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The concealment of obsessions

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Abstract

Patients’ deliberate concealment from others of the content and frequency of their obsessions is a common and important aspect of obsessive-compulsive disorder (OCD). It is an overlooked manifestation of the safety behaviour that is believed to sustain OCD (e.g., neutralizing, thought suppression, avoidance behaviour, concealment). The phenomenon of concealment is understandable in terms of the cognitive theory of obsessions which states that obsessions are caused when the person attaches catastrophic personal significance to their unwanted intrusive thoughts. It is suggested that the selected, planned, suitable disclosure of obsessions can be therapeutic — presumably because it exposes the patient to alternative interpretations of the significance of the unwanted thoughts.

Introduction

In the course of carrying out clinical trials of a treatment programme derived from the cognitive theory of obsessions we became increasingly aware of the prominence of concealment. Most of the patients had for many years kept secret the content and frequency of their obsessions. “I have never told anyone about this before; it is my dirty little secret”. The concealment of the obsessions is so obvious that it has been overlooked; a clinical oxymoron.

Section snippets

Defined

The concealment of obsessions is the action of deliberately hiding from other people the content and frequency of one’s obsessions, those unwanted intrusive and repugnant thoughts that can besiege and torment a person. Examples of these “dirty little secrets” include: “I wish to attack an infant”, “I may lose control and stab my parents”, “I may molest a child”, “I have repugnant images of sexual violence”, “I will shout obscenities in church”, “I have incestuous impulses”, “I have thoughts of

Theory

Our approach to the concealment of obsessions is embedded within the cognitive theory of obsessions (Freeston et al., 1993, Freeston et al., 1996, Rachman, 1993, Rachman, 1997, Rachman, 1998, Salkovskis, 1985, Salkovskis, 1999), according to which unwanted and intrusive thoughts are converted into obsessions as a result of the person attaching catastrophic significance to the very occurrence and content of these thoughts. If the unnecessary and catastrophic interpretation of the thoughts can be

Self-doubt

In recent research on the clinical implementation of the cognitive theory, our patients were troubled, shamed and even frightened by their repugnant thoughts, and in each case their maladaptive interpretation led to pools of self-doubt and self-denigration. Repugnant blasphemous thoughts lead to doubts about the sincerity and depth of one’s religious commitments and beliefs. Repugnant aggressive thoughts lead to doubts about the sincerity of one’s commitment to the welfare of others, even to

Frequency of obsessions

In addition to being distressed by the repugnant content of the thoughts, they were troubled by the very frequency of the obsessions. “The mere fact that I keep having them day after day, must mean that they are important.” They are inclined to believe that the frequency with which they experience the thoughts is a certain indicator of the importance of these thoughts. “I accept that other people have these types of thoughts, but why do I have them so often?” A common additional interpretation

Consequences

The concealment of obsessions arises and persists for fear of a variety of unpleasant consequences. As mentioned, most of the patients anticipate that other people will react with surprise and even horror when they hear the content of the thoughts and then reject the affected person. In capsule form, the people with obsessions are fearful that others will attach the same importance or significance to the thoughts as the patient himself or herself, and that as a result, others will regard the

Disclosure

In recognition of the distress caused by unnecessary concealment, plus the adverse consequences described above, the treatment programme (Rachman, 2000) includes the encouragement of disclosures. The early part of the programme, with its normalization and explanation of the causes of obsessions, helps to facilitate therapeutic disclosures. Disclosure to the therapist is usually the first step. It cannot be rushed and in some cases is facilitated in the early stages by asking the patient to

Acknowledgements

We would like to thank Tracy Lindberg, Michelle Patterson and Roz Shafran for their important contributions as project therapists, and Mark Freeston for his advice. We are grateful to the British Columbia Health Research Foundation for financial assistance.

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