Let’s Talk about CBT - Research Matters is a brand-new podcast from the BABCP, hosted by Steph Curnow, Managing Editor for the BABCP Journals Behavioural and Cognitive Psychotherapy and The Cognitive Behaviour Therapist.

In this episode, Steph talks with Sandra Krause a senior PhD student at Concordia University. Sandra is lead author on the paper “‘Things that shouldn’t be’: a qualitative investigation of violation-related appraisals in individuals with OCD and/or trauma histories” with her co-author Adam Radomsky published earlier this year in Behavioural and Cognitive Psychotherapy. Sandra explains what is known about the cognitive model for mental contamination and how her research builds on this to explore what her participants with lived experience of OCD or trauma define as violations and the implications of this for clinical practice.

You can find Sandra’s full paper here: https://bit.ly/3YLyoUn

If you enjoyed this episode, please rate, review, and subscribe to the podcast on your preferred platform. Follow us on Twitter @BABCPpodcasts for updates and join the conversation. Have feedback or suggestions for future episodes? We'd love to hear from you! Email us at [email protected].

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You can follow Sandre and Adam Radomsky on Twitter for more updates about their work or follow their lab at the links below:

@SandraKrause4

@AdamRadomsky

Lab website: https://www.radomskylab.ca/

Credits:

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Transcript:

Steph: Hello and welcome to Let’s Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT.

Today I am speaking with Sandra Krause. Sandra is the lead author on the paper ‘Things that shouldn’t be’: a qualitative investigation of violation-related appraisals in individuals with OCD and/or trauma histories published in Behavioural and Cognitive Psychotherapy.

Steph: Sandra, welcome to the podcast.

Sandra: Thank you. Thanks for having me.

Steph: No problem. So before we begin, would you like to introduce yourself and talk a little bit about the research that you do?

Sandra: Sure, my name is Sandra Krause, and I'm a senior PhD student at Concordia University, which is in Montreal in Canada. And all of my research that I've done as part of grad school has been in the anxiety and obsessive-compulsive disorders lab. So that's been under the supervision of Professor Adam Radomsky and really, yeah, we've been interested in trying to understand different cognitive mechanisms that are at play. I'm trying to kind of better understand different aspects of anxiety disorders, OCD. My particular interest is in kind of the crossover with trauma, ultimately, really, just so that we can improve treatments and better help people who are suffering from those kinds of issues, so that's kind of the broad strokes of what we do, and clinically kind of work to apply the knowledge that we learned from the research to evidence based approaches to working with individuals who are struggling with those concerns.

Steph: Okay. Brilliant. Thank you. So we'll start talking about the paper that you've just had published in BCP. So can you tell me a little bit about what the aims of the study were, and were there any particular motivations behind the research?

Sandra: yeah, so when I started grad school, my research interest was on trying to kind of understand, we know a lot about within OCD contamination related symptomatology, but there's kind of a sub section of those types of symptoms that we know less about, and it's called mental contamination. And so this is, we often see people wash excessively, feel dirty in response to kind of intrusive moral thoughts rather than in response to any kind of contact with physical germs or dirt. So, maybe having an intrusive thought about something like incest or paedophilia, or intrusive memories of past assaults, things like this that have happened to them and that that's the driver of kind of the contamination symptoms that they experience. And so coming into my PhD, I was really curious, there's a cognitive model of mental contamination that was proposed initially when sort of the symptom domain was newer, but there's a lot of aspects of the model that aren't super fleshed out. So, for example, a big part of the model is the fact that these feelings, this is feeling of dirtiness and the washing that comes up, comes up because of a perceived violation, but there's not a super clear definition of what is a violation? What constitutes a violation? What kinds of events are violating for people and why? And then also, as the name suggests, the cognitive model kind of proposes that it's the way that people appraise or think about those violations that lead to the symptoms of mental contamination, but there's not a ton of work yet too that's been done at, zeroing in on specific types of thoughts that are linked to mental contamination feelings after experiencing a violation, and kind of differentiating between the types of thoughts that lead to mental contamination versus other kinds of negative emotions that might come up after a violating experience. So things like shame or anger or sadness that you might expect someone to experience as well. And so that's kind of where my study came in was that I wanted to really start from the ground up and speak to people who have lived experience with either OCD or trauma histories and hear from them, how they define the construct of violations so that we could get a clear definition for the model.

And then also walking through past instances of violation that they've experienced to understand different types of thoughts that they have, different appraisals that they make, and how those appraisals are linked to different kinds of negative emotions. So, again, kind of differentiating between those that were associated with those feelings of dirtiness, disgust, contamination, and the ones that are related to other kinds of negative emotional experiences like anxiety, fear, anger, shame, Et cetera. So that was really the aim of aim of the study.

Steph: brilliant. Thanks so much. So, if we get into the paper then, I think that leads quite nicely onto your participants. I see from the paper that you interviewed 20 participants. Who were they and how did you recruit them?

Sandra: Yeah, so, the inclusion criteria for the study. So in order to be able to participate, we were interested in interviewing people who either met criteria for OCD or who met criteria for, we call Criterion A and the DSM for PTSD. And so this is people who have experienced a serious trauma, so either actual or threatened death or serious injury or sexual violence that they experienced themselves or witnessed firsthand. And so, in order to get participants, we have a clinical registry as part of the lab. So there was at the time of my study, there was also a randomized control trial happening in the lab for treatment for OCD. So, we advertised through that study to see if anyone was interested in participating in the study as well. And then we also advertised on Twitter and online. And so really we were just looking for people who had these experiences or kind of experienced these types of symptoms who are adults, so over 18, and who spoke English. So it was pretty broad inclusion criteria. And yeah, anyone who was interested reached out and then I had a phone screener with them and just went over those kind of symptom, sections of the Mini-International Neuropsychiatric Interview and confirm that they were eligible. And then we conducted the interview over Zoom with them. But yeah, these were just kind of people in the community. Some were seeking therapy, and some were just kind of interested in contributing to research.

Steph: And did you get many, people come forward from Twitter? I'm always intrigued when I see studies on Twitter and how much uptake they really have.

Sandra: Yeah, there was a bit of, interest. I would say that there was a lot more screening that was required of the broad social media ads that there was, again, we were just sort of in the ads were just describing the symptoms pretty generally. Yeah, so people can interpret that in different ways so that we didn't actually end up with a ton of participants from the Twitter ads. But actually ran into another sort of new research hiccup that we hadn't anticipated was bots that there was, we got one day like 300 emails from different Gmail addresses, that were sort of automated, I guess. The bots that had reached out about the study. So just, I guess, a caveat for anyone doing social media recruitment for research that to be careful about.

Steph: I hadn't even considered that. But yeah, I can imagine 300 emails is annoying.

Sandra: yeah, I mean, luckily for us, there was a screening call, so I was able to weed out all of those people through that, but, yeah, for people I know who have been doing just online questionnaire studies via social media that people kind of just go on, I guess there's automated ways of, getting whatever compensation at the end. So they go in and submit a bunch of responses and it's hard to screen out.

Steph: So going back to the interviews then, when you completed all the interviews, am I right in thinking that you did some analysis on the transcripts and then some apparent themes emerged from these interviews?

Sandra: Yeah. So the, again, because it was like a pretty exploratory study and we were going in pretty open ended because again, we didn't have like really specific hypotheses of what we were expecting to find because we didn't really know a lot about this area from previous research. So, yeah, I conducted the interviews, with pretty like broad questions just to get a sense of people's experience more or less and then, went in and used a grounded theory approach to the qualitative analysis. So, as the interviews were being conducted, I was also coding them and kind of adjusting the interview protocol based on what we were finding. And certain themes came out which was always nice when you see some consistency across participants. But yeah, we found kind of similar themes across participants in terms of, first of all, how they define violation, or what constitutes a violation. Most interestingly for me, we found similar themes in terms of, the types of thoughts people had about the violation so the way that they appraise the violation, and then also in terms of, the functions of the behaviours that they engaged in, in response to the violating thoughts or, experiences. So, yeah, so I guess, do you want me to get into the specifics of those?

Steph: Yes, I was going to ask you if you had any good examples that we can kind of really listen to and kind of picture, that would be great.

Sandra: Yeah, yeah. So, in terms of the definition, what I found really interesting was that across participants, every single person that we interviewed, alluded to the fact that in order for something to be a violation, it needed to contradict a previously held belief. So it wasn't sort of whether how bad something was that happened to you, how serious it was, how life threatening, how, how much it infringed on your body or your space, but it was really whether it violated or contradicted sort of the way that you saw yourself or the world previously to that experience. So, yeah, a lot of people kind of talked about, they thought they were a smart person, but then they experienced the situation and made them feel dumb or they thought other people were trustworthy and then they were betrayed and it kind of eroded the trust that they had in people or interestingly, on the opposite side of things, there was one participant who talked about how he had been assaulted and mugged at one point, but that he actually didn't see that as a violation because in his mind, that's something that could happen to people. So, it sort of reinforced a previously held belief he had about what was possible in the world. So I thought that was sort of interesting that it's, it's really this, this contradiction of your beliefs or your sort of expectations that makes an event feel violating or perceived as a violation. And then in terms of the appraisals, so there were kind of common themes in terms of appraisals of other people. So the way that people thought about others after experiencing a violation, the way that they thought about themselves and then the way that they thought about the future were sort of the 3 bigger picture themes that that came out of the appraisals. And so what we found was that when people talked about feeling dirty or disgusted or contaminated that that came up most often when people sort of in terms of the appraisals of the self, thought that they were responsible in some way for the violation, or thought that it was some indication of their self-worth. So, I'm worthless because of having experienced that, or I'm worth less than I was before. Or I don't bring anything to the table now that this is something that I've experienced, or, yeah had thoughts about and then the last one that was linked to the mental contamination feelings was this appraisal of permanence. So, this idea that I'm tainted forever now, because of this experience or because of this thought that I can't get rid of it. This has changed me now permanently because of that.

And then for the behaviours, what I found most interesting was that it didn't really matter what the actual behaviour was. People talked about all kinds of very, very specific behaviours that they engaged in. Some of them were similar across participants, but there was a lot of sort of unique from person to person behaviours or urges that they had. But what I found interesting about it was that the function of the behaviours were a lot more similar across people, even if the behaviour itself wasn't. So, whether it was, cleaning or washing or thought replacement or avoidance or self-harm that, even if the behaviour on surface level look different from person to person, for most people, all of these things either serve to kind of avoid or distract away from thoughts about the violation. To sort of punish the self or, or kind of, inflict some kind of yeah, self-punishment because of the violation that they felt that they deserved. Or to regain a sense of control. So to feel this thought that I can't control or this experience that happened to me in the past that I have no longer have control over. This is something in the here and now that I can do to try to regain a sense of control over that event, even if it doesn't actually impact it. So, whether that's washing or showering or arranging things, again, self-harm came up with a couple of participants. That all of these things in the here and now made it feel like, okay, I might not have control over the original thing that happened, but I can regulate that anxiety and sort of get a sense of control in the here and now, by doing these different behaviours.

So, those were kind of, yeah, I guess the spark notes of the different themes that came up. But, yeah, the take home, I guess, was that there were different appraisals, that seemed to be linked to different emotions and that we were able to zero in on specific ones that were linked to mental contamination for the participants.

Steph: and apologies if this is a stupid question,

Sandra: No such thing as stupid questions.

Steph: As you were saying some of that, I was just thinking, when we talk about trauma and we talk about PTSD, it's not necessarily the event itself, but it's the meaning that we make of it. And is that kind of linked into the appraisal? So it's not necessarily that, what has happened to them, but their behaviour is kind of the meaning that they've made then of that violation.

Sandra: Yeah, no, absolutely. That's 100 percent kind of in line with what we found. And within trauma, that's the case. And also within OCD, right, that it's not about the intrusive thoughts themselves. Actually, we know that most people in the world, almost everyone experiences intrusive thoughts, but it's more about the meaning that's attached to having those thoughts that leads to the urge to engage in different behaviours for both PTSD and for OCD. So whether that's avoidance or whether that's certain compulsions that people engage in and so this kind of reinforce what we know about these things and what we know about cognitive models of, the fact that meaning and appraisals tend to drive a lot of emotional and behavioural outcomes for people and gave us a lot more sort of specific details to work with when it comes to this symptom domain specifically which hasn't gotten as much attention when it comes to past research.

Steph: So given these findings, then what do you think are the implications for clinical practice or even future research?

Sandra: Yeah, it's kind of a, I think, an important building block. Like you said, there was only 20 participants, and it was done qualitatively which I think has a lot of strengths. We heard from people directly who, are living with these experiences and were able to kind of use that to construct the analysis that we use for the study. Taking what we found from the study and replicating it in bigger samples and experimentally to be able to see causally when we make people think about things in particular ways do we then see a causal impact on the feelings of mental contamination? I think it's an important next step.

But. I think that what we found is super practical and clinically useful in a lot of ways, because we know that actually people who experience higher levels of mental contamination when they start treatment. So, I think the research has been done in OCD, but theoretically, I think there's no reason why it wouldn't apply to trauma as well, but that individuals who start treatment with higher levels of mental contamination actually do worse after treatment that they don't improve quite as much. And a lot of what's been proposed, for the explanation as to why is that a lot of the first line treatments for OCD are pretty behaviourally focused. So exposure and response prevention where it's exposing people to their fears and then, preventing them from engaging in the compulsive behaviour so the washing or the cleaning that they might engage in, and actually, what seems to kind of have come out in a really rich way from this study and from previous work that's been done in this area is that mental contamination might be a much more kind of cognitive process than physical contact contamination concerns and so for treatments to incorporate more sort of targeted cognitive intervention. So targeting the specific types of thoughts people are having in the specific meaning that people have ascribed to these violating experiences that are driving the washing and the feelings of dirtiness, might actually prove to be a lot more effective for people. And so we've kind of known that for a long time, theoretically, but the study, I think, gives us concrete intervention targets of specific types of appraisals that you can target in cognitive therapy. So you could engage in psychoeducation, just about these models, but also designing behavioural experiments to be able to test out, these different appraisals and meanings that people are ascribing to see when it holds up, if there's room for flexibility, maybe there's certain context where those things are true, but maybe it's not true across the board and all types of context.

I think that the themes that came out here could be really useful clinically to target as yeah, cognitive intervention targets, either as an adjunct to ERP or in, in place of more sort of behaviourally focused treatment. And then I think the last thing that I see as being a particularly clinically useful piece from the study is, again, because of the history of where mental contamination, the theory and concept of it sort of evolved from, we tend to think of the, the feelings as being associated mostly with just like washing and cleaning behaviour. But actually, what the study showed is that people engage in all kinds of different types of behaviour and that we should really be focusing more on understanding what the function of the behaviour is that people are engaging in, and maybe assessing for sort of a broader range of different types of, urges or behaviours that people are engaging in beyond just kind of washing and cleaning, because it seems even for the feelings of dirtiness and disgusting contamination that people engaged in really idiosyncratic, unique behaviours from 1 person to another. And so kind of not pigeonholing your assessment into just those types of things, but taking a broader sort of lens when it comes to assessing those types of aspect of the model, I guess.

Steph: Yeah, and speaking of kind of like not pigeonholing people, did you find when you were looking at the type, because you said there's quite a range of different types of behaviours that all the participants engaged in were there particular behaviours that seemed, were there any that were surprising to you?

For example, did you expect the participants who, we're experiencing OCD to have more washing, for example, or were you, were you quite surprised at just like the range of behaviours that everyone had?

Sandra: Yeah, I was actually, and it's a good question. I think, Yeah, it's interesting because I mean, I can get into it more, where we talk about some of the limitations, but a lot of the people in the study had both OCD and trauma histories, and there is a smaller subset that had just OCD, and a smaller subset that had just experienced trauma in the past.

But based on just looking at the transcripts and analysing the behaviours and the patterns, you wouldn't really have been able to tell the difference so much between the sort of sub samples within the sample, which I thought was really fascinating because yeah, I think there's sort of this instinct to think that maybe that the OCD group would engage in more of the ritualistic washing and maybe the trauma group would be, I don't know, maybe more fearful or avoidant, more sort of like, anxious, fear based types of emotional experiences and behaviours, but there really was kind of across the board a pretty wide range. I think the part that maybe I wasn't expecting, in terms of the behavioural side of things was that, self-punishment or self-destructive kind of urges is not necessarily something I think I anticipated beforehand, that even for some people, like the washing itself, like they would wash with really hot water, for example, as a way to, you know, they experience some kind of intrusive thoughts that they experienced as violating, they perceive themselves as being a horrible person, disgusting person, forever tainted by those thoughts. And then, would wash themselves with like really hot water to sort of punish themselves for it. And so that wasn't one that I was necessarily going and expecting to find, but again, it makes sense based on what we know about cognitive models and the way that our appraisals drive our behaviours and our emotions. I think it was interesting how trans well, I mean, there was only 2 kind of diagnostic groups of focus in the study, but it really was. It felt like a homogenous sort of, experience, I guess, based on the transcripts and the analysis that I ran, both in terms of, the emotions and also in terms of the behavioural sort of outcomes that people expressed.

Steph: it sounds like it must have been really fascinating.

Sandra: Yeah, it was. And I think just I think qualitative research sometimes gets a bad rap, that like hardcore evidence-based researchers, really value, quantitative experimental work. And I think that there's obviously huge strengths to doing that kind of research, but just the richness of being able to hear firsthand from these people and use their language as the data. Often as researchers, we can get sort of siloed and have blinders on sometimes when we have a concept and we think we understand the concept fully and it sort of reifies a bit where we develop a concept and then we test that concept and prove that that concept kind of continues to exist. And I think, mental contamination is a good example of this, where it developed out of the contamination literature. So we define it kind of more narrowly in terms of the contamination feelings and urges to wash is sort of the behavioural part of the definition, but then when you go in and you hear from people who are living it that it actually kind of expands our viewpoint, I think, quite a bit by being able to see stuff that maybe, we don't necessarily come to instinctively as researchers with all of our theory and kind of knowledge of the field that is super useful and practical in a lot of ways, but I think can sometimes blind us to stuff that maybe is outside of what we've already know of an area. So, yeah, it was super rich and interesting to be able to talk to people 1st hand and see how the interviews evolved over time, too, because I think that's another awesome part about qualitative research is that it's meant to kind of evolve as you're working through stuff with people. So, as things came up in early interviews around, maybe these broader behavioural outcomes or specific types of thoughts that people had that I wasn't anticipating, I was able to kind of probe more for those things with later interviews and see that it actually was quite common and that a lot of people sort of experience those things as well. So, yeah, it was a really fascinating experience for me. And I think it's rich the data that comes out of it and the quotes from the participants that you can see in the paper.

Steph: Absolutely. So if you were going to start this all over again, was there anything that you would have done differently if you could do it again?

Sandra: Yeah, so it's a good question. I think, like I said, the nice part about qualitative research is that you can sort of course correct a bit as you're going. So, the interview became more open ended as I went on with later participants, which I think if I could do it over, I would start with a little bit more open-ended prompts rather than, really specific, more closed ended questions guided by the theory and research that we already have. I think if our theories are accurate then those things will come to light, even if you don't probe for them specifically. And that's what we found kind of later on with the interviews is that it allowed for a little bit broader information to come out and also to sort of demonstrate that our cognitive model holds up, even when we're not asking people specifically about what emotions were caused by that thought, or more sort of, I guess, closed ended or directive questioning. So, I think that's 1 thing. I think also, just in terms of the diagnostic profiles initially, I was sort of anticipating having 10 people with OCD and 10 people with trauma histories and actually getting out there, I think there's a lot more overlap between these groups, they're not so cleanly divided. And I mean, that lines up with epidemiological research that we have that shows that there's a lot of comorbidity between these things and that there's a big sub sample of people with OCD where the ideology is trauma or these violating experiences in the past.

And then I think, yeah, I think sort of along those lines, just looking at it as more of a transdiagnostic construct and not really zeroing in specifically on certain diagnostic categories, because even with the participants in the sample. So, as part of the study, I conducted the whole MINI, so it's a semi structured diagnostic interview for everybody. And so, in order to participate, they needed to meet criteria for either OCD or Criterion A for PTSD, but a lot of them, I'd say most of them also had comorbid other disorders. So things like social anxiety or depression or eating disorders. So I guess, maybe rather than trying to be more specific diagnostically in the future, based on what came out of this, I think it would actually be useful to just ignore the diagnostic categories and see whether this model holds up trans diagnostically as a more universal experience that people have. So, I guess, yeah, if I were to do it over again, those would be the main, the main things.

Steph: Cool. Thank you. And this might not be relevant, but I always like to ask authors, as a journals Managing Editor, it's always interesting to me, how did you find the peer review process? Were reviewer comments helpful? Did you find, was there anything that you disagreed with or that you found difficult about the process?

Sandra: So I think, I think qualitative research, especially like clinically focused qualitative research can be sort of hard to find a home for in terms of a journal just because I think a lot of hardcore clinical journals tend to prefer like quantitative research and then more qualitatively focused research journals, have sort of a rigor and standard in terms of the methodology that a lot of applied research doesn't kind of, I guess, meet the bar for. So I think in that sense, just finding the right place for it was an interesting experience. And also just the length of qualitative papers is quite long because of the quotes, rather than having a nice table that synthesizes all of your means and standard deviations. The data itself are these paragraphs of text from people. So I think that was a bit of a challenge initially, but, once we submitted it to Behavioural And Cognitive Psychotherapy, I actually found the review process was super helpful. And it was nice because the reviewers comments that we got, there were 2 reviewers and 1 was able to provide more comments about kind of the theoretical, practical, clinical, aspect of it. And the other, appeared to have a lot of experience with qualitative methodology. So, in terms of, adding reporting details about the analysis process was useful. I think for us, we're not a qualitative research lab. We've done some qualitative studies, but it's not sort of our area of expertise. And so there was a lot of really constructive feedback within that about, what to include what's maybe not necessary to include, from the methodological sort of standpoint. So I actually found it, I think it ended up with a much more sound balanced final product, which isn't always the case with peer review.

I think sometimes it can be a little nitpicky and not the most constructive, but in this case, I actually found that the combination of the reviewers feedback was super helpful and constructive and I learned a lot from it.

Steph: That’s really good to hear and it's so nice, for people to have good experiences as well. Cause like you say, some peer review can be very nitpicky and lke you say, if it took you a while to find the right place for your research, then I'm really glad that the peer review process was just as smooth as it was then. I think that's really great.

So just before I let you go what's coming up next for you? What else are you working on? Are you going to try and continue with the research that you've done here or anything you want to plug that's coming up?

Sandra: Yeah, so actually we used the interviews in the study that we just talked about as sort of a basis to develop a quantitative measure of appraisal. So, as I kind of alluded to earlier this interview data, I think, is super rich and points to a lot of really interesting directions. And I think that the next step is to kind of validate it more quantitatively and experimentally. So, we took the themes of the different appraisals that came out and tried to create a new measure of just kind of a broad range of different types of violation appraisals. And so that's where we just submitted that for publication. So, yeah, we validated this new measure and hopefully developed a clinically and research useful scale that people can use moving forward to look at quantitatively how different maybe themes of violation appraisals lead to different kinds of outcomes for people. So that's kind of, more imminently in the pipeline and then, Yeah, I think down the road, I'm looking to sort of use that experimentally and see if we can try to manipulate different types of appraisals and look at their impact on mental contamination and see, maybe clinically within sort of clinical populations on the flip side is whether we can sort of reduce those types of appraisals or get a little more flexible with those types of appraisals and see whether that can maybe help people who are, who are experiencing these kinds of symptoms. But yeah, overall, just I'm excited about more research in this area. I think it's a really interesting subset of clinical populations, this intersection between trauma and OCD. And I think it's getting more attention in the research world and in terms of sort of like clinical implications that stem from that. And I guess I'm just excited to be a part of whatever comes up in that domain down the line.

Steph: Yeah. Brilliant. Well, this has been really, really interesting. Thank you so much for coming on and talking to us.

Sandra: Thanks for taking the time to ask me interesting questions.

Steph: Thanks so much for listening. If you enjoyed this episode, then please rate, review and subscribe wherever you get your podcasts. And you can follow us on Twitter @BABCPpodcasts.

If you have any feedback or suggestions for future episodes, then I'd love to hear from you. Email us at [email protected]. And why not check out our sister podcast. Let's talk about CBT- Practice Matters. This is hosted by the lovely Rachel Handley. And it's the perfect podcast for clinicians working in CBT.

 Thanks for tuning in, and I'll see you next time on Research Matters. Bye.