The April BABCP Article of the Month is from Behavioural and Cognitive Psychotherapy (BCP) and is entitled “’Things that shouldn’t be’: a qualitative investigation of violation-related appraisals in individuals with OCD and/or trauma histories” by Sandra Krause and Adam Radomsky. Listen to the “Let’s Talk About CBT – Research Matters” podcast episode with Sandra here.

The term ‘violation’ can pertain to many different things – violations of moral/ethical/legal codes, violations of social norms, violations of one’s personal space. These can range from day-to-day occurrences (e.g. telling a white lie to a friend, parking in a no parking zone) to major traumas (e.g., sexual assault) or distressing repugnant thoughts (e.g., intrusive thoughts about paedophilia), and result in a range of negative outcomes for people, including feelings of guilt, shame, and anger. A lesser studied, yet commonly reported consequence of violations in those with obsessive-compulsive disorder (OCD) and in trauma survivors is feelings of contamination, referred to as ‘mental contamination’.

Cognitive theories suggest that what leads to negative violation-related outcomes, including mental contamination, is not the violation itself, but the way an individual appraises the meaning of the violation. For example, it is not the occurrence of an intrusive thought about incest or an intrusive memory about past sexual assault that leads to feeling dirty, angry, or ashamed, but rather the meaning that is ascribed to the experience. Understanding what types of appraisals lead to different negative feelings following a violation can, therefore, help identify possible intervention targets for sufferers.

For this reason, we aimed to identify themes of appraisals that might be relevant to mental contamination and other negative emotional outcomes. To do so, we conducted semi-structured qualitative interviews with 20 individuals with OCD and/or trauma histories and analyzed the transcripts for common themes.

We identified three overarching themes of violation appraisals – appraisals about the self, appraisals about others, and appraisals about the future. In line with cognitive models, we found that different types of appraisals were associated with different emotional and behavioural outcomes. Feelings of contamination were discussed when participants appraised the violation as an indication of their low self-worth, appraised themselves as responsible for the violation, or appraised the consequences of the violation as permanent.  

While there was large variability in what people described doing after a violation, there were common themes in why participants engaged in certain behaviour. Participants reported using different actions (e.g., washing, arranging, hypervigilance, exercise, thought replacement, self-harm) to reclaim a sense of control, to avoid or distract from unwanted feeling or thoughts, and/or to punish themselves for a perceived wrongdoing.  

The study is limited by the relatively small sample, the high number of participants with both OCD and trauma histories, and the presence of comorbid non-OCD or PTSD diagnoses. However, a major strength of the study is the use of a rigorous, bottom-up analytic approach to the lived experiences of those with OCD and/or trauma histories.  In doing so, we were able to identify key violation appraisals and differentiate between mental contamination-related appraisals and those related to other negative emotions that may emerge following a violation.

By expanding on and clarifying existing cognitive models, we hope to improve our understanding of these experiences and lay the foundation for future experimental and clinical work. These findings add to a growing body of research suggesting the importance of using cognitive interventions when working with mental contamination. Indeed, it seems that incorporating behavioural experiments to examine and evaluate key appraisals (e.g., I am worthless, I am responsible, I am forever tainted) may prove to be more beneficial than a purely behavioural approach in this context.

References

Coughtrey, A. E., Shafran, R., Knibbs, D., & Rachman, S. (2012). Mental contamination in obsessive-compulsive disorder. Journal of Obsessive-Compulsive and Related Disorders, 1(4), 244-250.

Coughtrey, A. E., Shafran, R., Lee, M., & Rachman, S. (2013). The treatment of mental contamination: A case series. Cognitive and Behavioral Practice, 20(2), 221-231.

Mathes, B. M., McDermott, K. A., Okey, S. A., Vazquez, A., Harvey, A. M., & Cougle, J. R. (2019). Mental contamination in obsessive-compulsive disorder: associations with contamination symptoms and treatment response. Behavior Therapy, 50(1), 15-24.

Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793-802. doi:10.1016/S0005-7967(97)00040-5

Rachman, S. (1998). A cognitive theory of obsessions: elaborations. Behaviour Research and Therapy, 36, 385-401. doi:10.1016/S0005-7967(97)10041-9

Rachman, S. (2004). Fear of contamination. Behaviour Research and Therapy, 42, 1227-1255. doi:10.1016/j.brat.2003.10.009

Rachman, S., Coughtrey, A. E., Shafran, R., & Radomsky, A. S. (2015). Oxford Guide to the Treatment of Mental Contamination: VOCI Mental Contamination Scale (VOCI-MC): Oxford University Press.

 From Paul Salkovskis, the Editor-in-Chief of BCP: Why I chose this article 

The late and much missed Jack Rachman was instrumental in identifying the importance of “mental contamination” as a likely subtype of OCD. There have been various attempts at subtyping OCD which an expert by experience (thanks AC) described as “same meat, different gravy”, indicating that subtyping did not substantially affect the approach to treatment. What Jack and his colleagues have noted is that mental contamination is probably different and its presence may contribute to the failure of “conventional” CBT for OCD. Recent research has indicated however that treatment may be effective if modified to take account of the issues linked to the experience of mental contamination. There is significant evidence that mental contamination may be associated with previous experience of violation and betrayal, and that effective treatment needs to consider such issues. This “article of the month” provides an in depth examination of links between experiences of violation and mental contamination in OCD. It also illustrates the value of integrating qualitative research into programmes of research seeking to identify factors involved in mental problems, and how qualitative and quantitative research complement each other.

Author bio:

Sandra is a senior PhD student in Clinical Psychology at Concordia University (Montréal, Canada) working in the Anxiety and OCD Laboratory. She is interested in better understanding cognitive mechanisms at play in lesser studied OCD and trauma symptomatology. Clinically, Sandra specializes in applying this knowledge to cognitive interventions for these populations.

Adam is a Professor of Psychology at Concordia University (Montréal, Canada), the director of the Anxiety and OCD Laboratory, and a core member of Concordia University’s Centre for Clinical Research in Health. His research and clinical interests lie in improving upon and applying cognitive-behavioural interventions for OCD and anxiety disorders.