followed by depression and anxiety scales. Next, Participants
completed the baseline measure of MAIA. Finally, participants completed the two dependent
measures of obsessive-compulsive tendencies and the tendency to seek and rely on proxies;
these dependent measures were counterbalanced across participants. The exact same procedure
was performed again after eight weeks. At the end of the second questionnaires completion,
participants were quickly debriefed about the study, and were thanked for their participation.
Results
Since the unplanned small sample size was expected to compromise the study's
statistical power, in the analysis we addressed marginally significant effects (p < .10) as well
as significant ones, with the required caution, to enable productive theoretical discussion.
Manipulation check
First, to examine whether the MBSR and control groups differ on participants' initial
level of interoceptive awareness, an independent samples t-test on MAIA unified baseline
scores was performed. The results show a marginally significant difference between groups, as
the MBSR group score (M = 3.27, SD = .86) was slightly lower than that of the control group
[(M = 3.69, SD = .88), t(76) = -1.89, p = .06]. To examine each sub-scale of the MAIA
separately, three additional independent samples t-tests on baseline scores were performed.
There was a significant difference between groups in the baseline body-listening score, as the
MBSR group score (M = 2.33, SD = 1.29) was lower than that of the control group [(M = 3.04,
SD = 1.23), t(76) = -2.21, p = .03]. There were no significant differences between groups in
17Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
the baseline measures of the noticing sub-scale [(M = 3.65, SD = .89), t(76) = -1.44, p = .15],
or of the emotional awareness sub-scale [(M = 3.68, SD = .96), t(76) = -1.24, p = .22].
To examine the effect of mindfulness training on changes in interoceptive awareness, a
series of four 2x2 mixed analyses of variance (ANOVA) was performed, with the group
(MBSR or control) as between-subject independent variable, time of measurement (1 or 2) as
repeated-measures variable, and MAIA unified and sub-scales scores as dependent variables.
One-tailed pairwise comparisons were added to the analysis, to examine the simple effect of
time on changes in MAIA scores within each group. The results show that the interaction effect
of time*group was not significant [F(1,76) = 1.87, p = .18, η p 2 = .02]. However, the results
R RP P
pattern matched the hypothesized direction, as shown in Figure 1 - as within the MBSR group,
a significant increase in MAIA scores between the two time points was found [Cohen’s d =
.20, MD = .14, SE = .08, t(56) = -1.67, p = .049], while there was no significant change in these
scores within the control group [MD = -.08, SE = .14, t(20) = .59, p = .28].
1)
In examining each individual sub-scale of the MAIA separately, the interaction effect
of time*group for the body listening scores was marginally significant [F(1,76) = 2.83, p =
.097, η p 2 = .04]. The simple effect analysis showed a significant increase in body listening
R RP P
18Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
scores within the MBSR group, between the two time points [Cohen’s d = .42, MD = .46, SE
= .08, t(56) = -3.23, p < .01], while there was no change in these scores within the control group
[MD < .01, SE = .23, t(20) < .01, p = 1.0], as shown in Figure 2a. There were no additional
significant changes in the noticing scores [MBSR: MD = .12, t(56) = 1.16, p = .25. Control:
MD = -.01, t(20) = -.07, p = .94] or in the emotional awareness scores [MBSR: MD = -.01,
t(56) = -.07, p = .91. Control: MD = -.12, t(20) = -.78, p = .43] in both groups, as shown in
Figure 2b and Figure 2c. These results suggests that the MBSR course affected participants'
tendency to listen to their body for insight, but did not affect other aspects of interoceptive
awareness that were examined.
2a)
2b)
19Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
2c)
The effect of Mindfulness training on SPISI and OSI-R scores
First, to examine whether the MBSR and control groups differ on participants' initial
level of reliance on proxies for internal states and of OC tendencies, two independent samples
t-tests on baseline SPISI and OCI-R summary scores were performed. There were no
significant differences between groups in SPISI baseline scores [(M = 31.88, SD = 10.67), t(76)
= -06, p = .95], or in OCI-R baseline scores [(M = 34.11, SD = 9.15), t(76) = .007, p = .99].
To examine the effect of mindfulness training on changes in reliance on proxies for
internal states and OC tendencies, two 2x2 mixed analyses of variance (ANOVA) were
performed, with group (MBSR or control) as an independent variable, time of measurement (1
or 2) as repeated-measures variable, and SPISI and OCI-R scores as dependent variables. One-
tailed pairwise comparisons were added to the analysis, to examine the simple effect of time
within groups. The interaction effect of time*group on SPISI scores was not significant
[F(1,76) = .96, p = .33, η p 2 = .01]. However, the results pattern (shown in Figure 3) matched
R RP P
the hypothesized direction, as within the MBSR group, a significant decrease in SPISI scores
between the two time points was found [Cohen’s d = .24, MD = -1.70, SE = .97, t(56) = -1.74,
p = .04], while there was no significant change in these scores within the control group [MD =
20Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
.14, SE = 1.60, t(20) = .09, p = .46]. The effect within the MBSR group remained significant
after controlling for participants' gender, age and education [t(56) = -1.72, p = .04].
3)
The interaction of time*group for OCI-R scores was not significant [F(1,76) = 2.50, p
= .12, η p 2 = .03]. However, again, a significant decrease in OCI-R scores between the two time
R RP P
points was found [Cohen’s d = .30, MD = -2.08, SE = .91, t(56) = -2.29, p = .01], while there
was no significant change in these scores within the control group [MD = .67, SE = 1.48, t(20)
= .45, p = .33], as shown in Figure 4, which also corresponds with our hypothesis. The effect
within the MBSR group remained significant after controlling for participants' gender, age and
education [t(56) = -2.47, p < .01].
4)
21Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
Examining the Mediation Hypothesis of the SPIS model
To test the hypothesis that enhancement in interoceptive awareness will predict
reduction in OC tendencies, and that this reduction will be mediated by a reduced tendency to
seek and rely on proxies, we used Baron & Kenny (1986) mediation process methodology. A
series of three simple regressions and two hierarchical regression analyses were conducted, for
the data of the MBSR group alone. The variables that represent changes in MAIA, SPISI and
OCI-R scores were calculated by subtracting participants' score in time 1 from their score in
time 2. Consequentially, positive values indicated an increase of participants' score between
the two time points, and negative values indicated a decrease in their score. The results of the
mediation model for all steps are shown in Table A.
In the first step, the change in MAIA unified score was entered as a predictor, and the
change in OCI-R score was entered as the dependent variable. The results of this model show
that the change in MAIA significantly predicted the corresponding change in OCI-R, indicating
that as participants demonstrated enhanced interoceptive awareness, their OC tendencies were
reduced. The results of step 2 show that the change in MAIA also significantly predicted the
corresponding change in SPISI. Step 3 of the mediation process showed that change in SPISI
scores (the mediator) significantly predicted the corresponding change in OCI-R. Interestingly,
Step 4 of the analysis revealed that the change in MAIA scores remained a significant predictor
for change in SPISI, when controlling for the change in OCI-R; however, the effect of change
in MAIA in predicting change in OCI-R, disappeared when controlling for change in SPISI
scores. A Sobel test was conducted and found full mediation in the model (z = -2.74, p = .006).
The same pattern of results for all steps was achieved when the change in body listening sub-
scale was entered as a predictor, instead of the MAIA unified score, with full mediation found
in the Sobel test (z = -2.61, p = .008).
22Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
Table A
Coefficientsa P
Step 1 b SE β t p
MAIA_df -.154 .067 -.258 -2.308 .024
a. Dependent: OCI_df
Step 2 b SE β t p
MAIA_df -.282 .086 -.404 -3.279 .002
a. Dependent: SPISI_df
Step 3 b SE β t p
SPISI_df .452 .091 .561 4.981 < .001
a. Dependent: OCI_df
Step 4a b SE β t p
1 OCI_df .697 .140 .561 4.981 < .001
2 OCI_df .600 .141 .483 4.238 < .001
MAIA_df -.180 .079 -.258 -2.263 .028
a. Dependent: SPISI_df
Step 4b b SE β t p
1 SPISI_df .452 .091 .561 4.981 < .001
2 SPISI_df .422 .100 .524 4.238 < .001
MAIA_df -.051 .069 -.091 -.739 .463
a. Dependent: OCI_df
23Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
Discussion
In the current paper, we reported a preliminary investigation for the clinical applications
of the SPIS model, which also constitutes the first attempt to study the effect of the MBSR
program on OC tendencies. We assumed that the MBSR program will boost participants' ability
to be in-touch with their internal states, and based on the SPIS theoretical framework and its
supporting findings, we hypothesized that this change will be followed by a reduction in
participants' tendency to seek and rely on proxies for internal states, and by reduced levels of
OC tendencies. We also postulated a specific chain of causality, in which the reduction in OC
tendencies will be mediated by the reduction in the tendency to seek and rely on proxies.
The results patterns were in line with our predicted trends, as within the MBSR group,
a significant increase in interoceptive awareness was found, along with a significant decrease
in the tendency to seek and rely on proxies, and a significant decrease in OC tendencies, while
there were no significant changes of these scores in the control group. However, for all the
measures mentioned, the distinct trends between the groups did not yield a significant
interaction of time*group. This means that we lack the statistical support for the claim that the
effect of time with mindfulness intervention was significantly different than the effect of time
without any intervention, making it difficult to establish causal relations.
Since the directions of the simple effects were in line with our predictions, the
nonsignificant interactions of group*time can most easily be explained by the unplanned
sample size, which was particularly small for the control group, with only 21 participants. As
the power analysis we performed indicated, a considerably greater sample size was needed for
detecting the predicted effect between groups. Despite of that, the findings of opposite trends
from those of the MBSR group that were observed within the control group, with decreased
interoceptive awareness and increased OC tendencies, support the possibility that the
intervention of MBSR may have outweighed the effect of time.
24Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
Another investigation we performed in the analysis was that of the mediation model.
While previous work made within the SPIS framework did not assume a precedence of SPIS
tendencies on OC tendencies or the other way around, the current paper was the first to
postulate and examine a specific chain of effects. We encountered here again the sample size
limitation, and since the interaction effects of time*group on any of the examined variables
were not significant, we had to employ the mediation process only for participants of the MBSR
group. Under these limitations, the results of the mediation process supported our hypothesis,
as the increase in interoceptive awareness predicted the reduction in OC tendencies found in
the MBSR group, and this reduction was mediated by the reduction in reliance on proxies for
internal states. It is important to note here that most mediation methodologies state that the
predictive variable should be manipulated, while we did not manipulate interoceptive
awareness directly, but wished to affect it through the MBSR program. A replication of our
findings within a standard mediation process, may hold implications for better understanding
the development of OCD, and may help in planning future interventions based on the SPIS
model.
Several other limitations of the study should be noted. First, participants were not
randomized between groups, and so the current study may be considered a natural experiment.
We attempted to address this issue by using the same pool of participants for sampling both
groups, as all of the participants were individuals who showed active interest in participating
in the same MBSR programs of the same educational center, at the same locations and time
periods. While it is possible that self-selection of people who eventually did or did not sign-up
for these programs affected our results, we did not observe any significant difference between
groups in participants' demographic background or in their initial depression and anxiety
symptoms. However, it could be argued that the lack of power discussed previously, masked
these differences between groups, if such did exist. In addition, our findings are based on a
25Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
non-clinical sample, and we examined the effect of mindfulness only on OC tendencies, which
vary considerably among the general population, but not on OCD symptoms. The
generalization of our findings to OCD requires replication with a clinical sample, with a proper
diagnosis criterion. Still, we believe that the current findings can enhance the understanding of
the mechanisms that create and maintain OCD symptoms, and may shed light on ways to
diminish them.
Another limitation of the current study involves the measures of interoceptive
awareness. To the point of writing the current paper, there was no designated measure available
for assessing access to internal states, and thus we used interoceptive awareness scales to
specifically assess sensory focus on inner body sensations. While interoceptive awareness
indeed represents an aspect of the ability to access internal states, the SPIS theoretical
framework considers a broader theoretical construct when discussing access to internal states.
This lack of compatibility of the theoretical and operational variables impacts the findings'
validity. In our view, this stresses an essential step for the continuation of research of the SPIS
model: Developing a validated and reliable measure for assessing access to internal states.
While the difficulty of defining and measuring such a broad concept is clear, we suggest that
the current study will be considered in such attempts, as it highlights the interface of the SPIS
model with the mindfulness theoretical framework.
Finally, we should consider our limited ability to gain insight regarding the manner in
which the MBSR program affected OC tendencies. In light of previous findings, which
demonstrate the efficiency of mindfulness-based therapies for various mental disorders,
including OCD (e.g., Külz et al., 2019; Twohig, Morrison, & Bluett, 2014), the indication we
achieved for the efficiency of the MBSR program for reducing OC tendencies, is not surprising.
Our choosing of MBSR as the manipulation in the study, was intended mainly to demonstrate
a proof of concept, by which the SPIS paradigm can be translated into clinical interventions
26Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
that boost individuals' access to internal states. However, a number of authors have suggested
different effective mechanisms for mindfulness-based therapies; these suggested mechanisms
include increased attention, awareness and acceptance of present moment (Bishop et al., 2004),
"questioning the factual accuracy of thoughts" (Baer, 2003), and learning to make non-
automatic behavioral choices (Teasdale et al., 2000). It is reasonable to assume at least some
of these mechanisms were in action in the current study, and so further studies will need to
implement a variety of measures for the different effects of mindfulness training in order to
isolate the effect of access to internal states. A measure that may be suitable for this purpose is
the Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, &
Toney, 2006), designed to measure five distinct factors that tend to corelate with mindfulness:
observing, describing, act with awareness, non-judgment, and nonreactivity.
While much is still left for future research, we believe that this preliminary investigation
contributes to the existing literature, as we managed to demonstrate the possible efficiency of
the MBSR program on OC tendencies, the feasible clinical applications of the SPIS model, the
untrivial mediating role of proxy seeking in the reduction of OC tendencies, and the interface
of the SPIS and mindfulness theoretical frameworks.
27Can Enhanced Access to Internal States Reduce Reliance on Proxies and OC Tendencies?
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