Beruflich Dokumente
Kultur Dokumente
Centre for Forensic Mental Health, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 2608670, Japan
University of Bath, UK
c
King College London, Institute of Psychiatry, London, UK
d
University College London, UK
b
a r t i c l e i n f o
abstract
Article history:
Received 4 July 2011
Received in revised form
21 September 2011
Accepted 22 September 2011
Available online 10 November 2011
Reassurance seeking is a common problem in clinically anxious populations, and is particularly obvious
in obsessivecompulsive disorder (OCD). This study seeks to examine the way individuals with OCD try
to seek reassurance and the perceived consequences of such reassurance seeking using a qualitative
analysis of the perspectives of individuals with OCD who seek reassurance from other people. A semistructured interview was employed to ask individuals with OCD to reect on occasions when they
sought reassurance, and its impact on themselves and others. Ten interviews were conducted,
transcribed, and analysed in detail using thematic analysis. Four overarching themes were identied
in terms of reassurance seeking; interrogating feelings to achieve a sense of certainty, ceaseless and
careful effort, reluctance to seek reassurance, and interpersonal concern. A thematic map was produced
to understand the relationship between themes and sub-themes.
& 2011 Elsevier Ltd. All rights reserved.
Keywords:
Thematic analysis
Obsessive-compulsive disorder
Reassurance seeking
Quality study
1. Introduction
1.1. Impact of OCD
Reassurance seeking is probably the most frequent interpersonal manifestation of OCD. When considering this common
symptom of OCD, Salkovskis (1985, 1999) suggests that from a
cognitive perspective reassurance seeking is best conceptualized
as a special type of checking behaviour. When asking for reassurance, the individual seeks not only to check with others that he or
she has done their best to prevent harm, but in doing so seeks to
implicitly disperse some of the responsibility for the feared
consequence by passing it to the person offering reassurance.
This aim is usually achieved because the person who offers
reassurance has, without necessarily meaning to, both acknowledged their own awareness of the danger and implicitly taken a
share of responsibility if harm were to occur by explicitly or
implicitly endorsing the idea that the person need not take
further action. Thus reassurance seeking is a super-safety seeking
behaviour as it serves both to reduce the perception of threat and
to transfer some of the responsibility for any danger (and therefore the possibility of being blamed) to another person. As a safety
seeking behaviour it also has the effect of maintaining pre-
2211-3649/$ - see front matter & 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jocrd.2011.09.001
26
2. Method
2.1. Design
In order to understand the nature of reassurance seeking behaviour, thematic
analysis was performed on interview transcripts of individuals with OCD. A semistructured interview schedule was developed with input from experienced
clinicians and service users. A preliminary version of the semi-structured interview was piloted with two individuals with OCD and one healthy control, and the
nal version was slightly modied to take account of their feedback. The structure
of the interview involved four loosely dened sections.
Firstly, the participants views of reassurance: What, in your opinion, is
Reassurance?; Is it good or bad to seek reassurance? Why? In each instance the
interviewer was enabled to ask further questions until he considered the answer
to be complete. Throughout the interview participants were encouraged to seek
clarication themselves if they were unsure of what was being asked.
Secondly, how reassurance was sought: Do you seek reassurance?; When do
you seek reassurance?; Who do you seek reassurance from?; How do you ask for
reassurance?; How long does it take until you stop asking?; How closely do you
listen to the person?; Do you ask the person to do things for you?; Do you seek
reassurance in more subtle ways?; Do you seek reassurance in hidden ways? The
range of reassurance seeking we attempted to identify in the interview was from
direct seeking from people (e.g., is it clean?), asking to assist in the ritual, asking to
do the ritual (e.g., asking his/her partner to wash hands in front of them), selfreassurance (e.g., telling themselves in their mind that it is clean?), to subtle or
hidden reassurance seeking (e.g., calling a friend to make an alibi of where they
were). However, we did not include seeking reassurance from external references
such as internet and medical dictionary.
Thirdly, the effect of being reassured: What happens to you after seeking
reassurance?; How do you feel when you have obtained reassurance?; What
happens to the person who you seek reassurance from?; Is there anything you try
to do for the person?; Is there anything you do to reduce the burden of
reassurance on the person?.
Fourthly, questions seeking to identify the reasons for seeking reassurance:
Are you aware of what the person would respond? If so, why ask?; What makes
reassurance from those people effective to you? Interviews were conversational
with the structure being only loosely superimposed.
2.2. Participants
Participants were 10 individuals who met DSM-IV criteria for a principal
diagnosis of obsessivecompulsive disorder and who reported seeking reassurance from others (i.e., not just self-reassurance). Nine participants were diagnosed
using the Structured Clinical Interview for DSM-IV (SCID, First, Spitzer, Gibbon, &
Williams, 1996) by trained psychologists, and one participant was diagnosed
locally (e.g., by General Practitioner or Primary Care Trust). For this participant
who was diagnosed locally, scoring more than 60 points on Obsessivecompulsive
Inventory distress scale (OCI; Foa, Kozak, Salkovskis, Coles, & Amir, 1998) was
used as a further inclusion criterion. The mean age of the participants was 37.85
years (med. 35, range 2553), and the mean baseline OCI score was 92.57 (med.
94, range 62149). Characteristics of the participants were summarised in Table 1.
2.3. Procedure
All participants of this study had participated in an experimental study about
reassurance seeking and completed OCI (Foa et al., 1998), RAS and RIQ (Salkovskis
et al., 2000), BDI (Beck & Steer, 1987), and BAI (Beck, Epstein, Brown, & Steer,
1988) prior to the semi-structured interview. Written information about the
studies was sent to potential participants in the post, and if they agreed to take
part, they returned the reply slip. After their eligibility for participation was
checked, an appointment was made for them to come to meet the investigators.
Written informed consent was obtained on their arrival, and the purpose of the
studies was explained. They performed an experimental task prior to the interview study. The interview adopted a non-interventionist approach. Interviews
were conducted by the rst author, who had also carried out other studies about
reassurance seeking over the past 2 years. It was believed that familiarity with the
research topic can enhance understanding of the interview response and coherence of the interpretation. Participants were offered a 20 gift voucher for their
participation in the research. The protocol of the current study was approved by
the Research Ethics Committee, as part of a larger study about reassurance seeking
behaviour.
2.4. Qualitative analysis
Audio-recordings of the interviews were transcribed verbatim by the third,
fourth, and fth authors; the current data set therefore comprised the 10
Table 1
Characteristics of the participants.
ID
Gender
Age
Ethnicity
Educational
qualication
Relationship
status
Employment
status
OCI
total
RAS
RIQ
BDI
BAI
1
2
3
4
5
6
7
8
9
10
Male
Female
Female
Male
Female
Female
Female
Female
Male
Female
27
53
25
43
34
27
Mixed
Caucasian
Caucasian
Caucasian
Caucasian
Black
Caucasian
Caucasian
Mixed
Caucasian
Secondary
Secondary
Secondary
Secondary
Secondary
Secondary
Single
Married
Dating
Married
Cohabiting
Single
Single
Cohabiting
Married
Married
Paid Work
On Sick Leave
Paid Work
Unemployed
Unemployed
Unemployed
86
116
112
72
94
113
94
81
139
62
144
128
102
81
107
142
124
159
151
113
66.87
68.75
45.63
28.12
65.00
73.75
6
22
24
23
13
20
6
20
33
31
19
20
30
40
35
Postgraduate
a
Secondary
Paid Work
On Sick Leave
Unpaid Work
55.00
72.5
21.25
25
14
10
19
34
13
3. Results
3.1. Overview
Four overarching themes were identied from the analysis of
the interview transcripts. These are shown with sub-themes and
codes in Table 2. The rst theme, Interrogating feelings to achieve
a sense of certainty, appears to be linked to the motivation of the
participants to seek reassurance in the rst place. The remaining
categories Ceaseless and careful effort, Reluctance to seek
reassurance, and Interpersonal concern represent the process
before, during, and after they seek reassurance. In the next
section, each overarching theme is described immediately followed by its subcomponents with specic examples from the
transcripts.
Table 2
Overarching themes and sub-themes.
Interrogating feelings to achieve a sense of certainty:
Need to feel certain/perfect
Need to feel right
Dispersing responsibility
Ceaseless and careful effort:
Seeking to be reassured in range of ways
Careful asking
Clarity and understanding of the reassurance given
Reluctance to seek reassurance:
Counterproductive effects of reassurance seeking
Limited effect of reassurance
Knowing its bad to seek
Interpersonal concern:
Embarrassment
Causing problems for others by reassurance seeking
Guilt, gratitude and compensation
Need to feel
certain/perfect
27
Dispersing
responsibility
Seeking to be reassured
in range of ways
Careful asking
Clarity and understanding of
the reassurance given
Reluctance to seek
reassurance
Interpersonal
concern
Embarrassment
Limited effect of
reassurance
Knowing it's
bad to seek Counterproductive effect
of reassurance seeking
Straining others by
reassurance seeking
28
that. I know that if I move that box twenty times it not going to
make any difference to the box, its not going to make any
difference to me, but the feeling is that its not safe to progress
onto other thingsy
3.2.3. Dispersing responsibility
Three participants felt that they were dispersing responsibility
for harm when they sought reassurance. That is, they tried to make
sure that they would not be to blame when bad things happened.
One participant described it as fear of people saying, oh its all your
fault.
Participant 8: Its like an insurance policy, too. So if the worst
does happen its not all my fault. So although its partly my
fault its like not. So the worst could happen and it would be
awful because it would all be my fault, but the worst could
happen and it would still be awful but at least I could say well,
it wasnt just my own bad judgment.
Another participant mentioned the link between feeling better
and dispersing responsibility:
Participant 1: If something was to happen then Ive got someone to blame, someone to get my anger out on and blame.
I dont know, it just makes me feel better.
3.3. Ceaseless and careful effort
This second overarching theme represents participants constant
caution and cares to ensure that they made sufcient effort to nd
the right reassurance given by the right person in order to be sure
that they could trust the reassurance given. They described trying
very hard to obtain good quality reassurance, and made an effort to
minimise the chance of bad or ill-timed reassurance. They describe
the constant effort involved in seeking to obtain and understand
reassurance in different ways so as to maximise the effect when
doubt emerges after reassurance. They also seek, in a range of ways,
to compensate for the absence of reassurance or bad reassurance.
3.3.1. Seeking to be reassured in range of ways
Seven participants were employing range of different ways to
obtain reassurance in order to maximise their chance of being
reassured, and to consolidate the effect of any reassurance they
had obtained. For example, one participant initially sought to
achieve self-reassurance, then she asked for reassurance from
someone else, and she subsequently self-reassured again:
Participant 6: Are the plates clean? Ill ask myself a few times
and Ill be loud. First of all its in my head and then I have to
ask. Then when I get told very sternly or they dont want to
know, then again internally. Its in-out-in.
Often when participants failed to obtain good reassurance
from someone else, they started to seek reassurance from themselves. For example, one participant self-reassured when no one
was around to ask for reassurance:
Participant 9: Yes I have learnt to do it (self-reassurance)
because of many occasions you dont get someone to reassure
you. [y] Ill ask my mind or head and that person will tell me
Ok, its alright now.
Participant 4: Well, well, this is the frustrating thing about it. The
logic is always there but, you know, its black and white, its
obvious that somethings there or somethings right, you know
29
30
4. Discussion
The purpose of the present study was to identify patients
report of the phenomenology of reassurance seeking, including
both their view of the motivation to seek it, and their reactions
once it was provided. In addition, the strategies used were
elaborated, and we sought to clarify the interpersonal consequences of reassurance seeking from the perspective of the
sufferer. The results that are obtained are consistent with the
view that reassurance seeking is motivated by the need for
certainty, with a common theme being the person with OCD
responding to reassurance provision by interrogating their feelings in reaction to reassurance to achieve a sense of certainty
about their obsessional fears. When they seek reassurance,
individuals with OCD are mostly (but not entirely) certain about
the answer. However, they experience lingering doubts, mostly
fuelled by the obsessional thoughts themselves (what if???) and
thus feel that they are not subjectively certain that bad things are
not going to occur or that they would not be entirely responsible
if bad things were to occur.
Reassurance thus has the same function as checking, which is
to remove all elements of uncertainty regarding the occurrence of
harm and their personal responsibility for it. Reassurance seeking
is another type of attempt to resolve intolerance of uncertainty
regarding the possibility of responsibility for harm to themselves
or other people. This manifests in the qualitative analysis in term
of OCD patients describing the function of reassurance in terms of
active, motivated attempts to achieve feelings of certainty, of
being perfect, of being right, feeling comfortable with the situation they are in and the actions they have taken and so on.
When they are driven by those motivations to seek reassurance, individuals with OCD become extremely careful, manifest in
the present study as consistent reports of consciously and
deliberately making a ceaseless effort to be certain/sure before,
during, and after they seek reassurance. They also seek reassurance in range of ways, which are either intended to maximise the
effects of their previous compulsive behaviour or compensate for
failed ritualising and reassurance seeking. They describe paying
careful attention to the reassurance provider in the course of their
seeking reassurance, but also describe the seeking of reassurance
in subtle/hidden ways, including the use of trick questions.
31
32
5. Conclusion
In conclusion, the present study sought to qualitatively investigate reassurance seeking in anxiety disorders. Main results
suggest that the reduction of uncertainty is a key perceived
motivation for reassurance seeking in OCD. Sufferers attempt to
ensure the validity of reassurance whilst they frequently seek to
minimise the negative impact of reassurance seeking and the
linked interpersonal problems.
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