Experiences and Suppression of Intrusive Thoughts

Experiences and Suppression of Intrusive Thoughts A Mixed Methods Research on the Experience and Suppression of Intrusive Thoughts and other ways of Thought-Control in the Non-Clinical Mauritian Adult Population ‘’The mind is its own place, and in itself can make heaven of Hell, a hell of heaven.’’ Milton The experience and suppression of intrusive thoughts, and the use of other thought-control strategies by normal or non-clinical individuals, are some of those complex cognitive phenomena, which are gradually gaining increasing thorough scientific attention in the world of Psychology. Significantly Wegner Pennebaker (1993) view the experience of intrusive thinking as a remarkably common clinical and normative phenomenon. Hence, it would be wise to underline that intrusive thoughts occur universally. Indeed research on intrusive thoughts always accompanies research on thought control especially thought suppression. Definition Because intrusive thinking is studied alongside manifold psychological disorders such as Obsessive-Compulsive Disorder (OCD), Post-Traumatic-Stress Disorder (PTSD), General-Anxiety Disorder (GAD), depression, phobias, eating disorders and even Substance-Use disorder, there are bound to be major differences in the definition of the term ’intrusive thought’. Notably Clark and Purdon (1995; Purdon Clark, 1999) underlined the construct validity problems of some measures utilised in studies about intrusive thoughts in non-clinical populations just because of the broad definitional problem of the term. These researchers have also suggested that both the cognitive characteristics (intrusiveness, thought-control difficulty) and the content of intrusive thoughts have to be considered while defining them. For the purposes of this research, which focuses on the experience and suppression of intrusive thoughts, and the use of other thought-control strategies by the non-clinical Ma uritian adult population, we would preferably agree with Rachman’s definition of intrusive thoughts as ‘cognitions that are spontaneous, disruptive, and difficult to control and unwanted’ (Rachman, 1981). Similarly, Clark Rhyno (2005,p.4) define the experience of intrusive thought as ‘any distinct, identifiable cognitive event that is unwanted, unintended, and recurrent’. The focus of this research is on negative intrusive thoughts which are unwelcome, involuntary and distressing. People generally approach these negative thoughts in a myriad of ways. Our next point is that people have different coping or appraisal styles in their approach to unwanted negative thoughts. Many people try to control their intrusive thoughts using different thought control strategies which reflect their appraisal styles. Appraisal is the way in which meaning is attached to intrusive thoughts (OCCWG,1997). It cannot be denied that when some negative intrusive thoughts int erfere with concentration and emotional equilibrium, they become unpleasant and distressing and many people try to banish these thoughts from their awareness. Notably, Sigmund Freud (1915,1957) explained the role of suppression and repression that keep unwanted, unpleasant and distressing thoughts out of awareness. The modern view, as supported by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association; APA, 2000) uses the concepts automatic (unconscious) and voluntary (conscious) processes to refer to the Freudian defence mechanisms: repression and suppression. Ever since Wegner et al (1987) started their White Bear experiments in an attempt to study suppression of intrusive thoughts, many other studies have been gradually carried out, which present thought suppression as an inadequate, counterproductive mental control strategy (Beevers et al, 1999; Bodenhausen Macrae, 1996; Monteith et al, 1998a; Purdon Clark 1999; Wegner 1989, 1992; Wegner et al 1994a; Wegner Wenzlaff 1996). Significant studies have also analysed other thought-control strategies like distraction, punishment, re-appraisal, worry and social control in an attempt to understand how individuals approach their intrusive thoughts (Wells Davies, 1994). Aim of Research The primary aim of this study is to review the research done on the experience and suppression of intrusive thoughts in the normal population and analyse the experience and suppression of intrusive thoughts in the normal or non-clinical Mauritian adult population, by shedding light specifically on the different thought-control strategies employed by normal people while coping with intrusive thoughts and most significantly, by analysing suppression as a maladaptive control strategy. Clinical Approach to Intrusive Thoughts and Obsessive Compulsive Disorder (OCD) Initial research on intrusive thoughts started with the analysis of the experience of intrusive thinking in the clinical context and it has verily been observed that intrusive thoughts characterize several clinical disorders, for example, GAD, OCD, Depression, PTSD (Brewin, 1998; Green, 2003; Langlois, Freeston, Ladouceur, 2000a,b; Pudon, 1999; Watkins, 2004). It has also been stated that as well as being symptoms of these disorders, intrusive thoughts also contribute to the maintenance of these disorders (Brett Ostroff, 1985; Brewin, Watson, McCarthy, Hyman Dayson, 1998). There is indubitably a significant relationship between intrusive thinking and OCD. The DSM-IV (American Psychiatric Association; APA, 2000) refers to recurrent, intrusive thoughts, images or impulses that are experienced as ego-dystonic (totally inconsistent with the self) and extremely distressing, as partly characterizing OCD. More specifically, many researchers have scrutinized the experience of intrusive tho ughts among OCD patients and have demonstrated that these patients feel compelled to perform compulsive rituals (for instance, neutralizing behaviours etc.) in an attempt to escape from the distressing intrusive thoughts. For them, the performance of these rituals is aimed at the reduction of anxiety and the prevention of a feared outcome from occurring. However these compulsive rituals increase intrusive thinking and therefore, maintain the disorder. Notably, research has demonstrated that OCD patients show deficiencies in cognitive inhibition and when they fail to suppress their thoughts, they make internal attributions of their suppression failures (Tolin et al., 2002). The Obsessive Compulsive Cognitions Working Group (2005) have denoted the relationship of OCD with several specific appraisal styles such as responsibility/overestimated threat, intolerance of uncertainty/perfectionism and importance/control of thoughts. In his cognitive model of OCD, Salkovskis underlines the centrality of responsibility. Rachman (1997) argues that as these intrusive thoughts are ego-dystonic (that is, they perfectly contrast what the self really wants),OCD patients often interpret these thoughts as having personal negative significance and having potentially severe consequences and predicting undesirable outcomes. Furthermore, emphasizing the importance of metacognitions (that is, thinking about thoughts), Wells, Gwilliam and Cartwright-Hatton (2001) elucidate the role of thought-fusion beliefs in the maintenance of the disorder. More concisely, these are: thought-event fusion (the belief that thoughts can change the course of events); thought-action fusion (the be lief that thinking about something means a possibility to act on the thought) and thought-object fusion (the belief that thoughts can be fused into objects). Responsibility beliefs and thought-action fusion beliefs are stronger in people with OCD than those without (Coles, Mennin Heimberg, 2001). Additionally recent cognitive-behavioural theories about OCD have assumed that obsessive thoughts have their roots in some of the thoughts currently experienced by normal individuals (Pudon Clark, 1999; Salkovskis, 1985, 1989). Intrusive thoughts in non-clinical population Ever since Rachman and de Silva (1978) scientifically found that intrusive thoughts are a common non-clinical phenomenon, a plethora of research, especially questionnaire studies have tried to replicate Rachman and de Silva’s research. Using the questionnaire of Rachman and de Silva, Salkovskis and Harrison (1984) confirmed that 88% of a sample of non-clinical individuals experienced at least one intrusive though t. Additionally, according to several other studies, around 79-99% of people in non-clinical samples experience intrusive thoughts similar in nature to those experienced by people suffering from OCD (Freeston, Ladouceur, Thibodeau Gagnon, 1991; Julien, O’Connor Aaredma, 2009; Rachman de Silva, 1978; Salkovskis Harrison, 1984). The real prevalence of intrusive thoughts in non-clinical populations is likely to be on the higher ends of these estimates, as research participants may have underreported their experience of intrusive thoughts due to embarrassment, hesitation and shame. Moreover Pudon and Clark (1993) and Belloch, Morillo, Lucero, Cabedo, and Carrio (2004) also found that 99% of their non-clinical samples (n=293, n=336 respectively) reported having experienced at least one intrusive thought listed in the Obsessive Intrusions Inventory (OII/ROII). But it should be underlined that these researchers also found a slight difference in contents of intrusive thoughts exp erienced by OCD patients and non-clinical samples. OCD patients reported thoughts of dirt, disease and contamination among others. However normal people mainly reported thoughts of unacceptable sex, harm to self, aggression towards others and accidents amongst others. But it might be that the normal people do not consider thoughts about disease, dirt and contamination distressing, thus they are underreported. A Severity Continuum from Normality to Clinical Obsessions The intrusive thoughts reported by normal individuals are considered the ‘normal’ analogues to clinical obsessions and their study allows for better comprehension of the nature of intrusive thoughts. Instead of the normality versus psychopathology breakdown, the modern view discusses the continuity from normality to clinical obsessions. Clark elaborates more on this continuum of intrusive thoughts, by placing clinical obsessions at the extreme end, stating that the difference between clinical and non-clinical cognitive intrusions is ‘one of degree, rather than kind’(Clark,2005, p.11). Similarly Rachman and de Silva (1978) denote a similarity between the content of intrusive thoughts experienced by normal people and people with OCD. The researchers even postulate that psychologists and psychiatrists, who only have the knowledge about the content of the thoughts, have difficulty distinguishing between clinical and non-clinical obsessions. However the same researchers identified a quantitative difference between normal intrusions and clinical obsessions. The difference lies in the intensity and frequency with which these thoughts are experienced. Other studies highlight differences in other variables such as the associated unpleasantness and the level of anxiety occasioned by obsessions, the difficulty in controlling them or freeing the mind from the thoughts, the extent to which people perform neutralizing behaviours or rituals to reduce discomfort and ease anxiety, and the ultimate consequences that result from these intrusive thoughts, because clinical intrusive t houghts interfere remarkably with the daily functioning and life of people suffering from them (Oltmanns Gibbs, 1995; Parkinson ranchman, 1981; Rachman de Silva,1978; Salkovskis Harrison, 1984). Freeston and Ladouceur ( 1997) found that among all the other variables, unpleasantness associated with intrusive thoughts is immensely clinically significant because the assessment of this variable can provide insight to therapists on whether clinical change has occurred or not. Hence this variable can be used to assess therapeutic effectiveness. Theoretical Explanations of Intrusive Thinking Various theorists have attempted to approach intrusive thinking in manifold ways using different approaches like the biological, psychodynamic, behavioural and cognitive approaches. A full discussion of all the approaches is beyond the scope of this thesis. Hence, our analysis will focus on the cognitive and metacognitive approaches. If intrusive thinking is initially a normal phenomenon, then why does it develop into obsessive thinking in a minority? Research has underlined the role of cognitive and behavioural variables in the transition from normality to pathology (Clark Purdon, 1993; Freeston et al, 1991,1992; Niler Beck, 1989; OCCWG, 1997; Purdon Clark, 1994a, 1994b; Rachman,1993). More concisely, cognitive variables are related to the evaluative process (cognitive appraisal) and meaning that an individual attach to his or her negative thought. In clinical cases the meaning assigned to intrusive thoughts might be immensely threatening and disturbing. The behavioural variables are related to the covert and overt actions that the individual performs in response to his or her negative thoughts in an attempt to feel better by decreasing anxiety and discomfort. Salkovskis (1989) highlights the neutralising responses to intrusive thoughts as the key element in the ultimate development of obsessions. Hence the c ontents of normal intrusions and clinical obsessions are basically similar; it’s only the mental and behavioural processing of the negative thoughts that put them on either end of the continuum. Rachman’s (1997) Cognitive Theory of Obsessions According to Rachman (1978), the transformation of normal intrusions into clinical obsessions occurs when the individual considers his thoughts as catastrophic and threatening by viewing them as being personally significant. In an attempt to explain the origins of intrusive thoughts, Rachman (1978) argues that exposure to stressful events occasions the occurrence of intrusive thoughts. Rachman and de Silva (1978) further highlight that external cues trigger the occurrence of normal intrusive thoughts (characterized as being less intense and less distressing) and even clinical obsessions (characterized as being more intense and distressing). This view gained support by the experimental research carried out by Horowitz (1985), Horow itz and Becker (1971), and Horowitz, Becker, Moslowitz and Rashid (1975) which summarized that patients and non- patients experienced increased intrusive thoughts when they were exposed to stressful films. A Metacognitive Approach Metacognitions refer to the beliefs and knowledge about thinking and also the strategies used in the regulation and control of thinking processes (Flavell, 1979). Indeed, metacognitions are responsible for the shaping of the attention we pay to things, thoughts and so on, and they also determine the appraisal and the strategies we employ to regulate our thoughts. Adrian Wells (1997) developed the metacognitive therapy by positing that people experience emotional disturbance, distress and anxiety because of the Cognitive Attentional Syndrome (CAS) which consists of the perseverative thinking style including worry, rumination, attention focused on threat, thought suppression, ineffective self-regulating strategies and maladaptive coping behaviours. The CAS i s a maladaptive style of responding to thoughts and feelings and it enhances negative emotions and the occurrence of intrusive thoughts. The author highlights the presence of a higher degree of this syndrome in clinical patients suffering from depression and other anxiety disorders. He also differentiates between the ‘object mode’ and ‘metacognitive mode’ of mental processing.