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Thought-action fusion in obsessive compulsive disorder
Journalof Anxiety Disorders,Vol. 10,No. 5, pp. 379-391.1996 Copyright8 1996ElsevierScienceLtd Printedin the USA. All rightsreserved 0887-618596 S15.00+ .OO
Pergamon
PII Soss7-618s(%)ooo18-7
Thought-Action Fusion in Obsessive Compulsive Disorder Roz SHAFXAN, PH.D., DANA S. THORDARSON, M-A., AND S. RACHMAN, PH.D.* University
of British
Columbia
Abstract - Recent psychometric results suggested that the phenomenon of thoughtaction fusion (TAF) is implicated in obsessive compulsive disorder (OCD). The construct of TAF has two components: (a) the belief that thinking about an unacceptable or disturbing event makes it mote likely to happen and (b) the belief that having an unacceptable thought is the moral equivalent of carrying out the unacceptable or disturbing action. The consttuct of TAF is explored, and its relevance to msponsibility and obse.5 sive-compulsive disorder examined. A highly reliable questionnaire to measure TAF has been developed, and psychometric data obtained from two studies are presented. TAF was higher in obsessional samples than in nonobsessional samples, particularly the belief that thinking about a negative event involving other people makes the event more likely to happen. You have heard that it was said, “Do not commit adultery.” But now I tell you: Anyone who looks at a woman and wants to possessher is guilty of committing adultery with her in his heart. Matthew X.27-28.
It has been suggested that some patients with OCD experience thought-action fusion (TAP) in which thoughts, particularly unwanted intrusive thoughts, are interpreted as having special significance (Rachman, 1993). Preliminary research has provided support for this hypothesis (Rachman, Thordarson, Shafran, & Woody, 1995), and TM appears to have two components: 1. The belief that thinking about an unacceptable or disturbing event makes that event more probable, more likely to happen in reality. This will be This research was supported by a grant from the British Columbia Health Research Foundation. The first author was supported by a Wellcome Trust Prize Studentship. The authors would like to thank Nichole Fairbrother, Adam Radomsky, and the anonymous reviewers for their helpful comments. Requests for reprints should be sent to to S. Rachman, Ph.D., Department of Psychology, University of British Columbia 2136 West Mall, Vancouver, B.C., Canada V6T lZ4. 379
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referred to as the likelihood type of TAF. For example, if a husband with this belief experiences an intrusive thought of his wife being in a car accident, he feels that his wife is at greater risk of having a car accident, because he has had the thought. As he has placed his wife in danger, he may feel that it is his responsibility to prevent harm coming to her, perhaps by mentally “neutralizing” the thought. 2. The interpretation of obsessional thoughts and forbidden actions as morally equivalent. The person feels that his or her unacceptable thoughts, images or impulses are.(almost) as bad as the actual events they describe. For example, if a mother with this belief experiences the intrusive thought that she is going to harm her child, she is likely to feel as though she is as morally responsible as if she had really harmed her child. It is possible that the mother interprets such an intrusion as revealing her “true” nature, that is, “only wicked people have this type of thought; I am wicked,*’ or, “perhaps I really want to do this; I am wicked.” This component will be referred to as the moral type of TAF. Our construct of TAF is derived from observing particular obsessional-compulsive phenomena. For example, a religious patient, while praying, experienced intrusive images of having sexual relations with Jesus. This patient believed that she had sinned against God by having such an image and was therefore an immoral person. A father experienced the intrusion that he was going to harm his son while dressing him. The patient regarded this as meaning that he was a wicked pedophile who was unsafe to be left alone with children because he was liable to harm them. We believe that obsessional-compulsive patients with TAF are particularly prone to experience a sense of inflated responsibility because of these beliefs (see Salkovskis, 1985). Salkovskis suggests that the link between the occurrence of a cognitive intrusion and the need for action is the misinterpretation of the cognition as an indication that the person might be responsible for harm unless he or she takes action to prevent it (emphasis added). We would suggest that for some patients, the psychological fusion of thoughts and actions is a fundamental part of the catastrophic misinterpretation, “I am responsible for harm.” A person is likely to believe that he has contributed to being the cause of the negative event if he believes that the probability of a negative event is increased by his thinking about it. He will therefore perceive himself to be at least partially responsible for the threat of the negative event and perhaps also consider it his responsibility to reduce or remove such a threat. Such a threat can be reduced or removed by mental “neutralizing,” for example, by mconstructing the image of a car accident so that passengers are no longer injured. Some examples of mental neutralizing can be seen as a form of TAF the person attempts to influence real world events by deliberately changing his or her thoughts or images. TAF is an internal source of the inflation of responsibility, that is, the trigger for feelings of responsibility is the patient’s own thoughts. This can be differentiated from the inflated responsibility that arises from external sources,
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namely, the typical triggers for feelings of responsibility in compulsive checkers, which include physical stimuli such as stoves, door locks, and knives. These external sources then trigger appraisals of responsibility. Regardless of the origin of the inflation of responsibility, whether it is from an internal or external source, it will promote the urge to check or to take other preventive actions to reduce risk. The external origins of perceived responsibility are familiar, but the internal provocations of such responsibility, notably in the form of TAF, have only recently come to attention (Rachman, 1993). There are a number of possible contributors to the development of TAF. Some aspects of TAF may be culturally determined. For example, Catholicism teaches that it is sinful to have blasphemous, adulterous, or aggressive thoughts: “sin by thought, sin by deed.” Tallis (1994) has suggested that a chance pairing of a thought and a negative event can lead to the belief that the thought is significant and may have the power to cause a negative event. For example, a patient often wished her father dead; after one such thought her father did die (unexpectedly), and she came to believe that her thought had caused his death. She interpreted later intrusive negative thoughts, particularly about someone dying, as both (a) putting the person at risk (likelihood TAR) and (b) her wishing evil on the person (moral TAF). Thus, she perceived herself as a bad person for having intrusive thoughts about people dying, and as a dangerous person for having these thoughts. Since she perceived her thoughts as putting people at risk, she felt it was her responsibility to prevent harm coming to them by having a positive thought about them (i.e., neutralizing). Moral and likelihood TAF should be related to each other: if you believe your thoughts are dangerous you are likely to feel that their occurrence is immoral and that you are a wicked person for having them. However, it is possible to believe that bad thoughts are immoral without also believing that they can cause bad events to happen, and vice versa. The relationship between the two forms of TAF was examined in two studies described in this paper. The two studies arose from our previous finding that TAF forms a coherent subscale that is strongly related to measures of obsessionality (Rachman, Thordarson, ShatYan, & Woody, 1995). The TAF factor was the one that correlated most consistently and strongly with the cleaning, checking, and doubting/conscientiousness subscales of the Maudsley Obsessional Compulsive Inventory (r = .35, .41, and .26, respectively). We therefore decided to investigate TAFT in OCD further, expecting that (a) TAF would be more evident and stronger in people with obsessional problems than in nonobsessional subjects, and (b) TAF scores would correlate positively with increases in obsessionalcompulsive characteristics. STUDY The aims of Study 1 were 1. to develop a questionnaire to assessTAF,
1
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2. to compare TAF in obsessional and nonobsessional samples, and 3. to explore the relationship between TAF and measures of obsessionality. METHOD Subjects Obsessional
sample. One hundred forty-seven subjects (mean age 38 years;
74% female) participated. These subjects had responded to an advertisement for people with OCD to participate in research. Subjects were included in this study if they scored above a clinical cutoff of 11 on the Maudsley Obsessional Compulsive Inventory (MOCI: Hodgson dz Rachman, 1977). Approximately two-thirds of the group had received formal diagnoses of OCD. There were no significant differences in MOCI scores between those who had received a diagnosis and those who had not, so all of the obsessional subjects were considered to belong to a single group. Student sample. One hundred ninety undergraduate students (mean age 19 years; 65% female) at the University of British Columbia completed the questionnaires in exchange for one course credit point. Measures The TAF Scale. The TAF Scale contained 34 items. Of these, 13 questions evaluated the fusion of thoughts and actions in terms of morality (e.g., having a blasphemous thought is almost as sinful as a blasphemous action), 7 questions assessed the TAF for negative events happening to a friend/relative (e.g., if I think of a friend/relative having a car accident, this increases the risk that he/she will have a car accident), 6 questions assessed TAF for negative events happening to oneself (e.g., if I think of myself having a car accident, this increases the risk that I will have a car accident), 4 questions asked about TAF for positive events happening to a friend (e.g., if I think of a relative/friend winning the lottery, this increases the chance that he/she will win), and 4 questions asked about TAF for positive events happening to oneself (e.g., if I think of a relative/friend winning the lottery, this increases the chance that he/she will win). Subjects were asked to endorse each item on a scale of 0, disagree strongly, to 4, agree strongly. No items were reversed scored. Maudsley Obsessional
Compulsive Inventory (MOCK; Hodgson & Rachman,
1977). The MOCI is a well-established 30-item true-false questionnaire measure obsessive-compulsive symptoms (see Taylor, 1995).
to
Beck Depression Inventory (BDI; Beck, 1967). This 21-item scale has been widely used in the measurement of depression (Beck, Steer, & Garbin, 1988).
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RESULTS Factor Structure A principal components analysis with direct oblimin transformation was conducted on the TAF items separately for each sample. The best solution for the student sample was a three-factor solution that accounted for 61.6% of the variance. The likelihood type of TAF was split into two factors: TAF for events happening to other people (TAPLikelihood-for-others), and TAF for events happening to oneself (IAF-Likelihood-for-self). The moral type of TAF (TAF-Moral) emerged as a cohesive factor. The factors were all moderately intercorrelated (r = .32 to .35). The best solution for the obsessional sample, however, was a two-factor solution that accounted for 61.1% of the variance. The items split into two factors, TM-Moral and TAF-Likelihood, which were correlated (r = 44). A three-factor solution in the obsessional group had poor sample structure and the likelihood factor did not divide into other versus self as in the student sample; rather, in the three-factor solution there was a tendency for TAF-Likelihood for positive events to separate from TAF-Likelihood for negative events. Internal consistency of the TAP-Moral and TAF-Likelihood scales was high both for obsessionals (Cronbach’s alpha = .95, .96, respectively) and for the students (alpha = .93 for each subscale). Group Differences Independent groups t-tests for TAF-Moral, TAF-Likelihood-for-others, and TAF-Likelihood-for-self subscales were conducted. The results are given in Table 1. People in the obsessional group scored higher than the student group on the TM-Moral and TAPLikelihood-for-others subscales; there was no significant difference between the groups on TAF-Likelihood-for-self. The obsessional sample also had significantly higher MOCI and BDI scores.
DEXREWVE
TAF Subscale MOld
Lieliiood-Other Likelihood-Self MOCI-Total BDI
No. Items 13 11 10 30 21
%-values and degrees of freedom *p< .OOl.
STAnSnCS
TABLE 1 GROW DIFFER@& as:
AND
STlmY
Obsessional Sample (n = 147) M W)
Student Sample (n = 190) M (W
25.74 (14.59) 13.19 (11.15) 14.68 (9.81) 16.85 (4.90) 20.11 (12.02)
19.52 (10.59) 5.70 (7.37) 13.54 (8.14) 7.25 (5.39) 7.59 (7.63)
adjusted
for heterogeneous
variances
1
where required.
t’(dna
4.25* 6.92* 1.12 16.03* 10.68*
(241) (228) (269) (310) (212)
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It should be noted that although the obsessional group scored more highly than the students on two of the subscales, most of the obsessional group members did not state that they strongly believed in many of the TAF items. For example, only 29% of the obsessional group members said that they agreed or agreed strongly with the statement, “If I think of a friend/relative being in a car accident, this increases the risk that he/she will have a car accident”; however, this is ten times greater than the 3% of the students who endorsed this item. Although we created the Likelihood subscale with both positive and negative items, the factor structure did not support this division in either sample. When we examined the means, there was a significant difference between the groups on TAF-Likelihood-for-others for positive events (t = 4.86, p c .OOl), but not on TAF-Likelihood-for-self for positive events (r = -1.11, ns). STUDY
2
The aim of Study 2 was to replicate the previous findings and expand them by including a sample of community adults. METHOD Subjects Obsessional sample. One hundred eighteen subjects (mean age 40 years; 64% female) completed the questionnaires. The criteria were the same as those for Study 1. Approximately 20% of these subjects had participated in Study 1. Community sample. One hundred twenty-two community ed the questionnaires (mean age 40 years, 58% female).
volunteers complet-
Student sample. Two hundred hundred seventy-two undergraduate students
(mean age 20 years; 65% female) at the University of British Columbia completed the questionnaires in exchange for one course credit point. Measures The TAF Scale (Revised). The positive items, which are least relevant to OCD, were removed from the TAF-Likelihood subscales. We retained the TAFLikelihood-for-self subscale (negative items only) since we were aiming to replicate the previous findings of different factor structures between obsessional and nonobsessional subjects. We also removed one negative item from the TAF-Likelihood-for-others subscale and one item from the TAF-Moral subscale as, upon reflection, they seemed ambiguous or repetitive. This revised TAF scale was a shorter, refmed form of the original. The original contained 34 items and the revised version only 19 items: 12 Moral, 4 Likelihood-forOthers, and 3 Likelihood-for-Self. The TAF measure was incorporated into a larger questionnaire package (Rachman, Thordarson, & Radomsky, 1995) (see Appendix). Items were rated as before.
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Maua!dey ObsessionalCompulsive Inventory (MOCI; Hodgson & Rachan, 1977). see Study 1. Beck DepressionInventory (BDI; Beck, 1967). (See Study 1).
RESULTS Factor Structure
A principal components analysis with direct oblimin transformation was performed on the TAF items separately for each sample. For student and community samples two- and three-factor solutions were equally interpretable and had excellent simple structure. The two-factor solutions accounted for 59% and 66% of the variance, respectively; the three-factor solutions accounted for 66% and 756, respectively. In both groups, a two-factor solution resulted in a clear distinction between the Moral and Likelihood subscales; in the tbree-factor solution, the Likelihood items were divided into Likelihood-Others and Likelihood-Self. ln the obsessional sample, two clear factors emerged, Moral and Likelihood TAF, accounting for 71% of the variance. As in Study 1, a three-factor solution in the obsessional sample had poor sample structure and produced no division between Likelihood-Others and Likelihood-Self. Internal consistency of the Moral and Likelihood (Other and Self) subscales was excellent for all the samples (Cronbach’s alpha ranged from 85 to .%). Group Diflerences
Descriptive statistics are shown in Table 2. A one-way analysis of variance (ANOVA) was conducted on each of the three TAF subscales. A significant group effect was found for all three scales: TAF-Moral F(2.222) = 12.38, p < .OOl; TAF-Likelihood-for-others F(2,245) = 35.88, p < .OOl; and TAFLikelihood-for-self F(2,245) = 19.12, p < .OOl.* As expected, there were also significant group differences on the MOCI, F(2,262) = 202.84, p < .OOl, and BDI, F(2.238) = 56.36,~ < .OOl, scales. Significant ANOVAs were followed up by evaluating all pairwise comparisons, using Bonferroni-adjusted t-tests for independent means (alpha = .05/15 = .003), corrected for heterogeneity of variance where required. For the TAFMoral subscale, there were significant differences between obsessionals and adults, and between adults and students, but not between obsessionals and students (p = .14). For the TAF-Likelihood-for-others subscale, the three groups were all significantly different. For the TAF-Likelihood-for-self subscale, there were significant differences between obsessionals and adults and adults and ‘F-values and degrees of freedom are adjusted according to Welch’s cant heterogeneity of variance and unequal samplesizes.
(1951)
procedurefor
signiti-
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D. S. I’HORDARSON,
AND
TABLE DESCRWTIVE
2
STATISTICS AND GROUP DIFFERENCES:
Obsessionals (n= 118) M (SO TAF: Moral TAF: Likelihood-other TAF: Likelihood-Self MOCI-Total BDI
S. RACHMAN
STUDY 2
Adults (n = 122) h-f
20.03* (13.17) 4.778 (4.74) 4.418 (3.57) 16.368 (5.35) 18Ha (10.93)
Students (II = 272) J+t (3
w
12.74b (11.13) 1.03b (2.14) 2.09b (2.49) 4.68b (3.23) 6.35b (6.02)
17.97’ (10.53) 2.w (3.29) 3.428 (3.00) 8.56C (5.33) 9.w (7.66)
N&e. DilTexent superscripts denote significant differences among means, calculated using Bonfemoniadjusted (alpha = .05/15 = .oCn) independent-samples r-tests, comcted for heterogeneous variances where llecesq.
students, but the difference between obsessionals and students was not significant at the Bonferroni-adjusted alpha level (p = .Ol). Associations
with Measures of Obsession&y
Pearson’s correlation coefficients were calculated to determine the strength of the association between the checking and washing subscales of the MOCI, BDI score and TAP for each group. Alpha was set at 405 owing to the number of correlation coefficient calculated. The results can be seen in Table 3. Partial correlations were also computed to control for the effects of depression. In the student sample, correlations retained their significance when partialling out BDI score. In the obsessional group, only the correlation between TABLE cORRE!LAllONS
BETWEEN
TAF,
MOCI-Chccking Obsfzssionals TAF - Moral TAF - Liielihood-Othen TAF - Likelihood-Self Community Adults TAF - Moral TAF - Likelihood-Others TAF - Likelihood-Self Students TAF - Moral TAF - Likelihood-Others TAF - Likelihood-Self
*p c .005.
3 MGCI
SUBSCALEP
AND BDI
MOCKleaning
BDI
.31* .38* .33*
.07
.04 .07 24
04
.12 .13
.ll .I0 .18
.30* .38* .28*
.34* .37* .21*
.22* .28* .16
.18* .16
.42* .37* .33*
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TAF-Likelihood-for-others and the checking subscale of the MOCI remained significant when depression was partialled out. DISCUSSION Results indicate that TAF is a highly reliable construct in student, adult, and obsessional samples. Items fell into coherent factors that accounted for a large proportion of the total variance. Scores from the obsessional sample were higher than those of the students and adults on the TAF-Likelihood-for-others subscale (i.e., TAF for events relating to others). The principal components analyses indicated that the obsessional sample did not distinguish between TAF-Likelihood-for-self (i.e., TAF for events relating to themselves), and TAF-Likelihood-for-others, whereas the student and adult community samples made this distinction. TAF-Likelihood-for-others was moderately related to checking behavior in the obsessional and student groups, and this association was significant when controlling for depression. Obsessionals believed in TAF-Likelihood-for-others to a similar extent (or slightly more) than they believed in TAF-Likelihood-for-self, whereas the comparison groups believed in TAF-Likelihood-for-self more than TAF-Likelihoodfor-others. Tbis finding, coupled with the results from the principal components analysis, implies that obsessional subjects consider TAI-Likelihood-for-others and TM-Likelihood-for-self to work in a similar way, while most of the students and adults appear to believe only in TAF-Likelihood-for-self. Thus obsessionals may be considered to be engaging in a second “fusion,” that is, the fusion of TAF-likelihood-for-self and TAF-likelihood for others. TAR-likelihood-for-self can explained in terms of “self-fulfilling prophe ties.” For example, it is rational to believe that “If I smile and am more pleasant to people, good things will happen to me” and “If I think negative thoughts, I will express them and future social interactions will be negative.” Thus an internal phenomenon (a thought) can have real-world consequences in terms of a person’s behavior and subsequent events that are influenced by that behavior. However, a person’s thoughts obviously do not have the same effect on another person’s behavior. Student and adult samples acknowledged the difference between the influence of their thoughts over their own behavior and the behavior of others, but the obsessional subjects did not. TAF-Likelihood-for-others was associated with compulsive checking in the obsessional and student groups, but not the community adults. The association was still significant in the obsessional group, once depression had been partialled out, although it was reduced to r = .30. This raises a number of possibilities. First, results suggest that depression promotes both TAF-Likelihood-for-others and checking. It may be that once depressed, a vulnerability to TAF-Likelihoodfor-others becomes activated. Believing that your thoughts increase the probability of an external negative event is likely to lead to increased checking to prevent the feared event from occurring and increasing efforts to obtain reassurance that
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it has not occurred. Alternatively, being depressed could exacerbate both checking and TAF-Likelihood-for-others independently. In support of this, checking behavior was still correlated with depression, even in the absence of TAFLikelihood-for-others. Being depressed may lower one’s resistance to the urges to check and hence increase compulsive behavior. Depression could also incmase TAF-Likelihood-for-others without leading to an increase in checking behavior, if a person believes that thoughts cannot be “undone” or neutralized. There is a close relationship between TAF and perceived responsibility for a negative event. A person who believes in TAF-Likelihood-for-others and has an intrusive thought about an accident is liable to consider that he/she has contributed, at least partially, to the potential occurrence of the accident. The person is also likely to consider that it is his/her responsibility to take action to undo the potential negative consequences by neutralizing. Some preliminary data from our laboratory have demonstrated that eliciting TAF for a negative event relating to others leads to a desire to neutralize and that neutralizing reduces perceived responsibility for the threat (Rachman, Shafran, Mitchell, Trant, & Teachman, 1996). Furthermore, there was a correlation between scores on the TAF-Likelihood-for-others subscale and estimates of the likelihood of the negative event following provocation. Similarly, people with TAF-Moral, who believe that thinking something is almost as bad as doing it, are likely to feel guilty and responsible for their intrusive negative thoughts and/or the potential effects of these thoughts. It is probable that feeling intense moral responsibility for your thoughts results in guilt, and it is possible that this guilt is then misinterpreted as a sign that the negative event would be serious and the person would be to blame. For example, if thinking about swearing is almost as bad as doing it, a person is liable to feel highly responsible both for their thoughts and the potential negative outcome (several subjects commented that thinking is one step before acting on their thoughts) and feel guilty. In turn, a person may misinterpret the feeling of guilt by thinking “Because I feel so guilty, the thought and the consequences must be my fault.” Clearly these speculations about the complex relations between TAF, responsibility, and guilt will need to be investigated. Given the high level of depression in the obsessional samples, it is likely that self-esteem was low. However, belief in TAI-Likelihood-for-others implies that one has extra powers and may be a somewhat narcissistic belief. The limit to this “power” is that it works for only negative events. Also, people with obsessional problems and a belief in TAF may consider that they can prevent or influence the course of a negative event occurring, but the initial obsessional thoughts are nevertheless intrusive, unacceptable, and unwanted, the person does not have the “power” to prevent them. Therefore, although low self-esteem and tbis element of narcissism seem incompatible, they can be closely connected, depending on the nature and limits of the assumed influence over events. Our findings are correlational and unfortunately do not shed light on the debate as to the relative importance of affect versus cog&ions in OCD. It is
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likely, however, that the two are closely linked and that depression or anxiety may increase the occurrence and believability of intrusive thoughts. In turn, increased endorsement of dysfunctional beliefs, particularly TAF-Likelihoodfor-others, is likely to exacerbate low self-esteem, depression, anxiety, and perceived responsibility for the event. The finding from our second study, that TAF-Moral was not higher in the obsessional population compared to the student sample, stands in need of explanation. It is unlikely that the change in the TM-Moral scale from 13 items to 12 items explains the difference. A more detailed look at our results shows that the mean item score for the TAF scale was stable across student samples in Studies 1 and 2, but that it was lower in the second obsessional sample than in the fust. The first sample was slightly more depressed than the second sample, which may be one explanation for our findings, since there is a high association between TAF-Moral and depression. More importantly, it may be that the beliefs about TAF-Moral are common and are not necessarily pathological. However, in combination with depression the beliefs may become more dysfunctional and may be interpreted in terms of responsibility, as discussed above. Hence, occurrence of TAF-Moral per se may be less important in obsessional problems than the personal relevance and salience of the belief, the frequency of its activation, and the resultant distress. This is consistent with earlier work on the nature of intrusive thoughts: the content of intrusive thoughts is similar across normal and obsessional subjects, but other characteristics of the thoughts (such as duration, degree of unacceptability, etc.) are more pronounced in obsessional subjects (Rachman & de Silva, 1978). Our scale may be missing an important aspect of TAF-moral beliefs, namely, what the occurrence of intrusive thoughts reflects about oneself. This should be addressed in future studies. Our results indicated that endorsement of items on the TAF-likelihood-forothers was often idiosyncratic and the majority of all populations did not experience strong TAE Many obsessional subjects endorsed only one item strongly, and therefore could obtain a low total score despite strong TAF in one domain. Such specificity is consistent with the phenomenology of obsessional complaints in which, for example, a person may repeatedly check light switches in the remote event of a fire occurring, but happily ride a motomycle, which is considerably more dangerous. Therefore, these scales may be better used as a starting point in identifying beliefs for a client, not as total scores to show the degree of TAF beliefs. It should be emphasized that the construct of TAF is in its early stages of development. TAF may be one of several metacognitions (beliefs about thoughts) that play a role in OCD (and perhaps other anxiety disorders). If TAF does turn out to have particular relevance for OCD, its identification has implications for treatment. Identification of this type of metacognition may provide an avenue for the therapist to begin challenging the beliefs. Techniques that have until now dealt only with the frequency of intrusive thoughts, such as
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thought-stopping, would not be helpful if the underlying metacognition of TAF remains unchanged. Similarly, targeting compulsive behavior, as with exposure and response prevention, will be less effective if core beliefs about TAF are not challenged. Further investigation of metacognitions and their effects on obsessional complaints is underway. REFERENCES Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper & Row. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical PsychorogY Review, 8.77-100. Hodgson, R., 8r Rachman, S. (1977). Obsessional compulsive complaints. Behaviour Research aad Therapy, 15.389-395. Rachman, S. (1993). Obsessions, responsibility and guilt. Behaviour Research and Therapy, 31, 149-w. Rachman, S., Shafran, R., Mitchell, D., Trant, J., & Teachman, B. (1996). How ro remain neutral: An experimental analysis of neutralization. Manuscript submitted for publication. Rachman, S., Thordamon. D. S., & Radomsky, A. S. (1995, July). A revision of the hfaudsley Obsessional Compulsive Invenfory. Poster presented at the World Congress of Behaviourai and Cognitive Therapies, Copenhagen. Rachman, S., Thordarson, D. S., Shafran, R.. & Woody, S. R. (1995). Perceived responsibility: Structure and significance. Behaviour Research and Therapy, 33,779-784. Salkovskis, l? M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviovr
Research
and Therapy,
25,571-583.
Salkovskis, P M. (1989). Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27.677-682. Salkovskis, P M. (1996). Cognitive-behavioural approaches to the understanding of obsessional problems. In R. Rapte (Ed.), Current controversies in anxiety disorders. New York: Guilford. Tallis, E (1994). Obsessions, responsibility and guilt: no case reports suggesting a common and specific aetiology. Behaviour Research and Therapy, 32, 143-145. Taylor, S. (1995). Assessment of obsessions and compulsions: Self-report inventories and observer-rated scales. Clinical Psychology Review, lS,261-296. Welch, B. L. (1951). On the comparison of several mean vahres:An alternative approach. Biomenika, 38.330-336.
APPENDIX:
REVISED TAF SCALE ITEMS
TAF-Moral
1. Thinking of making an extremely critical remark to a friend is almost as unacceptable to me as actually saying it. 2. Having a blasphemous thought is almost as sinful to me as a blasphemous action. 3. Thinking about swearing at someone else is almost as unacceptable to me as actually swearing. 4. When I have a nasty thought about someone else, it is almost as bad as carrying out a nasty action. 5. Having violent thoughts is almost as unacceptable to me as violent acts.
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6. When I think about making an obscene remark or gesture in church, it is almost as sinful as actually doing it. 7. If I wish harm on someone, it is almost as bad as doing harm. 8. If I think about making an obscene gesture to someone else, it is almost as bad as doing it. 9. When I think unkindly about a friend, it is almost as disloyal as doing an unkind act. 10. If I have a jealous thought, it is almost the same as making a jealous remark. 11. Thinking of cheating in a personal relationship is almost as immoral to me as actually cheating. 12. Having obscene thoughts in a church is unacceptable to me. TAF-Likelihood-Others
1. If I think of a relative/friend losing their job, this increases the risk that they will lose their job. 2. If I think of a relative/friend being in a car accident, this increases the risk that he/she will have a car accident. 3.. If I think of a friend/relative being injured in a fall, this increases the risk that he/she will have a fall and be injured. 4. If I think of a relative/friend falling ill this increases the risk that he/she will fall ill. TAF-Likelihood-Self
1. If I think of myself being injured in a fall, this increases the risk that I will have a fall and be injured. 2. If I think of myself being in a car accident, this increases the risk that I will have a car accident. 3. If I think of myself falling ill, this increases the risk that I will fall ill.
Pergamon
PII Soss7-618s(%)ooo18-7
Thought-Action Fusion in Obsessive Compulsive Disorder Roz SHAFXAN, PH.D., DANA S. THORDARSON, M-A., AND S. RACHMAN, PH.D.* University
of British
Columbia
Abstract - Recent psychometric results suggested that the phenomenon of thoughtaction fusion (TAF) is implicated in obsessive compulsive disorder (OCD). The construct of TAF has two components: (a) the belief that thinking about an unacceptable or disturbing event makes it mote likely to happen and (b) the belief that having an unacceptable thought is the moral equivalent of carrying out the unacceptable or disturbing action. The consttuct of TAF is explored, and its relevance to msponsibility and obse.5 sive-compulsive disorder examined. A highly reliable questionnaire to measure TAF has been developed, and psychometric data obtained from two studies are presented. TAF was higher in obsessional samples than in nonobsessional samples, particularly the belief that thinking about a negative event involving other people makes the event more likely to happen. You have heard that it was said, “Do not commit adultery.” But now I tell you: Anyone who looks at a woman and wants to possessher is guilty of committing adultery with her in his heart. Matthew X.27-28.
It has been suggested that some patients with OCD experience thought-action fusion (TAP) in which thoughts, particularly unwanted intrusive thoughts, are interpreted as having special significance (Rachman, 1993). Preliminary research has provided support for this hypothesis (Rachman, Thordarson, Shafran, & Woody, 1995), and TM appears to have two components: 1. The belief that thinking about an unacceptable or disturbing event makes that event more probable, more likely to happen in reality. This will be This research was supported by a grant from the British Columbia Health Research Foundation. The first author was supported by a Wellcome Trust Prize Studentship. The authors would like to thank Nichole Fairbrother, Adam Radomsky, and the anonymous reviewers for their helpful comments. Requests for reprints should be sent to to S. Rachman, Ph.D., Department of Psychology, University of British Columbia 2136 West Mall, Vancouver, B.C., Canada V6T lZ4. 379
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referred to as the likelihood type of TAF. For example, if a husband with this belief experiences an intrusive thought of his wife being in a car accident, he feels that his wife is at greater risk of having a car accident, because he has had the thought. As he has placed his wife in danger, he may feel that it is his responsibility to prevent harm coming to her, perhaps by mentally “neutralizing” the thought. 2. The interpretation of obsessional thoughts and forbidden actions as morally equivalent. The person feels that his or her unacceptable thoughts, images or impulses are.(almost) as bad as the actual events they describe. For example, if a mother with this belief experiences the intrusive thought that she is going to harm her child, she is likely to feel as though she is as morally responsible as if she had really harmed her child. It is possible that the mother interprets such an intrusion as revealing her “true” nature, that is, “only wicked people have this type of thought; I am wicked,*’ or, “perhaps I really want to do this; I am wicked.” This component will be referred to as the moral type of TAF. Our construct of TAF is derived from observing particular obsessional-compulsive phenomena. For example, a religious patient, while praying, experienced intrusive images of having sexual relations with Jesus. This patient believed that she had sinned against God by having such an image and was therefore an immoral person. A father experienced the intrusion that he was going to harm his son while dressing him. The patient regarded this as meaning that he was a wicked pedophile who was unsafe to be left alone with children because he was liable to harm them. We believe that obsessional-compulsive patients with TAF are particularly prone to experience a sense of inflated responsibility because of these beliefs (see Salkovskis, 1985). Salkovskis suggests that the link between the occurrence of a cognitive intrusion and the need for action is the misinterpretation of the cognition as an indication that the person might be responsible for harm unless he or she takes action to prevent it (emphasis added). We would suggest that for some patients, the psychological fusion of thoughts and actions is a fundamental part of the catastrophic misinterpretation, “I am responsible for harm.” A person is likely to believe that he has contributed to being the cause of the negative event if he believes that the probability of a negative event is increased by his thinking about it. He will therefore perceive himself to be at least partially responsible for the threat of the negative event and perhaps also consider it his responsibility to reduce or remove such a threat. Such a threat can be reduced or removed by mental “neutralizing,” for example, by mconstructing the image of a car accident so that passengers are no longer injured. Some examples of mental neutralizing can be seen as a form of TAF the person attempts to influence real world events by deliberately changing his or her thoughts or images. TAF is an internal source of the inflation of responsibility, that is, the trigger for feelings of responsibility is the patient’s own thoughts. This can be differentiated from the inflated responsibility that arises from external sources,
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namely, the typical triggers for feelings of responsibility in compulsive checkers, which include physical stimuli such as stoves, door locks, and knives. These external sources then trigger appraisals of responsibility. Regardless of the origin of the inflation of responsibility, whether it is from an internal or external source, it will promote the urge to check or to take other preventive actions to reduce risk. The external origins of perceived responsibility are familiar, but the internal provocations of such responsibility, notably in the form of TAF, have only recently come to attention (Rachman, 1993). There are a number of possible contributors to the development of TAF. Some aspects of TAF may be culturally determined. For example, Catholicism teaches that it is sinful to have blasphemous, adulterous, or aggressive thoughts: “sin by thought, sin by deed.” Tallis (1994) has suggested that a chance pairing of a thought and a negative event can lead to the belief that the thought is significant and may have the power to cause a negative event. For example, a patient often wished her father dead; after one such thought her father did die (unexpectedly), and she came to believe that her thought had caused his death. She interpreted later intrusive negative thoughts, particularly about someone dying, as both (a) putting the person at risk (likelihood TAR) and (b) her wishing evil on the person (moral TAF). Thus, she perceived herself as a bad person for having intrusive thoughts about people dying, and as a dangerous person for having these thoughts. Since she perceived her thoughts as putting people at risk, she felt it was her responsibility to prevent harm coming to them by having a positive thought about them (i.e., neutralizing). Moral and likelihood TAF should be related to each other: if you believe your thoughts are dangerous you are likely to feel that their occurrence is immoral and that you are a wicked person for having them. However, it is possible to believe that bad thoughts are immoral without also believing that they can cause bad events to happen, and vice versa. The relationship between the two forms of TAF was examined in two studies described in this paper. The two studies arose from our previous finding that TAF forms a coherent subscale that is strongly related to measures of obsessionality (Rachman, Thordarson, ShatYan, & Woody, 1995). The TAF factor was the one that correlated most consistently and strongly with the cleaning, checking, and doubting/conscientiousness subscales of the Maudsley Obsessional Compulsive Inventory (r = .35, .41, and .26, respectively). We therefore decided to investigate TAFT in OCD further, expecting that (a) TAF would be more evident and stronger in people with obsessional problems than in nonobsessional subjects, and (b) TAF scores would correlate positively with increases in obsessionalcompulsive characteristics. STUDY The aims of Study 1 were 1. to develop a questionnaire to assessTAF,
1
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2. to compare TAF in obsessional and nonobsessional samples, and 3. to explore the relationship between TAF and measures of obsessionality. METHOD Subjects Obsessional
sample. One hundred forty-seven subjects (mean age 38 years;
74% female) participated. These subjects had responded to an advertisement for people with OCD to participate in research. Subjects were included in this study if they scored above a clinical cutoff of 11 on the Maudsley Obsessional Compulsive Inventory (MOCI: Hodgson dz Rachman, 1977). Approximately two-thirds of the group had received formal diagnoses of OCD. There were no significant differences in MOCI scores between those who had received a diagnosis and those who had not, so all of the obsessional subjects were considered to belong to a single group. Student sample. One hundred ninety undergraduate students (mean age 19 years; 65% female) at the University of British Columbia completed the questionnaires in exchange for one course credit point. Measures The TAF Scale. The TAF Scale contained 34 items. Of these, 13 questions evaluated the fusion of thoughts and actions in terms of morality (e.g., having a blasphemous thought is almost as sinful as a blasphemous action), 7 questions assessed the TAF for negative events happening to a friend/relative (e.g., if I think of a friend/relative having a car accident, this increases the risk that he/she will have a car accident), 6 questions assessed TAF for negative events happening to oneself (e.g., if I think of myself having a car accident, this increases the risk that I will have a car accident), 4 questions asked about TAF for positive events happening to a friend (e.g., if I think of a relative/friend winning the lottery, this increases the chance that he/she will win), and 4 questions asked about TAF for positive events happening to oneself (e.g., if I think of a relative/friend winning the lottery, this increases the chance that he/she will win). Subjects were asked to endorse each item on a scale of 0, disagree strongly, to 4, agree strongly. No items were reversed scored. Maudsley Obsessional
Compulsive Inventory (MOCK; Hodgson & Rachman,
1977). The MOCI is a well-established 30-item true-false questionnaire measure obsessive-compulsive symptoms (see Taylor, 1995).
to
Beck Depression Inventory (BDI; Beck, 1967). This 21-item scale has been widely used in the measurement of depression (Beck, Steer, & Garbin, 1988).
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RESULTS Factor Structure A principal components analysis with direct oblimin transformation was conducted on the TAF items separately for each sample. The best solution for the student sample was a three-factor solution that accounted for 61.6% of the variance. The likelihood type of TAF was split into two factors: TAF for events happening to other people (TAPLikelihood-for-others), and TAF for events happening to oneself (IAF-Likelihood-for-self). The moral type of TAF (TAF-Moral) emerged as a cohesive factor. The factors were all moderately intercorrelated (r = .32 to .35). The best solution for the obsessional sample, however, was a two-factor solution that accounted for 61.1% of the variance. The items split into two factors, TM-Moral and TAF-Likelihood, which were correlated (r = 44). A three-factor solution in the obsessional group had poor sample structure and the likelihood factor did not divide into other versus self as in the student sample; rather, in the three-factor solution there was a tendency for TAF-Likelihood for positive events to separate from TAF-Likelihood for negative events. Internal consistency of the TAP-Moral and TAF-Likelihood scales was high both for obsessionals (Cronbach’s alpha = .95, .96, respectively) and for the students (alpha = .93 for each subscale). Group Differences Independent groups t-tests for TAF-Moral, TAF-Likelihood-for-others, and TAF-Likelihood-for-self subscales were conducted. The results are given in Table 1. People in the obsessional group scored higher than the student group on the TM-Moral and TAPLikelihood-for-others subscales; there was no significant difference between the groups on TAF-Likelihood-for-self. The obsessional sample also had significantly higher MOCI and BDI scores.
DEXREWVE
TAF Subscale MOld
Lieliiood-Other Likelihood-Self MOCI-Total BDI
No. Items 13 11 10 30 21
%-values and degrees of freedom *p< .OOl.
STAnSnCS
TABLE 1 GROW DIFFER@& as:
AND
STlmY
Obsessional Sample (n = 147) M W)
Student Sample (n = 190) M (W
25.74 (14.59) 13.19 (11.15) 14.68 (9.81) 16.85 (4.90) 20.11 (12.02)
19.52 (10.59) 5.70 (7.37) 13.54 (8.14) 7.25 (5.39) 7.59 (7.63)
adjusted
for heterogeneous
variances
1
where required.
t’(dna
4.25* 6.92* 1.12 16.03* 10.68*
(241) (228) (269) (310) (212)
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It should be noted that although the obsessional group scored more highly than the students on two of the subscales, most of the obsessional group members did not state that they strongly believed in many of the TAF items. For example, only 29% of the obsessional group members said that they agreed or agreed strongly with the statement, “If I think of a friend/relative being in a car accident, this increases the risk that he/she will have a car accident”; however, this is ten times greater than the 3% of the students who endorsed this item. Although we created the Likelihood subscale with both positive and negative items, the factor structure did not support this division in either sample. When we examined the means, there was a significant difference between the groups on TAF-Likelihood-for-others for positive events (t = 4.86, p c .OOl), but not on TAF-Likelihood-for-self for positive events (r = -1.11, ns). STUDY
2
The aim of Study 2 was to replicate the previous findings and expand them by including a sample of community adults. METHOD Subjects Obsessional sample. One hundred eighteen subjects (mean age 40 years; 64% female) completed the questionnaires. The criteria were the same as those for Study 1. Approximately 20% of these subjects had participated in Study 1. Community sample. One hundred twenty-two community ed the questionnaires (mean age 40 years, 58% female).
volunteers complet-
Student sample. Two hundred hundred seventy-two undergraduate students
(mean age 20 years; 65% female) at the University of British Columbia completed the questionnaires in exchange for one course credit point. Measures The TAF Scale (Revised). The positive items, which are least relevant to OCD, were removed from the TAF-Likelihood subscales. We retained the TAFLikelihood-for-self subscale (negative items only) since we were aiming to replicate the previous findings of different factor structures between obsessional and nonobsessional subjects. We also removed one negative item from the TAF-Likelihood-for-others subscale and one item from the TAF-Moral subscale as, upon reflection, they seemed ambiguous or repetitive. This revised TAF scale was a shorter, refmed form of the original. The original contained 34 items and the revised version only 19 items: 12 Moral, 4 Likelihood-forOthers, and 3 Likelihood-for-Self. The TAF measure was incorporated into a larger questionnaire package (Rachman, Thordarson, & Radomsky, 1995) (see Appendix). Items were rated as before.
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Maua!dey ObsessionalCompulsive Inventory (MOCI; Hodgson & Rachan, 1977). see Study 1. Beck DepressionInventory (BDI; Beck, 1967). (See Study 1).
RESULTS Factor Structure
A principal components analysis with direct oblimin transformation was performed on the TAF items separately for each sample. For student and community samples two- and three-factor solutions were equally interpretable and had excellent simple structure. The two-factor solutions accounted for 59% and 66% of the variance, respectively; the three-factor solutions accounted for 66% and 756, respectively. In both groups, a two-factor solution resulted in a clear distinction between the Moral and Likelihood subscales; in the tbree-factor solution, the Likelihood items were divided into Likelihood-Others and Likelihood-Self. ln the obsessional sample, two clear factors emerged, Moral and Likelihood TAF, accounting for 71% of the variance. As in Study 1, a three-factor solution in the obsessional sample had poor sample structure and produced no division between Likelihood-Others and Likelihood-Self. Internal consistency of the Moral and Likelihood (Other and Self) subscales was excellent for all the samples (Cronbach’s alpha ranged from 85 to .%). Group Diflerences
Descriptive statistics are shown in Table 2. A one-way analysis of variance (ANOVA) was conducted on each of the three TAF subscales. A significant group effect was found for all three scales: TAF-Moral F(2.222) = 12.38, p < .OOl; TAF-Likelihood-for-others F(2,245) = 35.88, p < .OOl; and TAFLikelihood-for-self F(2,245) = 19.12, p < .OOl.* As expected, there were also significant group differences on the MOCI, F(2,262) = 202.84, p < .OOl, and BDI, F(2.238) = 56.36,~ < .OOl, scales. Significant ANOVAs were followed up by evaluating all pairwise comparisons, using Bonferroni-adjusted t-tests for independent means (alpha = .05/15 = .003), corrected for heterogeneity of variance where required. For the TAFMoral subscale, there were significant differences between obsessionals and adults, and between adults and students, but not between obsessionals and students (p = .14). For the TAF-Likelihood-for-others subscale, the three groups were all significantly different. For the TAF-Likelihood-for-self subscale, there were significant differences between obsessionals and adults and adults and ‘F-values and degrees of freedom are adjusted according to Welch’s cant heterogeneity of variance and unequal samplesizes.
(1951)
procedurefor
signiti-
386
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D. S. I’HORDARSON,
AND
TABLE DESCRWTIVE
2
STATISTICS AND GROUP DIFFERENCES:
Obsessionals (n= 118) M (SO TAF: Moral TAF: Likelihood-other TAF: Likelihood-Self MOCI-Total BDI
S. RACHMAN
STUDY 2
Adults (n = 122) h-f
20.03* (13.17) 4.778 (4.74) 4.418 (3.57) 16.368 (5.35) 18Ha (10.93)
Students (II = 272) J+t (3
w
12.74b (11.13) 1.03b (2.14) 2.09b (2.49) 4.68b (3.23) 6.35b (6.02)
17.97’ (10.53) 2.w (3.29) 3.428 (3.00) 8.56C (5.33) 9.w (7.66)
N&e. DilTexent superscripts denote significant differences among means, calculated using Bonfemoniadjusted (alpha = .05/15 = .oCn) independent-samples r-tests, comcted for heterogeneous variances where llecesq.
students, but the difference between obsessionals and students was not significant at the Bonferroni-adjusted alpha level (p = .Ol). Associations
with Measures of Obsession&y
Pearson’s correlation coefficients were calculated to determine the strength of the association between the checking and washing subscales of the MOCI, BDI score and TAP for each group. Alpha was set at 405 owing to the number of correlation coefficient calculated. The results can be seen in Table 3. Partial correlations were also computed to control for the effects of depression. In the student sample, correlations retained their significance when partialling out BDI score. In the obsessional group, only the correlation between TABLE cORRE!LAllONS
BETWEEN
TAF,
MOCI-Chccking Obsfzssionals TAF - Moral TAF - Liielihood-Othen TAF - Likelihood-Self Community Adults TAF - Moral TAF - Likelihood-Others TAF - Likelihood-Self Students TAF - Moral TAF - Likelihood-Others TAF - Likelihood-Self
*p c .005.
3 MGCI
SUBSCALEP
AND BDI
MOCKleaning
BDI
.31* .38* .33*
.07
.04 .07 24
04
.12 .13
.ll .I0 .18
.30* .38* .28*
.34* .37* .21*
.22* .28* .16
.18* .16
.42* .37* .33*
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TAF-Likelihood-for-others and the checking subscale of the MOCI remained significant when depression was partialled out. DISCUSSION Results indicate that TAF is a highly reliable construct in student, adult, and obsessional samples. Items fell into coherent factors that accounted for a large proportion of the total variance. Scores from the obsessional sample were higher than those of the students and adults on the TAF-Likelihood-for-others subscale (i.e., TAF for events relating to others). The principal components analyses indicated that the obsessional sample did not distinguish between TAF-Likelihood-for-self (i.e., TAF for events relating to themselves), and TAF-Likelihood-for-others, whereas the student and adult community samples made this distinction. TAF-Likelihood-for-others was moderately related to checking behavior in the obsessional and student groups, and this association was significant when controlling for depression. Obsessionals believed in TAF-Likelihood-for-others to a similar extent (or slightly more) than they believed in TAF-Likelihood-for-self, whereas the comparison groups believed in TAF-Likelihood-for-self more than TAF-Likelihoodfor-others. Tbis finding, coupled with the results from the principal components analysis, implies that obsessional subjects consider TAI-Likelihood-for-others and TM-Likelihood-for-self to work in a similar way, while most of the students and adults appear to believe only in TAF-Likelihood-for-self. Thus obsessionals may be considered to be engaging in a second “fusion,” that is, the fusion of TAF-likelihood-for-self and TAF-likelihood for others. TAR-likelihood-for-self can explained in terms of “self-fulfilling prophe ties.” For example, it is rational to believe that “If I smile and am more pleasant to people, good things will happen to me” and “If I think negative thoughts, I will express them and future social interactions will be negative.” Thus an internal phenomenon (a thought) can have real-world consequences in terms of a person’s behavior and subsequent events that are influenced by that behavior. However, a person’s thoughts obviously do not have the same effect on another person’s behavior. Student and adult samples acknowledged the difference between the influence of their thoughts over their own behavior and the behavior of others, but the obsessional subjects did not. TAF-Likelihood-for-others was associated with compulsive checking in the obsessional and student groups, but not the community adults. The association was still significant in the obsessional group, once depression had been partialled out, although it was reduced to r = .30. This raises a number of possibilities. First, results suggest that depression promotes both TAF-Likelihood-for-others and checking. It may be that once depressed, a vulnerability to TAF-Likelihoodfor-others becomes activated. Believing that your thoughts increase the probability of an external negative event is likely to lead to increased checking to prevent the feared event from occurring and increasing efforts to obtain reassurance that
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it has not occurred. Alternatively, being depressed could exacerbate both checking and TAF-Likelihood-for-others independently. In support of this, checking behavior was still correlated with depression, even in the absence of TAFLikelihood-for-others. Being depressed may lower one’s resistance to the urges to check and hence increase compulsive behavior. Depression could also incmase TAF-Likelihood-for-others without leading to an increase in checking behavior, if a person believes that thoughts cannot be “undone” or neutralized. There is a close relationship between TAF and perceived responsibility for a negative event. A person who believes in TAF-Likelihood-for-others and has an intrusive thought about an accident is liable to consider that he/she has contributed, at least partially, to the potential occurrence of the accident. The person is also likely to consider that it is his/her responsibility to take action to undo the potential negative consequences by neutralizing. Some preliminary data from our laboratory have demonstrated that eliciting TAF for a negative event relating to others leads to a desire to neutralize and that neutralizing reduces perceived responsibility for the threat (Rachman, Shafran, Mitchell, Trant, & Teachman, 1996). Furthermore, there was a correlation between scores on the TAF-Likelihood-for-others subscale and estimates of the likelihood of the negative event following provocation. Similarly, people with TAF-Moral, who believe that thinking something is almost as bad as doing it, are likely to feel guilty and responsible for their intrusive negative thoughts and/or the potential effects of these thoughts. It is probable that feeling intense moral responsibility for your thoughts results in guilt, and it is possible that this guilt is then misinterpreted as a sign that the negative event would be serious and the person would be to blame. For example, if thinking about swearing is almost as bad as doing it, a person is liable to feel highly responsible both for their thoughts and the potential negative outcome (several subjects commented that thinking is one step before acting on their thoughts) and feel guilty. In turn, a person may misinterpret the feeling of guilt by thinking “Because I feel so guilty, the thought and the consequences must be my fault.” Clearly these speculations about the complex relations between TAF, responsibility, and guilt will need to be investigated. Given the high level of depression in the obsessional samples, it is likely that self-esteem was low. However, belief in TAI-Likelihood-for-others implies that one has extra powers and may be a somewhat narcissistic belief. The limit to this “power” is that it works for only negative events. Also, people with obsessional problems and a belief in TAF may consider that they can prevent or influence the course of a negative event occurring, but the initial obsessional thoughts are nevertheless intrusive, unacceptable, and unwanted, the person does not have the “power” to prevent them. Therefore, although low self-esteem and tbis element of narcissism seem incompatible, they can be closely connected, depending on the nature and limits of the assumed influence over events. Our findings are correlational and unfortunately do not shed light on the debate as to the relative importance of affect versus cog&ions in OCD. It is
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likely, however, that the two are closely linked and that depression or anxiety may increase the occurrence and believability of intrusive thoughts. In turn, increased endorsement of dysfunctional beliefs, particularly TAF-Likelihoodfor-others, is likely to exacerbate low self-esteem, depression, anxiety, and perceived responsibility for the event. The finding from our second study, that TAF-Moral was not higher in the obsessional population compared to the student sample, stands in need of explanation. It is unlikely that the change in the TM-Moral scale from 13 items to 12 items explains the difference. A more detailed look at our results shows that the mean item score for the TAF scale was stable across student samples in Studies 1 and 2, but that it was lower in the second obsessional sample than in the fust. The first sample was slightly more depressed than the second sample, which may be one explanation for our findings, since there is a high association between TAF-Moral and depression. More importantly, it may be that the beliefs about TAF-Moral are common and are not necessarily pathological. However, in combination with depression the beliefs may become more dysfunctional and may be interpreted in terms of responsibility, as discussed above. Hence, occurrence of TAF-Moral per se may be less important in obsessional problems than the personal relevance and salience of the belief, the frequency of its activation, and the resultant distress. This is consistent with earlier work on the nature of intrusive thoughts: the content of intrusive thoughts is similar across normal and obsessional subjects, but other characteristics of the thoughts (such as duration, degree of unacceptability, etc.) are more pronounced in obsessional subjects (Rachman & de Silva, 1978). Our scale may be missing an important aspect of TAF-moral beliefs, namely, what the occurrence of intrusive thoughts reflects about oneself. This should be addressed in future studies. Our results indicated that endorsement of items on the TAF-likelihood-forothers was often idiosyncratic and the majority of all populations did not experience strong TAE Many obsessional subjects endorsed only one item strongly, and therefore could obtain a low total score despite strong TAF in one domain. Such specificity is consistent with the phenomenology of obsessional complaints in which, for example, a person may repeatedly check light switches in the remote event of a fire occurring, but happily ride a motomycle, which is considerably more dangerous. Therefore, these scales may be better used as a starting point in identifying beliefs for a client, not as total scores to show the degree of TAF beliefs. It should be emphasized that the construct of TAF is in its early stages of development. TAF may be one of several metacognitions (beliefs about thoughts) that play a role in OCD (and perhaps other anxiety disorders). If TAF does turn out to have particular relevance for OCD, its identification has implications for treatment. Identification of this type of metacognition may provide an avenue for the therapist to begin challenging the beliefs. Techniques that have until now dealt only with the frequency of intrusive thoughts, such as
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thought-stopping, would not be helpful if the underlying metacognition of TAF remains unchanged. Similarly, targeting compulsive behavior, as with exposure and response prevention, will be less effective if core beliefs about TAF are not challenged. Further investigation of metacognitions and their effects on obsessional complaints is underway. REFERENCES Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York: Harper & Row. Beck, A. T., Steer, R. A., & Garbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical PsychorogY Review, 8.77-100. Hodgson, R., 8r Rachman, S. (1977). Obsessional compulsive complaints. Behaviour Research aad Therapy, 15.389-395. Rachman, S. (1993). Obsessions, responsibility and guilt. Behaviour Research and Therapy, 31, 149-w. Rachman, S., Shafran, R., Mitchell, D., Trant, J., & Teachman, B. (1996). How ro remain neutral: An experimental analysis of neutralization. Manuscript submitted for publication. Rachman, S., Thordamon. D. S., & Radomsky, A. S. (1995, July). A revision of the hfaudsley Obsessional Compulsive Invenfory. Poster presented at the World Congress of Behaviourai and Cognitive Therapies, Copenhagen. Rachman, S., Thordarson, D. S., Shafran, R.. & Woody, S. R. (1995). Perceived responsibility: Structure and significance. Behaviour Research and Therapy, 33,779-784. Salkovskis, l? M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviovr
Research
and Therapy,
25,571-583.
Salkovskis, P M. (1989). Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27.677-682. Salkovskis, P M. (1996). Cognitive-behavioural approaches to the understanding of obsessional problems. In R. Rapte (Ed.), Current controversies in anxiety disorders. New York: Guilford. Tallis, E (1994). Obsessions, responsibility and guilt: no case reports suggesting a common and specific aetiology. Behaviour Research and Therapy, 32, 143-145. Taylor, S. (1995). Assessment of obsessions and compulsions: Self-report inventories and observer-rated scales. Clinical Psychology Review, lS,261-296. Welch, B. L. (1951). On the comparison of several mean vahres:An alternative approach. Biomenika, 38.330-336.
APPENDIX:
REVISED TAF SCALE ITEMS
TAF-Moral
1. Thinking of making an extremely critical remark to a friend is almost as unacceptable to me as actually saying it. 2. Having a blasphemous thought is almost as sinful to me as a blasphemous action. 3. Thinking about swearing at someone else is almost as unacceptable to me as actually swearing. 4. When I have a nasty thought about someone else, it is almost as bad as carrying out a nasty action. 5. Having violent thoughts is almost as unacceptable to me as violent acts.
THOUGHT-ACTION
FUSION
391
6. When I think about making an obscene remark or gesture in church, it is almost as sinful as actually doing it. 7. If I wish harm on someone, it is almost as bad as doing harm. 8. If I think about making an obscene gesture to someone else, it is almost as bad as doing it. 9. When I think unkindly about a friend, it is almost as disloyal as doing an unkind act. 10. If I have a jealous thought, it is almost the same as making a jealous remark. 11. Thinking of cheating in a personal relationship is almost as immoral to me as actually cheating. 12. Having obscene thoughts in a church is unacceptable to me. TAF-Likelihood-Others
1. If I think of a relative/friend losing their job, this increases the risk that they will lose their job. 2. If I think of a relative/friend being in a car accident, this increases the risk that he/she will have a car accident. 3.. If I think of a friend/relative being injured in a fall, this increases the risk that he/she will have a fall and be injured. 4. If I think of a relative/friend falling ill this increases the risk that he/she will fall ill. TAF-Likelihood-Self
1. If I think of myself being injured in a fall, this increases the risk that I will have a fall and be injured. 2. If I think of myself being in a car accident, this increases the risk that I will have a car accident. 3. If I think of myself falling ill, this increases the risk that I will fall ill.