- Email: [email protected]
How to suppress obsessive thoughts
Behaviour Research and Therapy 41 (2003) 97–103 www.elsevier.com/locate/brat
Shorter communication
How to suppress obsessive thoughts Eric Rassin a,∗, Philip Diepstraten b a
Faculty of Social Sciences (Institute of Psychology), Erasmus University, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands b Overwaal Clinic, Pastoor van Laakstraat 48, 6662, CB, Lent, The Netherlands Accepted 18 March 2002
Abstract Thought suppression (i.e. consciously trying to avoid certain thoughts from entering consciousness) has been argued to be an inadequate strategy in case of unwanted intrusions. That is, thought suppression seems to result in more rather than less intrusions. Although this experimental finding has been explained in terms of failing attempts to distract oneself from the target thought, the White Bear Suppression Inventory (WBSI; a scale that measures chronic thought suppression tendencies) does not address the means by which respondents try to suppress unwanted thoughts. To examine which strategies of mental control people use to suppress unwanted thoughts, obsessive–compulsive disorder patients (N=47) completed the WBSI, the Thought Control Questionnaire, and two measures of psychopathology. Results suggest that the crucial mechanism in thought suppression may not be distraction, but self-punishment. 2003 Elsevier Science Ltd. All rights reserved. Keywords: Obsessive–compulsive disorder; Thought control strategies; Thought suppression
1. Introduction Obsessions are the core features of obsessive–compulsive disorder (OCD). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), obsessions can be defined as “persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety and distress” (p. 418). Rachman and De Silva (1978; see also Salkovskis & Harrison, 1984) found that intrusive thoughts are not specific for OCD, but are prevalent in the normal population as well. Furthermore, the content of ‘normal’ intrusions and clinical obsessions seemed to be similar. However, both ∗
Corresponding author. E-mail address: [email protected] (E. Rassin).
0005-7967/03/$ - see front matter 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 0 2 ) 0 0 0 4 3 - 8
98
E. Rassin, P. Diepstraten / Behaviour Research and Therapy 41 (2003) 97–103
kinds of intrusions were found to differ in some respects. More specifically, clinical obsessions were experienced as occurring more frequently, longer lasting, more intense, more discomforting, and eliciting more resistance, compared to normal intrusions. According to Wegner (1989), this pattern can be explained by means of the thought suppression paradigm. Wegner argues that suppression of unwanted intrusions has the paradoxical effect of subsequent increased numbers of intrusions. This idea has its roots in the so-called ‘white bear’ experiments. In these experiments, Wegner, Schneider, Carter, and White (1987) asked their participants to “try not to think of a white bear” for 5 minutes (p. 6). Results indicated that such suppression attempts are ineffective and, furthermore, lead to an increased number of white bear thoughts later on (i.e. after the suppression instructions are no longer applicable). The latter phenomenon is referred to as the rebound effect. Given the paradoxical effect of thought suppression, Wegner (1989) argues that this coping strategy may contribute to the development of obsessional intrusions. By this view, the paradoxical increase in the number of intrusions (which is in itself an obsessional feature) may result in an increased perceived intensity of intrusions, and consequently in more discomfort. Accordingly, Wegner (1989) concludes: “An obsession can grow from nothing but the desire to suppress a thought” (p. 167). Although the alleged causal role of thought suppression in OCD and other conditions has been studied intensively (see, for reviews, Purdon, 1999; Rassin, Merckelbach, & Muris, 2000), some important issues remain to be addressed. For example, the thought suppression paradigm has largely ignored the question why people would engage in thought suppression in the first place. Only recently, possible reasons for thought suppression have become the object of academic interest (see Rachman, 1998). Furthermore, thought suppression is broadly defined and, thus, it is not completely clear to which cognitive operations it exactly refers. According to Wells and Davies (1994), thought suppression is not a coping style, but a goal that may be reached in several ways. In their words: “It is defined in terms of its goals rather than in terms of the strategy or strategies used to achieve this goal” (p. 871). Therefore, Wells and Davies advocate the use of the Thought Control Questionnaire (TCQ), a self-report instrument that taps five mental control strategies (i.e. distraction, social coping, worrying, self-punishment, and cognitive re-appraisal), three of which can be construed as thought suppression strategies (viz. distraction, worrying, and self-punishment). Amir, Cashman, and Foa (1997) used the TCQ to compare strategies of mental control in OCD patients and non-clinical controls. These authors found that, compared to controls, OCD patients tend to react to unwanted intrusions more with worrying, self-punishment, re-appraisal, and seeking comfort with other people (i.e. social coping). Furthermore, they found that the strategies of self-punishment and worrying were specifically associated with obsessional problems [see, for an overview of coping strategies in a non-clinical sample, Purdon & Clark (1994)]. Based on Wegner’s (1994) theory, strong and positive associations between distraction, thought suppression and psychopathology can be expected. More specifically, Wegner (1994) argues that distraction is the vehicle behind the detrimental effects of thought suppression. By this view, people who try to prevent a specific thought from entering consciousness (i.e. thought suppression), will attempt to achieve this by attending to an environmental distracter. However, in spite of such distraction attempts, the target thought may come to mind. In that case, the distracter becomes associated with the target and, thus, turns into a retrieval cue, leaving the individual in need of another distracter. Repetition of this process will lead to an increased number
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of target thoughts, because the individual finds himself surrounded by retrieval cues. There is, indeed, some experimental evidence to support this “environmental cueing” hypothesis (Muris, Merckelbach, & De Jong, 1993; Wegner et al., 1987). The present study sought to examine the associations between thought suppression as measured by the White Bear Suppression Inventory (WBSI; Wegner & Zanakos, 1994) and the different mental control strategies measured by the TCQ. Given Wegner’s (1994) theoretical account, it was hypothesised that thought suppression is especially correlated with distraction. For the same reason, strong associations were expected between thought suppression and distraction on the one hand, and self-reported psychopathology on the other. To explore these associations, a sample of 47 OCD patients completed the WBSI, the TCQ, and two self-report measures of psychopathology. 2. Method 2.1. Participants Forty-seven patients (34 women) were included in the study. Mean age in this sample was 34.0 years (SD=10.2 years; range: 18-58). All participants were diagnosed by a clinical psychologist as suffering from OCD based on DSM-IV criteria. Participants were recruited from two mental health institutions, that is, the ‘Overwaal Clinic’ in Nijmegen, and the ‘RIAGG’ in Maastricht, The Netherlands. At the time of the measurement, patients had not yet received any treatment. 2.2. Measures Participants completed the WBSI, TCQ, the Maudsley Obsessional–Compulsive Inventory (MOCI; Hodgson & Rachman, 1977), and the Symptoms Checklist (SCL-90; Derogatis, 1977). The WBSI is a 15-items self-report instrument that addresses the habitual tendency to suppress unwanted thoughts. A typical WBSI-item is “I always try to put problems out of mind”. Items are answered on a five-point scale (1=strongly disagree; 5=strongly agree). Total scores (range: 15–75) are obtained by summing across items. Higher scores indicate stronger tendencies to suppress unwanted thoughts. The TCQ consists of 30 items that are answered on a four-point scale (1=never; 4=almost always). The TCQ taps five strategies of mental control: distraction (e.g. “When I experience an unpleasant/unwanted thought, I do something I enjoy”), social coping (e.g. “I talk to a friend about the thought”), worrying (e.g. “I focus on different negative thoughts”), punishment (e.g. “I slap or pinch myself to stop the thought”), and re-appraisal (e.g. “I try to re-interpret the thought”). Every strategy is measured by six items and, thus, total scores for each strategy range from 6 to 24 with higher scores indicating a stronger tendency to employ the pertaining strategy in case of unwanted intrusions. The MOCI consists of 30 yes/no items (e.g. “I spend a lot of time every day checking things over and over again”) that address various obsessive–compulsive symptoms such as checking, cleaning, and doubting. Every endorsed item yields one point. Higher total scores (range: 0–30) reflect the presence of more obsessive–compulsive symptoms.
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Table 1 Mean scores (standard deviations are given between parentheses) and alphas for the questionnaires (N=47)
WBSI TCQ-distraction TCQ-social coping TCQ-worrying TCQ-punishment TCQ-re-appraisal MOCI SCL-90
Mean scores
avalues
58.7 (12.1) 13.3 (3.1) 12.7 (3.4) 12.2 (3.0) 11.9 (3.9) 14.1 (2.5) 14.2 (5.7) 226.2 (61.0)
0.91 0.79 0.76 0.65 0.80 0.46 0.79 0.97
The SCL-90 is a widely used self-report instrument of general psychopathology. It measures a broad range of psychopathological symptoms such as anxiety, depression, obsessional problems, and sleep disturbances. Items are answered on a five-point scale (1=not at all; 5=a lot). Total scores range from 90 to 450 with higher scores indicating more self-reported psychopathology.
3. Results Mean scores on the questionnaires are presented in Table 1, while Table 2 shows Pearson product-moment correlations between the mental control strategy measures, on the one hand, and self-reported psychopathology, on the other hand. As can be seen, self-punishment was the only control strategy with which thought suppression (i.e. WBSI) correlated. Both thought suppression and punishment were correlated with self-reported psychopathology. Distraction and re-appraisal were negatively correlated with pathology.
Table 2 Correlations between the WBSI, TCQ, and the MOCI and SCL-90 (N=47)
WBSI TCQ-distraction TCQ-social coping TCQ-worrying TCQ-punishment TCQ-re-appraisal ∗
p⬍0.05. p⬍0.01.
∗∗
WBSI
MOCI
SCL-90
– 0.15 ⫺0.18 0.28 0.49∗∗ ⫺0.06
0.61∗∗ ⫺0.08 ⫺0.19 0.02 0.52∗∗ ⫺0.41 ∗
0.55∗∗ ⫺0.38∗ ⫺0.19 0.11 0.40∗ ⫺0.30
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4. Discussion In clinical literature, there is broadening consensus about the detrimental effects of thought suppression (see Purdon, 1999). Recently, Abramowitz, Tolin and Street (2001) conducted a metaanalysis of published suppression studies, and concluded that suppression, indeed, seems to result in a small to moderate increase of target thought frequency. This paradoxical effect has been explained in terms of failing attempts to distract oneself from the forbidden thought. Not only is this distraction theory the most elaborated theoretical account (Wegner, 1994), there also is some empirical support for this notion (Muris et al., 1993; Wegner et al., 1987). The WBSI, a generally used thought suppression self-report, however, is silent about which strategies respondents rely upon to suppress unwanted thoughts. Another self-report thought control measure (the TCQ) was designed to fill this gap. Based on theory and experimental studies, positive correlations between WBSI-scores and TCQ-distraction-scores can be expected. Against this background, the present study yielded some diverging results. First, contrary to expectation, WBSI-scores were not correlated with TCQ-distraction-scores in the current sample. This finding is relevant to the question of whether thought suppression can be defined in terms of the mental control strategies measured by the TCQ. Muris et al. (1996) did find a positive correlation between the WBSI and TCQ-distraction (r=0.21, p⬍0.01). However, their study relied on a sample of healthy volunteers. Hence, it may be the case that distraction and thought suppression are associated in experimental settings, and, more generally, in healthy people’s cognitive operations, but less so in people who have developed OCD. Second and furthermore, distraction did not seem to be positively, but negatively related with psychopathology. According to Wegner (1994), the association between suppression and psychopathological obsessions is mediated by failing distraction attempts. But again, the associations assumed in this theoretical account, as well as observed in experimental thought suppression studies are not evident in clinically relevant, self-reported thought suppression tendencies in patients who have already developed obsessional problems. Like distraction, cognitive re-appraisal was negatively related with psychopathology. This negative correlation is not surprising given that cognitive restructuring is a crucial feature of cognitive therapy (Salkovskis, 1999). However, the cross-sectional nature of the present data precludes firm interpretations of these relationships. For example, one could argue that distraction and re-appraisal may be effective in, or at least associated with, attenuating pathological complaints. On the other hand, it may well be the case that the strategies of distraction and re-appraisal are only used by patients with mild symptom severity, while patients with severe symptomatology are reluctant to employ these strategies, because they know that these strategies are less effective for them. Third, WBSI-scores were found to correlate with TCQ-punishment-scores, while both measures were, furthermore, related with self-reported pathology. A positive correlation between suppression and psychopathology was expected, and replicates previous findings. For example, Muris et al. (1996) found that thought suppression was correlated with MOCI-scores in a normal sample. Our finding that self-punishment is related with psychopathology also replicates previous results, although in other studies, the strategy of worrying was also found to correlate with pathology (Amir et al., Foa, 1997; Guthrie & Bryant, 2000; Wells & Davies, 1994; Wells & Papageorgiou, 1995). This correlational pattern is somewhat difficult to explain. It could be argued that selfpunishment (e.g. slapping, pinching, or swearing) is to be construed as a compulsive act, which
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should account for the correlation between TCQ-punishment and psychopathology (in particular MOCI). Indeed, people who misinterpret their intrusive thoughts as indicators of their real self may tend to punish themselves whenever they experience a thought of violent, sexual, or otherwise ‘unacceptable’ content (S. Rachman, personal communication). The observed association between thought suppression and punishment might be explained by assuming that (compulsive) punishment serves to distract from the unwanted thought. However, this should also hold true for TCQworrying, and, of course, TCQ-distraction, although these subscales were not found to correlate with WBSI-scores. In sum, the hypothesis that thought suppression generally takes the form of failing distraction which results in more unwanted thoughts, and thus in increased self-reported psychopathology, was not confirmed. Thought suppression, as indexed by the WBSI, did correlate with measures of psychopathology in our sample of OCD patients, but, surprisingly, distraction did not fit in as an inadequate strategy of thought suppression. In this respect, the dynamics between thought suppression, distraction, and psychopathology, as measured by self-report instruments differ from those seen in experimental studies. Hence, the present results suggest that, under some circumstances, distraction may be a fruitful suppression strategy after all.
Acknowledgements This study was made possible by the Overwaal Clinic, Nijmegen, and the RIAGG, Maastricht, The Netherlands.
References Abramowitz, J. S., Tolin, D. F., & Street, G. P. (2001). Paradoxical effects of thought suppression: a meta-analysis of controlled studies. Clinical Psychology Review, 21, 683–703. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington: American Psychiatric Association. Amir, N., Cashman, L., & Foa, E. B. (1997). Strategies of thought control in obsessive–compulsive disorder. Behaviour Research and Therapy, 35, 775–777. Derogatis, L. R. (1977). SCL-90: administration, scoring and procedures manual-I for the revised version. Baltimore: Johns Hopkins School of Medicine. Guthrie, R., & Bryant, R. (2000). Attempting suppression of traumatic memories over extended periods in acute stress disorder. Behaviour Research and Therapy, 38, 899–907. Hodgson, R. J., & Rachman, S. (1977). Obsessional–compulsive complaints. Behaviour Research and Therapy, 15, 389–395. Muris, P., Merckelbach, H., & De Jong, P. (1993). Verbalization and environmental cueing in thought suppression. Behaviour Research and Therapy, 31, 609–612. Muris, P., Merckelbach, H., & Horselenberg, R. (1996). Individual differences in thought suppression. The White Bear Suppression Inventory: factor structure, reliability, validity and correlates. Behaviour Research and Therapy, 34, 501–513. Purdon, C. (1999). Thought suppression and psychopathology. Behaviour Research and Therapy, 37, 1029–1054.
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Purdon, C., & Clark, D. A. (1994). Obsessive intrusive thoughts in nonclinical subjects part II: cognitive appraisal, emotional response and thought control strategies. Behaviour Research and Therapy, 32, 403–410. Rachman, S. (1998). A cognitive theory of obsessions: elaborations. Behaviour Research and Therapy, 36, 385–401. Rachman, S., & De Silva, P. (1978). Abnormal and normal obsessions. Behaviour Research and Therapy, 16, 233–248. Rassin, E., Merckelbach, H., & Muris, P. (2000). Paradoxical and less paradoxical effects of thought suppression: a critical review. Clinical Psychology Review, 20, 973–995. Salkovskis, P. M. (1999). Understanding and treating obsessive–compulsive disorder. Behaviour Research and Therapy, 37, s29–s52. Salkovskis, P. M., & Harrison, J. (1984). Abnormal and normal obsessions: a replication. Behaviour Research and Therapy, 22, 549–552. Wegner, D. M. (1989). White bears and other unwanted thoughts: suppression, obsession, and the psychology of mental control. London: The Guilford Press. Wegner, D. M. (1994). Ironic processes of mental control. Psychological Review, 101, 34–52. Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53, 5–13. Wegner, D. M., & Zanakos, S. (1994). Chronic thought suppression. Journal of Personality, 62, 615–640. Wells, A., & Davies, M. I. (1994). The Thought Control Questionnaire: a measure of individual differences in the control of unwanted thoughts. Behaviour Research and Therapy, 32, 871–878. Wells, A., & Papagiorgiou, C. (1995). Worry and the incubation of intrusive images following stress. Behaviour Research and Therapy, 33, 579–583.
Shorter communication
How to suppress obsessive thoughts Eric Rassin a,∗, Philip Diepstraten b a
Faculty of Social Sciences (Institute of Psychology), Erasmus University, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands b Overwaal Clinic, Pastoor van Laakstraat 48, 6662, CB, Lent, The Netherlands Accepted 18 March 2002
Abstract Thought suppression (i.e. consciously trying to avoid certain thoughts from entering consciousness) has been argued to be an inadequate strategy in case of unwanted intrusions. That is, thought suppression seems to result in more rather than less intrusions. Although this experimental finding has been explained in terms of failing attempts to distract oneself from the target thought, the White Bear Suppression Inventory (WBSI; a scale that measures chronic thought suppression tendencies) does not address the means by which respondents try to suppress unwanted thoughts. To examine which strategies of mental control people use to suppress unwanted thoughts, obsessive–compulsive disorder patients (N=47) completed the WBSI, the Thought Control Questionnaire, and two measures of psychopathology. Results suggest that the crucial mechanism in thought suppression may not be distraction, but self-punishment. 2003 Elsevier Science Ltd. All rights reserved. Keywords: Obsessive–compulsive disorder; Thought control strategies; Thought suppression
1. Introduction Obsessions are the core features of obsessive–compulsive disorder (OCD). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994), obsessions can be defined as “persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety and distress” (p. 418). Rachman and De Silva (1978; see also Salkovskis & Harrison, 1984) found that intrusive thoughts are not specific for OCD, but are prevalent in the normal population as well. Furthermore, the content of ‘normal’ intrusions and clinical obsessions seemed to be similar. However, both ∗
Corresponding author. E-mail address: [email protected] (E. Rassin).
0005-7967/03/$ - see front matter 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 0 0 5 - 7 9 6 7 ( 0 2 ) 0 0 0 4 3 - 8
98
E. Rassin, P. Diepstraten / Behaviour Research and Therapy 41 (2003) 97–103
kinds of intrusions were found to differ in some respects. More specifically, clinical obsessions were experienced as occurring more frequently, longer lasting, more intense, more discomforting, and eliciting more resistance, compared to normal intrusions. According to Wegner (1989), this pattern can be explained by means of the thought suppression paradigm. Wegner argues that suppression of unwanted intrusions has the paradoxical effect of subsequent increased numbers of intrusions. This idea has its roots in the so-called ‘white bear’ experiments. In these experiments, Wegner, Schneider, Carter, and White (1987) asked their participants to “try not to think of a white bear” for 5 minutes (p. 6). Results indicated that such suppression attempts are ineffective and, furthermore, lead to an increased number of white bear thoughts later on (i.e. after the suppression instructions are no longer applicable). The latter phenomenon is referred to as the rebound effect. Given the paradoxical effect of thought suppression, Wegner (1989) argues that this coping strategy may contribute to the development of obsessional intrusions. By this view, the paradoxical increase in the number of intrusions (which is in itself an obsessional feature) may result in an increased perceived intensity of intrusions, and consequently in more discomfort. Accordingly, Wegner (1989) concludes: “An obsession can grow from nothing but the desire to suppress a thought” (p. 167). Although the alleged causal role of thought suppression in OCD and other conditions has been studied intensively (see, for reviews, Purdon, 1999; Rassin, Merckelbach, & Muris, 2000), some important issues remain to be addressed. For example, the thought suppression paradigm has largely ignored the question why people would engage in thought suppression in the first place. Only recently, possible reasons for thought suppression have become the object of academic interest (see Rachman, 1998). Furthermore, thought suppression is broadly defined and, thus, it is not completely clear to which cognitive operations it exactly refers. According to Wells and Davies (1994), thought suppression is not a coping style, but a goal that may be reached in several ways. In their words: “It is defined in terms of its goals rather than in terms of the strategy or strategies used to achieve this goal” (p. 871). Therefore, Wells and Davies advocate the use of the Thought Control Questionnaire (TCQ), a self-report instrument that taps five mental control strategies (i.e. distraction, social coping, worrying, self-punishment, and cognitive re-appraisal), three of which can be construed as thought suppression strategies (viz. distraction, worrying, and self-punishment). Amir, Cashman, and Foa (1997) used the TCQ to compare strategies of mental control in OCD patients and non-clinical controls. These authors found that, compared to controls, OCD patients tend to react to unwanted intrusions more with worrying, self-punishment, re-appraisal, and seeking comfort with other people (i.e. social coping). Furthermore, they found that the strategies of self-punishment and worrying were specifically associated with obsessional problems [see, for an overview of coping strategies in a non-clinical sample, Purdon & Clark (1994)]. Based on Wegner’s (1994) theory, strong and positive associations between distraction, thought suppression and psychopathology can be expected. More specifically, Wegner (1994) argues that distraction is the vehicle behind the detrimental effects of thought suppression. By this view, people who try to prevent a specific thought from entering consciousness (i.e. thought suppression), will attempt to achieve this by attending to an environmental distracter. However, in spite of such distraction attempts, the target thought may come to mind. In that case, the distracter becomes associated with the target and, thus, turns into a retrieval cue, leaving the individual in need of another distracter. Repetition of this process will lead to an increased number
E. Rassin, P. Diepstraten / Behaviour Research and Therapy 41 (2003) 97–103
99
of target thoughts, because the individual finds himself surrounded by retrieval cues. There is, indeed, some experimental evidence to support this “environmental cueing” hypothesis (Muris, Merckelbach, & De Jong, 1993; Wegner et al., 1987). The present study sought to examine the associations between thought suppression as measured by the White Bear Suppression Inventory (WBSI; Wegner & Zanakos, 1994) and the different mental control strategies measured by the TCQ. Given Wegner’s (1994) theoretical account, it was hypothesised that thought suppression is especially correlated with distraction. For the same reason, strong associations were expected between thought suppression and distraction on the one hand, and self-reported psychopathology on the other. To explore these associations, a sample of 47 OCD patients completed the WBSI, the TCQ, and two self-report measures of psychopathology. 2. Method 2.1. Participants Forty-seven patients (34 women) were included in the study. Mean age in this sample was 34.0 years (SD=10.2 years; range: 18-58). All participants were diagnosed by a clinical psychologist as suffering from OCD based on DSM-IV criteria. Participants were recruited from two mental health institutions, that is, the ‘Overwaal Clinic’ in Nijmegen, and the ‘RIAGG’ in Maastricht, The Netherlands. At the time of the measurement, patients had not yet received any treatment. 2.2. Measures Participants completed the WBSI, TCQ, the Maudsley Obsessional–Compulsive Inventory (MOCI; Hodgson & Rachman, 1977), and the Symptoms Checklist (SCL-90; Derogatis, 1977). The WBSI is a 15-items self-report instrument that addresses the habitual tendency to suppress unwanted thoughts. A typical WBSI-item is “I always try to put problems out of mind”. Items are answered on a five-point scale (1=strongly disagree; 5=strongly agree). Total scores (range: 15–75) are obtained by summing across items. Higher scores indicate stronger tendencies to suppress unwanted thoughts. The TCQ consists of 30 items that are answered on a four-point scale (1=never; 4=almost always). The TCQ taps five strategies of mental control: distraction (e.g. “When I experience an unpleasant/unwanted thought, I do something I enjoy”), social coping (e.g. “I talk to a friend about the thought”), worrying (e.g. “I focus on different negative thoughts”), punishment (e.g. “I slap or pinch myself to stop the thought”), and re-appraisal (e.g. “I try to re-interpret the thought”). Every strategy is measured by six items and, thus, total scores for each strategy range from 6 to 24 with higher scores indicating a stronger tendency to employ the pertaining strategy in case of unwanted intrusions. The MOCI consists of 30 yes/no items (e.g. “I spend a lot of time every day checking things over and over again”) that address various obsessive–compulsive symptoms such as checking, cleaning, and doubting. Every endorsed item yields one point. Higher total scores (range: 0–30) reflect the presence of more obsessive–compulsive symptoms.
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Table 1 Mean scores (standard deviations are given between parentheses) and alphas for the questionnaires (N=47)
WBSI TCQ-distraction TCQ-social coping TCQ-worrying TCQ-punishment TCQ-re-appraisal MOCI SCL-90
Mean scores
avalues
58.7 (12.1) 13.3 (3.1) 12.7 (3.4) 12.2 (3.0) 11.9 (3.9) 14.1 (2.5) 14.2 (5.7) 226.2 (61.0)
0.91 0.79 0.76 0.65 0.80 0.46 0.79 0.97
The SCL-90 is a widely used self-report instrument of general psychopathology. It measures a broad range of psychopathological symptoms such as anxiety, depression, obsessional problems, and sleep disturbances. Items are answered on a five-point scale (1=not at all; 5=a lot). Total scores range from 90 to 450 with higher scores indicating more self-reported psychopathology.
3. Results Mean scores on the questionnaires are presented in Table 1, while Table 2 shows Pearson product-moment correlations between the mental control strategy measures, on the one hand, and self-reported psychopathology, on the other hand. As can be seen, self-punishment was the only control strategy with which thought suppression (i.e. WBSI) correlated. Both thought suppression and punishment were correlated with self-reported psychopathology. Distraction and re-appraisal were negatively correlated with pathology.
Table 2 Correlations between the WBSI, TCQ, and the MOCI and SCL-90 (N=47)
WBSI TCQ-distraction TCQ-social coping TCQ-worrying TCQ-punishment TCQ-re-appraisal ∗
p⬍0.05. p⬍0.01.
∗∗
WBSI
MOCI
SCL-90
– 0.15 ⫺0.18 0.28 0.49∗∗ ⫺0.06
0.61∗∗ ⫺0.08 ⫺0.19 0.02 0.52∗∗ ⫺0.41 ∗
0.55∗∗ ⫺0.38∗ ⫺0.19 0.11 0.40∗ ⫺0.30
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4. Discussion In clinical literature, there is broadening consensus about the detrimental effects of thought suppression (see Purdon, 1999). Recently, Abramowitz, Tolin and Street (2001) conducted a metaanalysis of published suppression studies, and concluded that suppression, indeed, seems to result in a small to moderate increase of target thought frequency. This paradoxical effect has been explained in terms of failing attempts to distract oneself from the forbidden thought. Not only is this distraction theory the most elaborated theoretical account (Wegner, 1994), there also is some empirical support for this notion (Muris et al., 1993; Wegner et al., 1987). The WBSI, a generally used thought suppression self-report, however, is silent about which strategies respondents rely upon to suppress unwanted thoughts. Another self-report thought control measure (the TCQ) was designed to fill this gap. Based on theory and experimental studies, positive correlations between WBSI-scores and TCQ-distraction-scores can be expected. Against this background, the present study yielded some diverging results. First, contrary to expectation, WBSI-scores were not correlated with TCQ-distraction-scores in the current sample. This finding is relevant to the question of whether thought suppression can be defined in terms of the mental control strategies measured by the TCQ. Muris et al. (1996) did find a positive correlation between the WBSI and TCQ-distraction (r=0.21, p⬍0.01). However, their study relied on a sample of healthy volunteers. Hence, it may be the case that distraction and thought suppression are associated in experimental settings, and, more generally, in healthy people’s cognitive operations, but less so in people who have developed OCD. Second and furthermore, distraction did not seem to be positively, but negatively related with psychopathology. According to Wegner (1994), the association between suppression and psychopathological obsessions is mediated by failing distraction attempts. But again, the associations assumed in this theoretical account, as well as observed in experimental thought suppression studies are not evident in clinically relevant, self-reported thought suppression tendencies in patients who have already developed obsessional problems. Like distraction, cognitive re-appraisal was negatively related with psychopathology. This negative correlation is not surprising given that cognitive restructuring is a crucial feature of cognitive therapy (Salkovskis, 1999). However, the cross-sectional nature of the present data precludes firm interpretations of these relationships. For example, one could argue that distraction and re-appraisal may be effective in, or at least associated with, attenuating pathological complaints. On the other hand, it may well be the case that the strategies of distraction and re-appraisal are only used by patients with mild symptom severity, while patients with severe symptomatology are reluctant to employ these strategies, because they know that these strategies are less effective for them. Third, WBSI-scores were found to correlate with TCQ-punishment-scores, while both measures were, furthermore, related with self-reported pathology. A positive correlation between suppression and psychopathology was expected, and replicates previous findings. For example, Muris et al. (1996) found that thought suppression was correlated with MOCI-scores in a normal sample. Our finding that self-punishment is related with psychopathology also replicates previous results, although in other studies, the strategy of worrying was also found to correlate with pathology (Amir et al., Foa, 1997; Guthrie & Bryant, 2000; Wells & Davies, 1994; Wells & Papageorgiou, 1995). This correlational pattern is somewhat difficult to explain. It could be argued that selfpunishment (e.g. slapping, pinching, or swearing) is to be construed as a compulsive act, which
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should account for the correlation between TCQ-punishment and psychopathology (in particular MOCI). Indeed, people who misinterpret their intrusive thoughts as indicators of their real self may tend to punish themselves whenever they experience a thought of violent, sexual, or otherwise ‘unacceptable’ content (S. Rachman, personal communication). The observed association between thought suppression and punishment might be explained by assuming that (compulsive) punishment serves to distract from the unwanted thought. However, this should also hold true for TCQworrying, and, of course, TCQ-distraction, although these subscales were not found to correlate with WBSI-scores. In sum, the hypothesis that thought suppression generally takes the form of failing distraction which results in more unwanted thoughts, and thus in increased self-reported psychopathology, was not confirmed. Thought suppression, as indexed by the WBSI, did correlate with measures of psychopathology in our sample of OCD patients, but, surprisingly, distraction did not fit in as an inadequate strategy of thought suppression. In this respect, the dynamics between thought suppression, distraction, and psychopathology, as measured by self-report instruments differ from those seen in experimental studies. Hence, the present results suggest that, under some circumstances, distraction may be a fruitful suppression strategy after all.
Acknowledgements This study was made possible by the Overwaal Clinic, Nijmegen, and the RIAGG, Maastricht, The Netherlands.
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