Impact of Religiosity on Coping with Intrusive Thoughts

A thesis presented to

the faculty of

the College of Arts and Sciences of Ohio University

In partial fulfillment

of the requirements for the degree

Master of Science

Allison J. Petrarca

May 2013

This thesis titled

Impact of Religiosity on Coping with Intrusive Thoughts

ALLISON J. PETRARCA

has been approved for

the Department of Psychology

and the College of Arts and Sciences by

Brook A. Marcks

Special Adjunct Professor of Psychology – University of Memphis

Robert Frank

Dean, College of Arts and Sciences

Abstract

PETRARCA, ALLISON J., M.S., May 2013, Psychology

Impact of Religiosity on Coping with Intrusive Thoughts

Director ofThesis: Brook A. Marcks

Intrusive thoughts are unwanted, distressing thoughts that are experienced by the majority of individuals, and are one of the key features of obsessive-compulsive disorder

(OCD). It is theorized that maladaptive beliefs about intrusive thoughts, such as thought- action fusion (TAF) beliefs, as well as the use of avoidant coping strategies, such as thought suppression, in response to intrusive thoughts may cause them to escalate into obsessions. Religiosity may be another factor that influences the way an individual responds to intrusive thoughts. Previous studies have found that religiosity is related to

TAF and the tendency to suppress unwanted thoughts. However, it is unclear whether religiosity impacts the effectiveness of thought suppression. Therefore, the purpose of this study was to compare the effects of different coping strategies (thought suppression, acceptance-based approach, and monitor-only control) to manage an intrusive thought on distress and thought frequency, while also taking into consideration levels of religiosity.

This study also aimed to test a model in which the relationship between TAF beliefs, thought suppression, and OC symptoms is moderated by religiosity. The results suggest that religiosity does not account for a significant amount of the variance in intrusive thought frequency, anxiety, negative appraisals, or changes in intrusive thought frequency and anxiety over time. Religiosity was also not found to moderate the relationship between TAF beliefs, thought suppression, and OC symptoms. Limitations 4 of the experimental manipulation make interpreting the results from the experimental portion difficult. However, additional exploratory analyses provided evidence showing that thought suppression is related to increased intrusions, higher levels of anxiety, and negative appraisal ratings. The limitations of the current study and directions for future research are discussed.

Table of Contents Page

Abstract ...... 3 List of Tables ...... 7 Introduction ...... 8 Intrusive Thoughts ...... 9 Coping Strategies ...... 10 Cognitive-Behavioral Model of Obsessive-Compulsive Disorder ...... 15 Scrupulosity ...... 18 Current Study ...... 21 Hypotheses ...... 22 Method ...... 25 Participants ...... 25 Materials ...... 26 Procedure ...... 34 Results ...... 39 Thought-Action Fusion Induction Check ...... 39 Experimental Manipulation Check ...... 39 Experimental Hypotheses ...... 40 Exploratory Analyses ...... 47 Discussion ...... 50 References ...... 64 Appendix A: Demographics Questionnaire ...... 92 Appendix B: SCSRFQ ...... 94 Appendix C: DRI ...... 95 Appendix D: TAFS ...... 97 Appendix E: WBSI ...... 98 Appendix F: AAQ-II ...... 99 Appendix G: PI-WSUR ...... 100 Appendix H: PIOS ...... 102 Appendix I: PANAS ...... 103 6

Appendix J: Appraisal Ratings ...... 104 Appendix K: Intrusive Thought Induction Check ...... 105 Appendix L: Coping Strategy Manipulation Check ...... 106 Appendix M: Selection of Target Individual Form ...... 107 Appendix N: Sentence Copy Form ...... 108

List of Tables

Page

Table 1: Descriptive Statistics for Demographic Variables by Group ...... 83

Table 2: Percentages of Participants’ Religious Affiliation by Group…………………84

Table 3: Descriptive Statistics for Religiosity Measures ...... 85

Table 4: Descriptive Statistics for Coping Strategy Affect Measures ...... 86

Table 5: Descriptive Statistics for OC Related Beliefs and Symptoms Measures ...... 87

Table 6: Descriptive Statistics for TAF Induction Check and Appraisal Ratings…….. 88

Table 7: Descriptive Statistics for Appraisal Ratings Across Time Periods 1 and 2 By

Group ...... 89

Table 8: Hierarchical Multiple Regression Analysis for the Interactions of Religiosity and

OC Beliefs in Predicting Obsessive-Compulsive Symptoms ...... 90

Table 9: Unique Predictor of OC Experiences: Effort Suppressing Intrusive Thought .91

Introduction

Intrusive thoughts play an important role in the development and maintenance of a number of psychological disorders (Ladouceur et al., 2000). Repetitive and persistent thoughts, images, and/or impulses are included in the definition of obsessive-compulsive disorder (OCD) (American Psychiatric Association, 2000). Indeed, beliefs about, appraisals of, and strategies used to cope with such thoughts are hypothesized to be involved in the escalation of intrusive thoughts into obsessions in OCD (Clark & Purdon,

1993; Ehlers & Steil, 1995; Freeston & Ladouceur, 1993; Rachman 1997; Salkovskis,

1985). Religion may also be a factor in the development of the disorder, in that individuals higher in religiosity may have more negative beliefs about intrusive thoughts, due to religious doctrine, and may in turn use thought suppression more often

(Abramowitz, Deacon, Woods, & Tolin, 2004; Yorulmaz, Gençöz, & Woody, 2009). This may explain why some individuals with OCD experience religiously themed obsessions and compulsions, which is a presentation of the disorder called 'scrupulosity'

(Abramowitz, Huppert, Cohen, Tolin, & Cahill, 2002; Fallon et al., 1990; Miller &

Hedges, 2008). Indeed, research suggests that individuals who are devoutly religious and suffer from OCD report more religious obsessions and compulsions than other OCD symptoms (Steketee, Quay, & White, 1991). Other researchers have found that in individuals with OCD, their specific cultural and religious behaviors are often a part of their symptoms (Okasha, Saad, Khalil, Seif El Dawla, & Yehia, 1994). Each of these topics related to intrusive thoughts, coping strategies, and scrupulosity will be discussed in greater detail throughout the course of this document. 9

Intrusive Thoughts

Intrusive thoughts are defined as unwanted thoughts that are recurrent and unintended (Kelly & Kahn, 1994). Intrusive ideation can be in the form of thoughts, images, or impulses (Wegner, 1994). Although intrusive thoughts are idiosyncratic in nature, some examples include thoughts of self-doubt, harm, aggression, disease, or sexual content (Clark & de Silva, 1985; Edwards & Dickerson, 1987; Parkinson &

Rachman, 1981; Purdon & Clark, 1993; Rachman & de Silva, 1978). The content of intrusive thoughts tends to be inconsistent with one’s beliefs, values, or perceptions of self (Wang & Clark, 2002). Since intrusive thoughts are unintended and unwanted, they differ from purposeful thoughts such as daydreams or fantasy. Furthermore, intrusive thoughts impede the ability to concentrate, and they tend to disturb and interfere with an individual’s cognitive activity (Yee & Vaughan, 1996). Likewise, intrusive thoughts are associated with feelings of distress (Edwards & Dickerson, 1987; Salkovskis & Harrison,

1984), unpleasantness (Parkinson & Rachman, 1981), unacceptability (Clark & de Silva,

1985), and perceived harmfulness (Edwards & Dickerson, 1987).

Among non-clinical samples, research suggests that 80-99% of individuals experience intrusive thoughts (Freeston, Ladouceur, Thibodeau, & Gagnon, 1991; Purdon

& Clark, 1993). For clinical populations, intrusive thoughts play a critical role in the development certain psychological disorders, most notably OCD (Ladouceur et al.,

2000). Obsessions, by definition, are intrusive, unwanted thoughts that are distressing to the individual (American Psychiatric Association, 2000). Given this, it is not surprising then that there are several similarities between non-clinical intrusive thoughts and 10 obsessions seen in those with OCD. Both obsessions and nonclinical intrusive thoughts tend to be idiosyncratic in nature and unacceptable to the individual (Wang & Clark,

2002). Research has demonstrated that both the form and content of nonclinical intrusive thoughts are similar to obsessions in those with OCD, with clinicians being unable to distinguish between the content of clinical obsessions and non-clinical intrusive thoughts

(Rachman & de Silva, 1978). Both are also difficult to resist and control, and recur rapidly. Furthermore, both are appraised negatively, related to negative mood states, lead to the use of similar coping strategies (e.g., neutralization, thought suppression), and cause distress (Belloch, Morillo, Lucero, Cabedo, & Carrió, 2004; Purdon & Clark, 2002;

Rachman & de Silva, 1978; Salkovskis, 1988; Salkovskis & Harrison, 1984, Wang &

Clark, 2002). Despite these similarities, there are some differences between obsessions in

OCD and non-clinical intrusive thoughts, mainly the degree of severity to which these thoughts are experienced. In clinical OCD samples, intrusive thoughts occur more frequently, are more intense, are harder to resist or dismiss, and provoke more anxiety than in non-clinical populations (Morillo, Belloch, & García-Soriano, 2007; Rachman & de Silva, 1978; Rassin, Cougle, & Muris, 2007; Veale, 2004).

Coping Strategies

Coping with intrusive thoughts can be difficult, due to the distressing nature of such thoughts. Furthermore, the coping strategies used with intrusive thoughts have been hypothesized to play a role in escalation of intrusive thoughts into obsessions (Clark &

Purdon, 1993; Rachman, 1993, 1997, 1998; Salkovskis, 1985). A number of studies have been conducted to investigate how individuals cope with intrusive thoughts and 11 associated mood states, as well as the effects of different strategies (Corcoran & Woody,

2009; Genest, Bowen, Dudley, & Keegan, 1990; Kelly & Kahn, 1994; Marcks & Woods,

2005; Marcks & Woods, 2007; Rippere, 1979; Wegner, Schneider, Carter, & White,

1987). Research suggests that thought suppression is generally the first coping strategy used in order to eliminate an intrusive thought. Thought suppression is the process of putting forth effort into trying to stop or suppress certain thoughts (Wegner, 1994).

Thought suppression can take different forms, including telling oneself to stop having a particular thought or turning one’s attention toward a distraction (Wenzlaff & Wegner,

2000). Although thought suppression is used in an attempt to deal with the distress associated with intrusive thoughts, individuals with OCD report it is not particularly successful, only helping approximately 11% of the time (Purdon, 2004). Not only does thought suppression appear to be ineffective, its use may cause many unintended negative consequences.

In terms of which type of coping strategy is most utilized in non-clinical populations, correlational research suggests that almost 99% of college students have tried thought suppression at some point when experiencing unwanted thoughts (Kelly &

Kahn, 1994). Furthermore, in highly religious individuals, the need to control thoughts is a prevalent belief (Sica, Novaro, & Sanavio, 2002). Research has found that highly religious individuals attempt to control their thoughts with thought suppression more often than moderately religious persons or individuals who are atheist/agnostic, possibly due to some of the doctrines of their religion (Abramowitz et al., 2004). Indeed,

Yorulmaz et al. (2009) found that highly religious individuals were more troubled by 12 intrusive thoughts and placed greater importance on controlling their own thoughts.

Thus, when such beliefs are present, it makes sense why these individuals would be motivated to suppress intrusive thoughts.

Considerable correlational research exists examining thought suppression, experiencing intrusive thoughts, and OC symptoms. Much of the correlational research conducted on thought suppression has used the White Bear Suppression Inventory

(WBSI), developed by Wegner and Zanakos (1994). The WBSI is used to assess whether an individual is more likely to use suppression for coping with intrusive thoughts. A moderate, positive correlation has been demonstrated between the WBSI and self-report measures of OCD, such as the Maudsley Obsessive-Compulsive Inventory (MOCI;

Hodgson & Rachman, 1977) and the Obsessive Compulsive Thoughts Checklist (OCTC), developed by Bouvard and colleagues (1997) (Darri Rafnsson & Smari, 2001; Muris,

Merckelbach, & Horselenberg, 1996; Rassin & Diepstraten, 2003; Wegner & Zanakos,

1994). These findings suggest that individuals who have a tendency to use thought suppression are more likely to endorse obsessive-compulsive symptoms. WBSI scores have also been found to have a moderate, positive relationship with presence and frequency of obsessions, as well as the severity of OCD symptoms (Wegner & Zanakos,

1994).

Research has also examined the relationship between scores on the WBSI, presence of intrusive thoughts, and ability to use thought suppression. More specifically, there is a positive correlation between WBSI scores and the number of intrusive thoughts an individual experiences (Muris et al., 1996; Purdon & Clark, 1994b). Muris and 13 colleagues (1996) also found that WBSI scores were significantly related to most thought control strategies, including distraction, worry, punishment, and re-appraisal (r’s ranging from 0.15 to 0.33). WBSI scores also predict beliefs about how much control one has over their intrusive thoughts with higher scores indicating a stronger belief that one has the ability to control intrusive thoughts (Purdon & Clark, 1994b). During thought suppression experiments, participants with higher scores on the WBSI experience their intrusive thought more frequently, tend to put more effort towards suppression, and experience more distress when their intrusive thoughts occur (Muris et al., 1996).

Marcks and Woods (2005) found similar results in that participants who tried harder to suppress their intrusive thoughts experienced more intrusive thoughts (d = .65) and reported more discomfort (ƞ² = .09). The results also indicated that there was a significant relationship between the urge to “do something” to reduce or cancel out the effects of having such thoughts and the effort the participants put toward suppressing their intrusive thought (r = .28).

Numerous lab-based experimental studies have also been conducted on thought suppression. One of the first studies was by Wegner and colleagues (1987) to examine the effects of thought suppression on neutral intrusive thoughts. In their study, participants were asked to either suppress or express thoughts of a white bear during a five minute period. Results showed that when participants were asked to suppress thoughts of a white bear, they were unable to do so and they had thoughts of a white bear at a greater rate than those who were asked to express thoughts. This finding was termed the

“immediate enhancement effect”, in that thought suppression actually caused a higher 14 frequency of intrusive thoughts. The study also showed that when participants were asked to express thoughts of a white bear during another five minute period, after having suppressed the same thought, they experienced thoughts of a white bear more frequently as compared to participants who initially expressed rather than suppressed. This was termed the “rebound effect”, in that suppression attempts caused a subsequent increase, or rebound, of the suppressed thought. Thus, the results from this study suggest that thought suppression has paradoxical effects and actually causes an individual to experience more intrusive thoughts while suppressing and after suppression attempts have ended.

Given the potential harm that thought suppression may have on an individual, an acceptance-based approach has been considered as an alternative (Marcks & Woods,

2005; Marcks & Woods, 2007). This approach is based on acceptance and commitment therapy (ACT) (Hayes, Strosahl, & Wilson, 1999) and mindfulness-based cognitive therapy (Segal, Williams, & Teasdale, 2002). The acceptance-based approach focuses on increasing willingness to experience unpleasant thoughts and related feelings without trying to avoid such stimuli or change them. Thus, this approach does not attempt to change the frequency of intrusive thoughts, but instead one's relationship with them.

From an acceptance-based approach, thoughts then become simply something to be noticed (Marcks & Woods, 2007).

Recent studies have begun to examine whether such an approach might be useful for coping with intrusive thoughts. Marcks and Woods (2005) found that individuals who had a natural tendency to accept their intrusive thoughts experienced less discomfort and 15 lower levels of depression, anxiety, and obsessionality. Furthermore, in the experimental portion of this study, an acceptance-based approach for coping with personal intrusive thoughts decreased participants' anxiety levels compared to a monitor-only control condition. Of note, the acceptance-based approach did not result in fewer intrusive thoughts, but rather participants who used this strategy were less bothered by the intrusive thoughts. Marcks and Woods (2007) conducted a follow up study, providing additional evidence supporting the benefits of an acceptance-based approach for personal intrusive thoughts. More specifically, this study found that those using an acceptance- based approach for managing an obsessive-like thought were more willing to have the thought (i.e., were less avoidant), after having used this strategy, which could impact the experience of the intrusive thought when it recurs (Marcks & Woods, 2007).

Cognitive-Behavioral Model of Obsessive-Compulsive Disorder

In addition to thought suppression, cognitive-behavioral models of OCD propose that certain thought-related beliefs, such as TAF beliefs, impact the development of obsessions (Rachman, 1998; Shafran, Thordarson, & Rachman, 1996). Indeed, research has shown that individuals with OCD endorse certain thought-related beliefs more strongly than do non-clinical samples and individuals with other (non-OCD) anxiety disorders, including beliefs on the importance of thoughts, the need to control thoughts

(i.e., that one can and should control the content of his/her thoughts), and over- responsibility related to thoughts (Lapotka & Rachman, 1995; Obsessive Compulsive

Cognitions Working Group, 2003; Shafran, 1997). Research has also shown that the need to control one’s thoughts predicts thought suppression, suggesting that beliefs 16 concerning the need to control thoughts may be related to the efforts to control thoughts

(Purdon, 2001).

The first study investigating TAF beliefs found that there was a significant and positive association with obsessionality (Rachman, Thordarson, Shafran, & Woody,

1995). The results of this study led to the development of a measure, the Thought-Action

Fusion Scale (TAF-S; Shafran, Thordarson, & Rachman, 1996), to assess TAF in a more comprehensive and systematic manner. The TAF-S is a self-report questionnaire containing moral TAF and likelihood TAF subscales. Experimental studies on TAF beliefs have found that it is possible to induce high levels of TAF beliefs. More specifically, Rachman et al. (1996) developed a TAF induction method which required participants to write out an “obsession-like” sentence (“I hope… is in a car accident”), fill in the blank with a name of a close friend or relative, and then visualize the car accident.

Rachman et al. found this method successful in inducing high levels of TAF, in that individuals endorsed higher amounts of anxiety and guilt from pre to post manipulation.

Various other studies have since used this induction (Rassin, 2001; van den Hout, Kindt,

Weiland, & Peters, 2002; van den Hout, van Pol, & Peters, 2001; Zucker, Craske,

Barrios, & Holguin, 2002), with the findings showing that this induction method results in OC-like experiences, such as anxiety, guilt, feelings of responsibility, and urges to neutralize, even in non-clinical samples. Therefore, it appears that the potential for TAF is present in most individuals, and that it can be activated or increased in this type of an experimental manipulation (Rassin, 2001). 17

In another study (Marcks & Woods, 2007) on the combined effects of TAF beliefs and thought suppression, participants were asked to either use thought suppression, an acceptance-based approach, or to only monitor their thoughts in response to the Rachman et al. (1996) induction. They then recorded an instance of the intrusive thought during two, 5-minute time periods, using the assigned coping strategy for the first time period.

Then, for the second time period, all participants only monitored their thoughts. Results showed that initial suppression was related to greater anxiety, guilt, and perceived moral wrongness. There was also a relationship between suppression and greater perceived responsibility, stronger urge to neutralize, and higher likelihood the thought would actually occur after having used thought suppression. The findings from this study provide preliminary evidence supporting the combined role of TAF beliefs and thought suppression in the escalation of intrusive thoughts.

Previous research has examined how religiosity relates to TAF beliefs.

Correlational studies have found that highly religious individuals score significantly higher on the moral subscale of the TAF-S as compared to atheist or agnostic individuals or those who are not as devout (Abramowitz et al., 2004; Berman et al. 2010; Rassin &

Koster, 2003; Sica, Novara, & Sanavio, 2002; Siev & Cohen, 2007). Furthermore, in studies comparing individuals with different religious affiliations, Protestant Christians demonstrate the strongest relationship between their degree of religiosity and moral TAF beliefs due to their generally higher levels of religiosity (Rassin & Koster, 2003; Siev &

Cohen, 2007). In line with this research, studies on different religions and TAF beliefs have indicated that Protestants hold a higher amount of significance towards immoral 18 thoughts than Jewish individuals (Cohen, 2003; Cohen & Rankin, 2004; Cohen & Rozin,

2001; Siev, Chambless, & Huppert, 2010). These findings suggest that religiosity is related to TAF beliefs, particularly for certain religious affiliations.

Experimental studies related to the concept of TAF have also been conducted in religious samples. Cohen and Rozin (2001) presented Protestant and Jewish participants with a hypothetical situation that depicted an individual thinking about committing adultery. The aim of this study was to determine whether there were differences between

Jewish and Protestant participants regarding their beliefs on whether it is immoral to simply think about performing an immoral action. Participants were presented a vignette about a married man who has thoughts of having an affair with an attractive female coworker. Results from the study showed that Protestant participants rated the thoughts about an immoral action as more controllable and more likely to be acted on than the

Jewish participants. The Protestant participants were also more likely to rate the moral significance of having such a thought as much higher than the Jewish participants. This study and others lend evidence in support of the hypothesis that Protestant individuals may be more likely to experience moral TAF than individuals of other religious affiliations (Cohen, 2003; Cohen & Rankin, 2004; Cohen & Rozin, 2001; Siev,

Chambless, & Huppert, 2010).

Scrupulosity

Currently, 'scrupulosity' is a term used to describe individuals with OCD who have religiously themed symptoms (Deacon & Nelson, 2008). Scrupulosity is defined as a subset of OCD which is characterized by intense guilt or obsessions related to moral or 19 religious issues. It is often accompanied by compulsive moral or religious observance as well as high amounts of distress (Abramowitz, Huppert, Cohen, Tolin, & Cahill, 2002;

Fallon et al., 1990; Miller & Hedges, 2008). Although estimates vary by country, within the U.S., approximately 10 – 38% of individuals with OCD have scrupulosity (Greenberg

& Huppert, 2010). Foa and Kozak (1995) found that out of 425 individuals with OCD,

5.9% of the individuals had religious obsessions as their primary obsessional symptom, making it the fifth most common obsessional symptom in their sample. Antony, Downie, and Swinson (1998) found that 24.2% of a sample of 182 adults and adolescents with

OCD reported obsessions having to do with religion, although this may not have been their primary or secondary obsessional symptom. Not only is this presentation of OCD fairly common, there is some evidence suggesting that individuals with scrupulosity may be more difficult to treat than those without religious themed obsessions (Abramowitz,

Franklin, Schwartz, & Furr, 2003; Alonso et al., 2001; Greenberg & Huppert, 2010;

Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002). Nevertheless, scrupulosity is still considered an “ego-dystonic” disorder because the thoughts and doubts about morality are unwanted and unwelcome, similar to the other presentations of OCD (Nelson,

Abramowitz, Whiteside, & Deacon, 2006).

In order to discover possible differences between scrupulosity and non-religious

OCD, Nelson, Abramowitz, Whiteside, and Deacon (2006) used a series of measures and correlational analyses to differentiate the many presentations of the disorder. Through these analyses, they found that scrupulosity, as measured by the Penn Inventory of

Scrupulosity (PIOS) (Abramowitz, Huppert, Cohen, Tolin, & Cahill, 2002), was related 20 to higher moral TAF beliefs, but not higher likelihood TAF beliefs, as well as all three subscales (Importance of Thoughts, Responsibility, and Control of Thoughts) of the

Interpretation of Intrusions Inventory (III) (Obsessive Compulsive Cognitions Working

Group, 2003). Nelson et al. (2006) also used multiple regression analyses to determine which measures of clinical severity and cognitions could be used to predict participants' scores on the PIOS. Their final model consisted of the Obsessive-Compulsive Inventory-

Revised's (OCI-R) Obsessing subscale, the III Control of Thoughts subscale, and the

Thought Action Fusion Scale's (TAFS) moral subscale. This model accounted for 45% of the variance in the participants' total PIOS scores. Nelson and colleagues explain that scrupulosity is best accounted for by three variables: obsessional symptoms, beliefs that unwanted thoughts about unacceptable actions are morally equal to unacceptable actions, and maladaptive beliefs about the ability and necessity to control one's thoughts. Thus, the presence of these variables combined with an individual's strong religious beliefs can make treatment of scrupulosity extremely difficult.

Due to the complicated interaction of religious beliefs and psychopathology, there has been limited research on the effectiveness of various therapeutic strategies.

Regarding acceptance-based therapy, there are data that imply it can be an effective strategy, especially for religious individuals dealing with serious physical illness (Canda,

2001; 2002; Karekla & Constantinou; 2010). Although there is little empirical research on acceptance-based therapy of scrupulosity, Huppert and Siev (2010) suggest that in order for treatment for scrupulosity to be successful, acceptance is a key component.

Huppert and Siev (2010) suggest that although an individual with scrupulosity may try to 21 suppress unacceptable thoughts, if they instead allow them a place in their mind, they will end up reducing the frequency and intensity of such thoughts. This will also have an impact on their anxiety and distress levels by decreasing them. Despite these recommendations, to date, no studies have examined the effects of an acceptance-based approach for managing intrusive thoughts in this population.

Current Study

In summary, intrusive thoughts are experienced by the majority of people and are one of the key features of OCD. It is theorized that maladaptive beliefs about intrusive thoughts, such as TAF beliefs, as well as using maladaptive coping strategies (i.e., thought suppression) in response to intrusive thoughts cause these thoughts to escalate into obsessions (Clark & Purdon, 1993; Ehlers & Steil, 1995; Freeston & Ladouceur,

1993; Rachman 1997; Salkovskis, 1985). One factor that may impact the way in which intrusive thoughts are experienced and coped with is religiosity. Indeed previous studies have found that religiosity is related to TAF beliefs and tendencies to suppress unwanted thoughts, both of which have been implicated in OCD (Abramowitz et al., 2004;

Yorulmaz et al., 2009).

To date, little research exists on the effectiveness of thought-related coping strategies, while also taking into account individuals’ religiosity. Although prior research finds religious individuals report being more likely to use thought suppression as a coping strategy, it is unclear whether there may be differential effects of this strategy based on degree of religiosity (Abramowitz et al., 2002; Nelson et al., 2006).

Furthermore, although previous research has found beneficial effects of an alternative, 22 acceptance-based approach for managing intrusive thoughts in general (Marcks &

Woods, 2005; Marcks & Woods, 2007; Huppert & Siev, 2010), no studies have examined such an approach while also considering religiosity. Therefore, the purpose of this study was to compare the effects of using different coping strategies (thought suppression, acceptance-based approach, and monitor-only control) to manage an intrusive thought on distress and thought frequency, while also taking into consideration the participants' levels of religiosity. This study also aimed to test a model in which the relationship between TAF beliefs, thought suppression, and OC symptoms would be moderated by religiosity.

Hypotheses

Hypothesis 1a: Higher scores on religiosity (as measured by the SCSRFQ) would be associated with higher scores on measures of thought-action fusion beliefs (TAF scale), thought suppression tendencies (WBSI), and OCD symptoms (PI-WSUR), and lower scores on religiosity would be related to higher levels of acceptance as measured by the Acceptance and Action Questionnaire (AAQ).

Hypothesis 1b: Religiosity (as measured by the SCSRFQ) would act as a moderator in the relationship between thought-action fusion (as measured by TAF scale), tendency to suppress thoughts (as measured by WBSI), and obsessive compulsive symptoms (as measured by PI-WSUR). More specifically, religiosity would strengthen the relationship between TAF beliefs and thought suppression, and OC symptoms.

Hypothesis 2: Higher scores in religiosity would be associated with greater distress/anxiety, guilt, and more negative appraisals (e.g., perceived responsibility, moral wrongness, perceived likelihood of the event occurring, urge to do something to reduce/cancel the effects) in response to the intrusive thought induction.

Hypothesis 3a: During time 1, participants in the thought suppression group would have greater frequency of the intrusive thought than those in the monitor-only group. Religiosity would have a significant effect on this difference. Specifically, it was expected that there would be a stronger relationship (i.e. positive correlation) between religiosity and frequency of intrusive thought in the thought suppression group compared to the monitor-only group.

Hypothesis 3b: There would be a significant difference between coping strategies

(thought suppression vs. monitor-only) in terms of the change in frequency of the intrusive thought from time 1 to time 2, with the thought suppression group having a greater change (increase) in frequency of intrusive thought compared to the monitor-only group. It was also hypothesized that there would be a stronger relationship (positive correlation) between religiosity and changes in frequency of intrusive thought in the thought suppression group compared to the monitor-only group.

Hypothesis 3c: During time 1, it was expected that there would be a significant difference between coping strategies on anxiety ratings, with religiosity having an effect on this difference. More specifically, participants in the thought suppression group would have greater anxiety than those in the monitor-only group, and participants in the acceptance group would have less anxiety than those in the monitor-only group. 24

Hypothesis 3d: There would be a significant difference between coping strategies in terms of the change in anxiety from time 1 to time 2, with religiosity having a significant effect on this change. It was hypothesized that the thought suppression group would have a greater change in anxiety (increase) compared to the monitor-only group, and the acceptance group would have greater change (decrease) in anxiety over the time periods compared to the monitor-only group. It was also expected that there would be a stronger relationship (positive correlation) between religiosity and changes in anxiety ratings in the thought suppression group compared to the monitor-only group. It was also believed that there would be a stronger relationship (negative correlation) between religiosity and changes in anxiety ratings in the acceptance group compared to the monitor-only group.

Hypothesis 3e: These hypotheses are related to appraisals ratings (e.g., guilt, perceived responsibility, perceived moral wrongness, perceived likelihood of the event occurring, urge to do something to reduce/cancel the effects) during time period 1, with religiosity having a significant effect on the differences between coping strategies. More specifically, participants in the thought suppression group would have more negative appraisals than those in the monitor-only group and participants in the acceptance group would have less negative appraisals than those in the monitor-only group. Furthermore, it was expected that there would be a stronger relationship between religiosity and these appraisal ratings in the thought suppression group compared to the monitor-only group, and a weaker relationship between religiosity and these appraisal ratings in the acceptance group compared to the monitor-only group. 25

Method

Participants

113 college students were recruited from psychology courses at a large university and offered course credit for their participation in the study. Due to the study’s focus, only data from participants (n = 100) who endorsed either Christianity or

Atheism/Agnosticism as their current religious affiliation on the Demographics

Questionnaire were included in the analyses. In addition, one participant did not complete the study, four withdrew, and five participants’ data were deemed unusable due to a language barrier or there was a violation of the study protocol. This left a total of 90 participants, which were randomly assigned to one of three groups: thought suppression

(n = 30), acceptance (n = 30) or monitor-only (n = 30).

In order to ensure there were no significant differences between the groups on demographic variables, a series of ANOVA and Chi-Square analyses were conducted on the demographic variables. The results of these analyses showed no significant differences between the three groups on any of the demographic variables. The 90 participants ranged in age from 18 to 24 years (M = 19.64, SD = 1.30) and 53% of the sample was female. All participants received at least some college education (M = 13.31,

SD = 1.15). Participant race/ethnicity was as follows: 79% Caucasian, 2% Hispanic, 3%

African-American, 1% Asian, 3% other, 2 % Multiracial, and 0% Native American. The majority of participants were single (99%), with only 1% being married. Table 1 contains descriptive statistics for the demographic variables by group. The participants’ current religious affiliations were as follows: 83% Christian (n = 75) and 17% Atheist/Agnostic 26

(n = 15). There were no significant differences amongst the three groups in terms of their current religious affiliation, X²(2) = 1.44, p = .49. Of those who endorsed Christianity as their current religious affiliation, 14% identified as Protestant (n = 13), 41% as Catholic

(n = 37), 2% as Orthodox (n = 2), and 24% as other (n = 22). There were no significant differences amongst the three groups in terms of current Christian affiliation, X²(8) =

8.53, p = .38. Table 2 contains the descriptive statistics for religious affiliation by group.

To test for pre-experiment group differences on the religiosity, coping and affect, and OCD-related measures, a series of one-way ANOVAs were conducted. Due to the large number of comparisons made, the Bonferroni procedure was used to control for family-wise Type I error. Therefore, the p value that was set for the religiosity measures was .05/2 = .025 (for the SCSRFQ and the DRI), .05/3 = .02 for the coping and affect measures (WBSI, AAQ, and PANAS) and .05/3 = .02 for the OCD-related questionnaires

(PIOS, PI-WSUR, & TAF Scale). No significant differences were found between the three groups on the pre-experiment questionnaires on religiosity, coping and affect, or

OCD-related experiences. Therefore, the data from these questionnaires were collapsed across groups and the descriptive statistics for these measures can be found in Tables 3,

4, and 5. It is important to note that all means and standard deviations were within the normal ranges for a non-clinical sample.

Materials

Frequency counter. Participants used a small, hand-held frequency counter to record the number of target intrusive thoughts and/or images they had during the two time periods. 27

Demographics. A brief demographics questionnaire (Appendix A), developed for this study, was used to obtain information on gender, age, marital status, education level, race, ethnicity, and past/present religious affiliation.

Religiosity.

Santa Clara Strength of Religious Faith Questionnaire. The SCSRFQ (Plante &

Boccaccini, 1997) is a 10-item self-report measure that assesses the strength of an individual's religious beliefs (Appendix B). Items are rated on a four-point scale (1=

“strongly disagree” to 4 = “strongly agree”) and are summed to create a total score, with higher scores indicating stronger religious beliefs. The mean SCSRFQ score based on the normative, undergraduate student sample is 26.39, with a standard deviation of 8.55.

The SCSRFQ has demonstrated excellent internal consistency and split-half reliability (α

= .95 and r = .92, respectively). For the current study, the SCSRFQ demonstrated excellent internal consistency as well (α = .95). There are also data supporting the validity of the SCSRFQ. More specifically, using four different samples of participants

(two samples of primarily undergraduate university students, one sample of primarily female cancer or cancer screening patients, and one sample of primarily healthy women in a clinic environment), the scale has been found to correlate well with other measures of religiosity including the Age Universal Religious Orientation Scale (Gorsuch & Venable,

1983) (AUROS; r’s range from 0.70 to 0.90) and the Religious Life Inventory (Allport &

Ross, 1967) (RLI; r’s range from 0.76 to 0.90) as well as with extrinsic religiousness as measured by the AUROS (r’s range from 0.64 to 0.73). The SCSRFQ tends also to 28 closely correlate with the Duke Religious Index (Koenig, Meador, & Parkerson, 1997)

(r’s ranging from 0.71 to 0.85) (Plante & Boccaccino, 1997).

Duke Religion Index (DRI). The DRI (Koenig et al., 1997) is a five item self- report measure that assesses an individual's religiosity (Appendix C). The purpose for including this particular measure in the current study was to assess the participants' religious activities and involvement. There are three dimensions of religiosity measured by the DRI: organizational, non-organizational, and intrinsic. Organizational religiosity is a one-item measurement of the frequency with which one attends religious services.

Non-organizational religiosity is also measured by one item, and it is defined as the amount of time spent in private religious activities such as prayer or meditation. Intrinsic religiosity, measured by three items, assesses the degree to which one integrates their religious beliefs into their life. The organizational and non-organizational items on the measure are rated on a six-point frequency scale (1 = “more than once/week” to 6 =

“never”) while the intrinsic items are rated on a five-point scale (1 = “definitely true of me” to 5 = “definitely not true”). Higher scores correspond to greater religiousness. The

DRI has been shown to be highly correlated with another measure of religiosity, the

SCSRFQ (Plante & Boccaccini, 1997) (r's range from 0.71 to 0.85). The DRI has also been shown to have excellent internal consistency (ɑ = .91) in a normative sample

(Storch, Roberti, Heidgerken, Storch, et al., 2004). In the current study, the DRI demonstrated good internal consistency for the total score (α = .88) and for the intrinsic religiosity subscale (α = .89).

Thought-Action Fusion.

Thought-Action Fusion Scale. The TAF Scale (Shafran et al., 1996) is a 19-item self-report measure that assesses TAF beliefs, including beliefs that thinking about an unacceptable event makes it more likely to happen (i.e., likelihood TAF) and that having an unacceptable thought is the moral equivalent of carrying out the unacceptable action

(i.e., moral TAF) (Appendix D). Items are rated on a five-point scale (0= “disagree strongly” to 4 = “agree strongly”) and are summed to create a total score and two subscale scores (likelihood and moral), with higher scores indicating stronger TAF beliefs. The TAF Scale has demonstrated good test-retest reliability (r = .88) (Rassin et al., 2001). Internal consistency of the TAF-Moral and TAF-Likelihood subscales was high both for individuals with OCD (α= .95, .96, respectively) and individuals without psychopathology (α = .93 for each subscale) (Shafran, Thordarson, & Rachman, 1996).

The internal consistency for the TAF-Moral subscale and the total score in the current study was in the “good” range at .85 and .87, and in the “excellent” range for the likelihood self and other subscales, and the total likelihood score (α = .94, .96, and .93, respectively).

Thought Suppression.

White Bear Suppression Inventory (WBSI). The WBSI (Wegner & Zanakos,

1994) is a 15-item measure of the tendency to suppress one's unwanted thoughts

(Appendix E). Items are rated on a five-point scale (1 = “strongly disagree” to 5 =

“strongly agree”) with higher scores indicating a greater tendency towards thought suppression. The WBSI has been shown to have high levels of internal consistency (ɑ = 30

.88) in a normative sample. It also has been shown to have acceptable levels of test-retest reliability over a period varying between three weeks and 3 months (r = .69) and over a period of one week (r = .92) in a normative sample. In the current study, the WBSI demonstrated good levels of internal stability (α = .89).

Acceptance.

Acceptance and Action Questionnaire-II. The AAQ-II (Bond et al., 2011) is a 7- item self-report measure that assesses experiential avoidance, which is unwillingness to be in contact with emotions, thoughts, or memories (Appendix F). Items are rated on a seven-point scale (1 = “never true” to 7 = “always true”), with higher scores indicating greater avoidance. The reliability of the AAQ-II is consistently above the AAQ-I (Hayes,

Strosahl, Wilson, Bissett, Pistorello et al., 2004), with a mean alpha coefficient across six samples of .84 (.78 - .88), and the 3- and 12-month test-retest reliability is .81 and .79, respectively. The AAQ-II demonstrated good levels of internal stability in the current study (α = .87). Higher levels of experiential avoidance and psychological inflexibility, as measured by the AAQ-II, have been found to relate to higher levels of depression, anxiety, stress, and overall psychological distress (Bond et al., 2011).

OCD Symptoms.

Padua Inventory-Washington State University Revision. The PI-WSUR (Burns et al., 1996) is a 39-item self-report measure that assesses OCD symptoms (Appendix G).

Items are rated on a 5-point scale (0= “not at all” to 4= “very much”) and are summed to create a total score, with higher scores indicating greater endorsement of OC symptoms.

The PI-WSUR also contains 5 subscales: Contamination Obsessions and Washing 31

Compulsions Subscale, Dressing/Grooming Compulsions Subscale, Checking

Compulsions Subscale, Obsessional Thoughts of Harm to Self/Others Subscale, and

Obsessional Impulses to Harm Self/Others Subscale. The PI-WSUR has shown excellent levels of internal consistency (α = .92) and test-retest reliability (r = .76) in previous studies. In the current study, the PI-WSUR thoughts of harm to self/others subscale demonstrated good levels of internal consistency (α = .84), as did the obsessional impulses to harm self/others subscale and the dressing/grooming compulsion subscale (α

= .88 and .84, respectively). The contamination and checking subscales, as well as the total PI-WSUR score all demonstrated excellent internal consistency (α = .91, .91, .95, respectively). In OCD samples, the mean total score was 54.93 (SD = 16.72) and in a non-clinical sample the mean score was 21.78 (SD = 16.33) (Burns et al., 1996).

Penn Inventory of Scrupulosity (PIOS). The PIOS (Abrawmotiz, Huppert,

Cohen, Tolin, & Cahill, 2002) is a 19-item self-report measure of religious OCD symptoms (Appendix H). Items are rated on a five-point scale (0 = “never” to 4 =

“constantly”). There are two subscales on the PIOS: fear of sin and fear of God.

Cronbach's alpha was high for both subscales (ɑ = .90 for fear of sin subscale and .88 for fear of God subscale) in past studies. In the current study, the PIOS demonstrated excellent levels of internal consistency for both the fear of sin subscale and the fear of

God subscale, as well as the total PIOS score (α = .91, .91, .94, respectively). The PIOS has also demonstrated convergent validity by significantly correlating with the Maudsley

Obsessional Compulsive Inventory (MOCI) (Hodgson & Rachman, 1977) (r = .36).

Affect.

Positive and Negative Affect Schedule. The PANAS (Watson, et al., 1988) is a list of 20 adjectives measuring positive and negative affect (Appendix I). It contains 10 items for positive and 10 items for negative affect, which are summed, respectively, to create positive and negative affect scores. The items are rated on a 1 to 5 scale, with 1 indicating that the respondent feels the particular emotion ‘very slightly or not at all’ and

5 indicating that the respondent feels the emotion ‘extremely.’ The PANAS has demonstrated high internal consistency (α = .86 for items assessing positive affect and α

= .87 for negative affect) and test-retest reliability (r = .79 for positive affect items and r

= .81 for negative affect items). In the current study, both the PANAS positive affect subscale and the negative affect scale demonstrated good internal consistency (α = .89 and .82, respectively). The PANAS has been shown to correlate well with other measures of affect, demonstrating its convergent validity (Watson, et al., 1988). For the current study, the PANAS was completed twice, once immediately prior to the experimental portion of the study, and the second time after the second thought monitoring period, in order to assess change in affect over the course of the experiment.

Intrusive Thought Related Appraisals.

Appraisal ratings. Appraisal ratings, adapted from a previous study (Marcks &

Woods, 2007), were used to assess the effects of the intrusive thought induction and coping strategies as well as to assess for baseline guilt and anxiety (Appendix J). The following 8 items were rated on a 100 mm Visual Analogue Scale (VAS) (0 = “not at all” to 100 = “extremely”): (1) “How anxious/distressed do you feel right now?” (2) “How 33 much guilt do you feel right now?” (3) “How hard did you try to not think about the car accident?” (4) “How morally wrong was it to think about the car accident?” (5) “How much control do you feel you have over the car accident occurring?” (6) “What is the likelihood of the car accident occurring in the next 24 hours?” (7) “How strong is your urge to do something to reduce or cancel the effects of thinking about the car accident?” and (8) “How willing are you to further think about the car accident?” The participants completed the first two items as a baseline measure of anxiety and guilt, prior to the experimental portion of the study, and all eight items after the intrusive thought induction and after each of the two thought monitoring periods.

Manipulation Checks.

Intrusive thought induction check. After the intrusive thought induction, participants completed a manipulation check, adapted from a previous study (Marcks &

Woods, 2007), using a 100mm VAS (0 = “not at all” to 100 = “extremely”) (Appendix

K). The questions were as follows and were the same for each group: (1) “How vivid were the thoughts and images of the car accident?” (2) “How severe of a car accident did you image?” (3) “How much effort did you put forth in attempting to visualize the car accident?” (4) “What was your level of engagement with your thoughts and images of the car accident?” and (5) How believable was the car accident?” These items were completed immediately after the intrusive thought induction.

Coping strategy manipulation check. After each of the thought monitoring time periods, participants completed a manipulation check rating, adapted from a previous study (Marcks & Woods, 2007), using a 100 mm VAS (0 = “not at all” to 100 = 34

“extremely”) (Appendix L). The questions were as follows and varied by group: “How hard did you try to suppress thoughts and images of the car accident?”(thought suppression group), “How hard did you try to watch your thoughts and images of the car accident without arguing with them or trying to make them go away?” (acceptance group), and “How hard did you try to think about anything you wanted to?” (monitor- only group). During time period 2, all groups answered the same question: “How hard did you try to think about anything you wanted to?” In addition, item 3 of the appraisal ratings (“How hard did you try to not think about the car accident?”) was included to assess for spontaneous suppression in all groups during each of the time periods.

Procedure

Participants were recruited through the online Sona system and they were all enrolled in undergraduate psychology courses. Before enrolling in the study, individuals were informed that participation may cause distress or anxiety, participation is voluntary, and they can withdraw from the study at any time. After providing informed consent, participants completed the demographics questionnaire, SCRSFQ, DRI, TAF-S, WBSI,

PI-WSUR, PIOS, AAQ-II, PANAS, and provided baseline ratings of anxiety and guilt

(Appendices A-J, respectively). Instructions were given to the participants by a trained research assistant. All measures were administered through a paper and pencil format with the frequency counter being the only exception. The intrusive thought induction and coping strategies were presented via an audio-recording, in order to standardize the instructions.

Intrusive Thought Induction.

Participants underwent the intrusive thought induction procedure (Rachman et al.,

1996) after completing the questionnaire packet. First, participants completed the

Selection of Target Individual Form (Appendix M). The individual identified on this form was used as the target individual for the remaining portion of the study. Participants then heard the following instructions: “Keeping in mind this individual who is close to you (pause), I would like you to write out the following sentence on this piece of paper inserting the name of the person in the blank.” Participants were handed a pen and piece of paper with the typed sentence (“I hope that ______will soon be in a car accident”) and a blank space to copy the sentence to (Appendix N). They were then asked to insert the name of the target individual and copy the sentence in the space provided.

Participants were told that this procedure has been previously used with over 500 subjects in 7 published studies. They were also reminded that they can withdraw from the current study at any time. Participants were then asked to read the completed sentence aloud, after which they heard the following instructions, adapted from Rachman et al. (1996):

Close your eyes and take a few moments to visualize your loved one’s car

accident (pause). It is important that you have a clear and vivid image of your

loved one and the car accident in mind. Visualize what the accident scene looks

like; for instance, the location of the accident, time of day, what your loved one

looks like, the nature of your loved one’s involvement in the accident, and the 36

severity of the accident (pause). Once you have a clear and vivid image in mind of

both your loved one and the car accident, please open your eyes.

After this induction, participants were asked a series of questions in order to assess their anxiety, guilt, and appraisals (i.e., appraisal ratings form; Appendix J) as well as to check if the induction had the intended effects (Intrusive thought induction manipulation check ratings; Appendix L).

Coping Strategy Manipulation.

Participants were then asked to record any instances of the target intrusive thought

(i.e., thoughts or images of their loved one’s car accident) using a frequency counter during two, 5-min time periods (experimental and monitor-only periods). During the experimental period (i.e., time period 1), participants listened to one of three possible coping strategy messages (thought suppression, acceptance, or monitor-only), depending on their group. These instructions have been adapted from previous research studies

(Marcks & Woods, 2005; Marcks & Woods, 2007). The thought suppression coping strategy message was:

During the next five minutes, it is very important that you try as hard as you can

to suppress thoughts and images of your loved one’s car accident. So try not to

think about the car accident, but be sure to record thoughts or images if they occur

by pressing the button once for each occurrence. It is important that you continue

in the same way for the full five minutes.

The acceptance coping strategy message was: 37

Struggling with thoughts or images of a car accident is like struggling in

quicksand. I want you to watch your thoughts. Imagine that they are coming out

of your ears on little signs held by marching soldiers. I want you to allow the

soldiers to march by in front of you, like a little parade. Do not argue with the

signs, or avoid them, or make them go away. Just watch them march by. Record

thoughts/images of the car accident if they occur by pressing the button once for

each occurrence. It is important that you continue in the same way for the full five

minutes.

The monitor-only coping strategy message was:

During the next five minutes, you may think about anything you like. Your task is

to simply monitor your thoughts. If at any time you have a thought or image of

the car accident, record it by pressing the button once for each occurence. It is

important that you continue in the same way for the full five minutes.

During the second time period, all participants heard the monitor-only message.

After each time period, participants completed a coping strategy manipulation check

(Appendix L) and appraisal ratings (Appendix J). In addition to this, all participants completed the PANAS (Appendix I) after the second time period. When participants completed the study, they were debriefed by the research assistant and thanked for their participation. More specifically, participants were provided a written debriefing statement that the research assistant reviewed with them orally and answered any questions. Then, all participants completed a Post-Debriefing measure that assessed anxiety, guilt, and perceived need for assistance in dealing with thoughts and feeling 38 brought up by the experiment. After the participant completed this measure, the research assistant checked the participant’s responses to ensure that the participant did not endorse needing extra assistance in dealing with the anxiety he/she felt during the experiment. If a participant endorsed that he/she needs extra assistance, he/she was provided a referral to

Counseling and Psychological Services and strongly encouraged to seek out mental health services. Participants that withdrew from the study during their participation also underwent the same debriefing procedure described above.

Results

Thought-Action Fusion Induction Check

A one-way MANOVA was performed in order to determine whether the three groups differed on the TAF induction check ratings. Results showed no significant differences between the three groups on these ratings, F(2, 87) = .26, p = .99, Wilks’ Λ =

.99, partial η² = .01. This finding suggests that all three groups were similar in terms effort put forth, level of engagement, believability, and vividness of imagery related to the TAF induction. A one-way MANOVA was performed in order to determine whether the three groups differed on the appraisal ratings given immediately after the TAF induction. Results showed no significant differences between the three groups on these ratings, F(2, 87) = .67, p = .82, Wilks’ Λ = .88, partial η² = .06. Table 6 shows the combined means and standard deviations of these ratings for the three groups.

Experimental Manipulation Check

A one-way ANOVA was performed in order to determine whether the three different groups differed on effort put forth using the specific coping strategy during the experimental period. Results showed no significant differences between the groups on effort put forth following the instructions during the experimental period, F(2, 87) = 1.29, p = .28, 2 = .03. Thus, the thought suppression group (M = 65.30, SD = 29.52) did not differ significantly from the acceptance group (M = 55.77, SD = 25.60) or the monitor- only group (M = 54.10, SD = 32.18) on this rating. This finding suggests that the groups put forth similar levels of effort following the coping strategy instructions.

Experimental Hypotheses

Hypothesis 1a.

It was hypothesized that higher scores on religiosity (as measured by the

SCSRFQ) would be associated with higher scores on measures of TAF beliefs (TAF scale), thought suppression tendencies (WBSI), and OCD symptoms (PI-WSUR), and lower scores on religiosity would be related to higher levels of acceptance as measured by the Acceptance and Action Questionnaire (AAQ-II). A series of correlational analyses were conducted to examine the relationship between these variables. A significant, positive correlation was found between religiosity and obsessive-compulsive symptoms. More specifically, higher religiosity was related to higher concerns with contamination, r(88) = .25, p < .05, checking behaviors, r(88) = .22, p < .05, and the total

PI-WSUR score, r(88) = .21, p < .05. No significant correlations were found between religiosity and TAF beliefs, r(88) = .07, p = .49, levels of acceptance, r(88) = .11, p = .29, nor tendency toward thought suppression, r(88) = .13, p = .20. Thus, hypothesis 1a was only partially supported, in that religiosity did significantly predict obsessive-compulsive symptoms, however no relationships were found between religiosity and the other variables of interest.

Hypothesis 1b.

The focus of hypothesis 1b was to determine if religiosity (as measured by the

SCSRFQ) moderates the relationship between TAF (as measured by TAF scale) and tendency to suppress thoughts (as measured by WBSI), and OC symptoms (as measured by PI-WSUR). Baron and Kenney’s (1986) method was used to test this moderation 41 model. Thus, a hierarchical multiple regression analysis predicting PI-WSUR scores was conducted, with the main effects of the predictors (i.e., TAF scores and WBSI scores) and moderator (scores on SCSRFQ) being entered in block 1. In block 2, the variables included in block 1 and all possible two-way interactions (TAF x WBSI, TAF x

SCSRFQ, WBSI x SCSRFQ) and the three-way interaction (TAF x WBSI x SCSRFQ) were entered. The significance of R2 change from block 1 to 2 determined if the interaction terms improve the model. To eliminate issues with multicollinearity, the predictor variables (TAF and WBSI scores) were centered before testing the interaction terms in the model (Aiken & West, 1991). To accomplish this, each participant's scores were subtracted from the sample mean score on the variable, which resulted in a revised sample mean of zero. Block 1, which contained TAF scores, WBSI scores, and SCSRF scores, significantly predicted PI-WSUR scores, ΔF(3, 86) = 4.67, p < .01, R² = .14.

Regarding unique predictors of PI-WSUR scores, only WBSI scores uniquely predicted

PI-WSUR scores, β = -.64, t(86) = -3.01, p < .01, sr² = .10, although this was not in the expected direction. None of the two-way interactions were significant. Likewise, the three-way interaction was non-significant, β = .24, t(82) = .64, p = .52. Thus, these findings did not support the hypothesis, in that religiosity was not found to moderate the relationship between thought-action fusion beliefs and thought suppression and OCD symptoms. Table 7 displays the multiple regression analysis results.

Hypothesis 2.

It was hypothesized that higher scores in religiosity would be associated with greater distress/anxiety, guilt, and more negative appraisals (e.g., perceived 42 responsibility, moral wrongness, perceived likelihood of the event occurring, urge to do something to reduce/cancel the effects) in response to intrusive thought induction. This was measured by the appraisal ratings completed immediately after the TAF induction. A series of correlational analyses were performed in order to examine the relationship between religiosity and these variables. No significant correlations were found between religiosity and anxiety ratings, r(88) = .03, p = .80, guilt, r(88) = .08, p = .45, perceived responsibility if the car accident should occur, r(88) = -.01, p = .90, moral wrongness of thinking about the accident, r (88) = .13, p = .22, perceived likelihood of the accident occurring, r(88) = .08, p = .47, or urge to do something to reduce/cancel the effects of thinking about the accident, r(88) = .09, p = .40. Therefore, hypothesis 2 was not supported.

Hypothesis 3a.

It was hypothesized that during time 1, participants in the thought suppression group would have greater frequency of the intrusive thought than those in the monitor- only group. Religiosity would have a significant effect on this difference. Specifically, there would be a stronger relationship (i.e., positive correlation) between religiosity and frequency of intrusive thought in the thought suppression group compared to the monitor- only group. A one-way analysis of covariance (ANCOVA) was conducted to test this hypothesis. The religiosity by coping strategy interaction was non-significant, F(3, 56) =

.001, p = .98, partial η ² = .00. Therefore, religiosity was not found to account for a significant amount of the variance in the difference between coping strategies. Also, there was no significant difference between the thought suppression and the monitor-only 43 groups regardless of religiosity, F(1, 56) = .04, p = .84, partial η² = .001. Thus, the number of intrusive thoughts at time period 1 for the thought suppression group (M =

8.73, SD = 6.27) did not differ from the number of intrusive thoughts for the monitor- only group (M = 7.67, SD = 5.86). Therefore, religiosity did not impact the effects of the coping strategies on frequency of intrusion at time 1. Furthermore, the thought suppression group did not have a greater frequency of intrusive thoughts than the monitor-only group. Thus, the hypothesis was not supported.

Hypothesis 3b.

It was hypothesized that there would be a significant difference between coping strategies (thought suppression vs. monitor-only) in terms of the change in frequency of the intrusive thought from time 1 to time 2, with the thought suppression group having a greater change (increase) in frequency of intrusive thought compared to the monitor-only group. Religiosity would have a significant effect on this difference. It was believed that there would be a stronger relationship (positive correlation) between religiosity and changes in frequency of intrusive thought in the thought suppression group compared to the monitor-only group. A one-way ANCOVA was conducted in order to examine whether there were differential changes in frequency of intrusive thought over the time periods based on coping strategy (thought suppression vs. monitor-only), with religiosity having a significant effect on this change. After calculating the residualized change scores using the frequency counts from time period 1 and time period 2 and conducting the ANCOVA, the religiosity by coping strategy interaction was non-significant, F(3, 56)

= .001, p = .98, partial η ² = .00. Therefore, the results indicated that religiosity did not 44 impact the effects of coping strategy on the change in frequency of the intrusive thought over the time periods; thus, the hypothesis was not supported. Also, there was no significant difference between the thought suppression group and the monitor-only group, regardless of religiosity, F(1, 56) = .04, p = .84, partial η² = .001. Thus, the change in frequency of intrusive thought from time period 1 to 2 for the thought suppression group

(M = -3.77, SD = 2.71) did not differ from the monitor only group (M = -3.31, SD =

2.53).

Hypothesis 3c.

It was hypothesized that during time 1, there would be a significant difference between coping strategies on anxiety ratings, with religiosity having an effect on this difference. More specifically, participants in the thought suppression group would have greater anxiety than those in the monitor-only group, and participants in the acceptance group would have less anxiety than those in the monitor-only group. An ANCOVA was conducted in order to examine whether religiosity had a significant effect on anxiety at time 1 between the three coping strategies. The religiosity by coping strategy interaction was non-significant, F(5, 84) = .62, p = .54, partial η² = .01. Therefore, religiosity was not found to account for a significant amount of the variance in the differences between coping strategies on anxiety ratings. Also, there was no significant difference between the coping strategies on anxiety, F(2,84) = .67, p = .51, partial η² = .02. Thus, the anxiety ratings at time period 1 for the thought suppression group (M = 33.27, SD = 25.95) did not differ from the monitor-only group (M = 23.70, SD = 24.44). Similarly, the anxiety 45 ratings at time period 1 for the acceptance group (M = 35.80, SD = 31.17) did not differ from the monitor-only group (M = 23.70, SD = 24.44). Hypothesis 3c was not supported.

Hypothesis 3d.

It was hypothesized that there would be a significant difference between coping strategies in terms of the change in anxiety from time 1 to time 2, with religiosity having a significant effect on this change. It was hypothesized that the thought suppression group would have a greater change in anxiety (increase) compared to the monitor-only group, and the acceptance group would have greater change (decrease) in anxiety over the time periods compared to the monitor-only group. It was also expected that there would be a stronger relationship (positive correlation) between religiosity and changes in anxiety ratings in the thought suppression group compared to the monitor-only group. It was also believed that there would be a stronger relationship (negative correlation) between religiosity and changes in anxiety ratings in the acceptance group compared to the monitor-only group. A one-way ANCOVA was conducted to test this hypothesis.

After calculating the residualized change scores using the anxiety ratings from time period 1 and time period 2, the ANCOVA results indicated that the religiosity by coping strategy interaction was non-significant, F(5, 84) = .062, p = .54, partial η² = .01.

Therefore, religiosity did not have a significant effect on the change in reported anxiety over the time periods, and the hypothesis was not supported. Also, there was no significant difference between the coping strategies by themselves, F(2, 84) = .67, p =

.51, partial η² = .02. The change in anxiety for the thought suppression group (M = -

12.67, SD = 9.79) did not differ from the monitor only group (M = -9.06, SD = 9.21). 46

Also, the change in reported anxiety for the acceptance group (M = -13.63, SD = 11.75) did not differ from the monitor-only group (M = -9.06, SD = 9.21).

Hypothesis 3e.

These hypotheses were related to appraisals ratings (e.g., guilt, perceived responsibility, perceived moral wrongness, perceived likelihood of the event occurring, urge to do something to reduce/cancel the effects) during time period 1, with religiosity having a significant effect on the differences between coping strategies. More specifically, it was hypothesized that participants in the thought suppression group would have more negative appraisals than those in the monitor-only group, and participants in the acceptance group would have less negative appraisals than those in the monitor-only group. Furthermore, it is expected that there would be a stronger relationship between religiosity and these appraisal ratings in the thought suppression group compared to the monitor-only group, and a weaker relationship between religiosity and these appraisal ratings in the acceptance group compared to the monitor-only group. A one-way

MANCOVA was conducted in order to determine whether religiosity had a significant effect on the differences between coping strategies on the appraisal ratings (items 2 and

4-8) at time period 1. The results of the MANCOVA indicated that the religiosity by coping strategy interaction was non-significant, F(2,84) = .88, p = .56, Wilks’ Λ = .88, partial η² = .06 . Therefore, religiosity did not significantly impact the effects of coping strategy on the appraisal ratings, and the hypothesis was not supported. Coping strategy by itself also did not impact the appraisal ratings at time period 1, F(2,84) = .94, p = .51, 47

Wilks’ Λ = .87, partial η² = .07. The means and standard deviations of anxiety ratings and the appraisal ratings at time 1 and time 2 by group can be found in table 8.

Exploratory Analyses

After the hypotheses were tested, additional analyses were performed in order to further explore the data, given the unexpected findings. More specifically, analyses were conducted in order to examine whether the groups differed on how much effort they put forth suppressing the intrusive thought. Additional analyses were also performed in order to examine whether religiosity and/or effort put forth following the coping strategy instructions was related to the dependent variables (i.e., anxiety and intrusive thought frequency at time period 1, the change in anxiety and intrusive thought frequency across both time periods, and the appraisal ratings) for the thought suppression group.

Although analysis of the experimental manipulation check ratings revealed no group differences in following the specific coping strategy instructions, it is possible that participants in the acceptance and/or monitor-only groups may have been attempting to suppress the target intrusive thought. This would mean that the participants may not have been completely following the acceptance and/or monitor-only instructions, if they indeed were attempting to suppress. If spontaneous suppression was occurring in these groups, this could have impacted the findings. It was expected that the thought suppression group would have put forth significantly more effort toward suppressing the intrusive thought than both the acceptance and the monitor-only group. In order to examine this, a one-way ANOVA was conducted with one between subjects factor

(coping strategy) on appraisal item 3, which asked all participants how much effort they 48 put forth trying not to think about the car accident. The results of the ANOVA indicate that there was no significant overall difference between the three groups on this item,

F(2, 87) = 2.59, p = .08, η² = .06. Post-hoc tests showed there was a significant difference between the thought suppression group (M = 67.63, SD = 27.35) and the monitor-only group on this item (M = 50.63, SD = 30.01), F(1, 88) = 4.92, p < .05, 2 =

.08. This finding suggests that as a whole, spontaneous suppression was not reported in the monitor-only group. However, no significant difference was found between the thought suppression (M = 67.63, SD = 27.35) and acceptance groups (M = 56.23, SD =

29.06) on this rating, suggesting that the two groups put forth a similar amount of effort in suppressing the intrusive thought, F(1, 88) = 2.45, p = .46, 2 = .04. It should be noted though that none of the hypotheses were aimed at directly comparing these two coping strategies. However given that the acceptance group was in fact attempting to suppress to some degree, the comparisons between the acceptance group and the monitor-only group may be questionable.

In order to further examine the relationship between effort put forth suppressing the intrusive thought and the dependent variables, a series of multiple regression analyses were run on the data collected in the thought suppression group, with the thought suppression manipulation check item (“How hard did you try to suppress thoughts and images of the car accident?”) and religiosity as predictors of the various dependent variables (i.e., anxiety and intrusive thought frequency at time period 1, change in anxiety and intrusive thought frequency over the two time periods, and the appraisal ratings). The results of the analyses revealed that thought suppression and religiosity significantly 49 predicted intrusive thought frequency at time period 1, F(2, 27) = 5.12, p < .05, R² = .27, anxiety at time period 1, F(2, 27) = 4.81, p < .05, R² = .26, change in intrusive thought frequency across time periods, F(2, 27) = 5.15, p < .05, R² = .27, change in anxiety across time periods, F(2, 27) = 4.81, p < .05, R² = .26, guilt at time period 1, F(2, 27) = 6.13, p <

.01, R² = .31, moral wrongness of thinking about the car accident, F(2, 27) = 6.30, p <

.01, R² = .32, and the urge to do something cancel or reduce the effects of thinking about the car accident, F(2, 27) = 6.73, p < .01, R² = .33. In all of the multiple regression analyses, it was found that the effort put forth trying to suppress the intrusive thought was the only unique predictor. Religiosity was not a unique predictor in any of the analyses.

Table 9 displays the significant predictor of the dependent variables.

Discussion

The cognitive behavioral theory of OCD suggests that intrusive thoughts play an important role in the development and maintenance of the disorder (Clark & Purdon,

1993; Ladouceur et al., 2000; Rachman, 1993, 1997, 1998; Salkovskis, 1985, 1989).

Beliefs about, appraisals of, and strategies used to cope with such thoughts are hypothesized to be involved in the escalation of intrusive thoughts into obsessions (Clark

& Purdon, 1993; Ehlers & Steil, 1995; Freeston & Ladouceur, 1993; Rachman 1997;

Salkovskis, 1985). Religion may also be a factor in the development of the disorder, in that individuals higher in religiosity may have more negative beliefs about intrusive thoughts and in turn use thought suppression more often (Abramowitz et al., 2004;

Yorulmaz et al.,2009). Therefore, the purpose of this study was to examine the relationship between religiosity, TAF beliefs, coping strategies, and OC experiences.

A number of hypotheses were tested in this study. The first hypothesis predicted that higher levels of religiosity would be associated with higher TAF beliefs, greater tendency toward thought suppression, more OC symptoms, and more negative appraisals in response to the intrusive thought induction. It was also thought that higher levels of religiosity would be correlated with lower levels of acceptance. Results only partially supported this hypothesis. Indeed, higher levels of religiosity were found to have a significant, positive relationship with OC symptoms (higher levels of contamination, checking behaviors, and overall OC symptoms). However, religiosity was not found to have a significant relationship with TAF beliefs, tendency to use thought suppression, levels of acceptance, or negative appraisals in response to the intrusive thought. These 51 findings contradict previous research that has shown that highly religious individuals use thought suppression more frequently (Abramowitz et al., 2004; Yorulmaz et al., 2009).

Furthermore, the results are discrepant from prior studies that have found a positive relationship between religiosity and TAF beliefs, especially moral TAF beliefs

(Abramowitz et al., 2004; Berman et al. 2010; Rassin & Koster, 2003; Siev & Cohen,

2007).

It is important to note that most of the studies that have found a relationship between religiosity and TAF beliefs used highly religious participants and compared these participants to those who identified as atheist or agnostic (Abramowitz et al., 2004;

Berman et al., 2010; Cohen & Rozin, 2001; Rassin & Koster, 2003). The current study examined religiosity more generally and participants were not recruited based on their level of religiosity. Previous studies have found that higher religiosity is related to more

TAF beliefs, whereas lower religiosity is related to less TAF beliefs (Abramowitz et al.,

2004; Berman et al., 2010; Cohen & Rozin, 2001; Rassin & Koster, 2003). As stated in the introduction, TAF is the belief that having certain thoughts are just as bad as doing that action or that having a thought makes it more likely that a particular event will occur.

Some religious teachings may make reference to having sinful thoughts as being as bad as doing a sinful action. Thus, highly religious individuals would likely be more aware of these teachings and therefore more bothered by certain thoughts. In the current study, the participants’ mean score on the measure of religiosity, the Santa Clara Strength of

Religiosity Questionnaire, was a 25.51 (SD = 7.83), which is very close to the mean for the normative undergraduate sample (M = 26.39, SD = 8.55) from Plante & Boccaccini 52

(1997). Thus, the current study’s participants did not fall within either extreme of the religiosity continuum. This may explain the lack of relationship that was found between religiosity and TAF beliefs, and why these findings are discrepant from previous studies.

In terms of religiosity and levels of acceptance, no prior research has directly examined the relationship between these variables, thus this is the first study to explore this relationship and there are no studies with which to compare the current findings. It is possible though that if the current study had recruited a sample at the extreme ends of the religiosity continuum, the findings may have been different.

It was also hypothesized that religiosity moderates the relationship between TAF beliefs, tendency toward thought suppression, and OC symptoms. The findings from the current study failed to provide support for this hypothesis. The only unique predictor of

OC symptoms was tendency toward thought suppression, but this relationship was in the opposite direction (i.e., a negative relationship). This finding contradicts earlier research suggesting that greater tendency toward thought suppression is positively related to OC symptoms (Darri Rafnsson & Smari, 2001; Muris, Merckelbach, & Horselenberg, 1996;

Rassin & Diepstraten, 2003). In the current study, the mean for the OCD measure, the total PI-WSUR score, was 22.41 with a standard deviation of 20.74. Thus, it appears that there was considerable variability in the sample’s level of OC symptoms, which may have influenced the results of the moderation model. This is compared to the normative, nonclinical sample that had a mean of 21.78 with a standard deviation of 16.33 (Burns et al., 1996). Also, in all three of the previous studies (Darri Rafnsson & Smari, 2001;

Muris et al., 1996; Rassin & Diepstraten, 2003), the Maudsley Obsessive Compulsive 53

Inventory (MOCI) was used, instead of the PI-WSUR. While the MOCI assesses OC symptoms, it is important to note that it has different subscales than the PI-WSUR

(Hodgson & Rachman, 1977). Thus, it’s possible that the MOCI may assess different types of OC symptoms than the PI-WSUR, which could account for the discrepancies between previous findings and the current study. Furthermore, none of the previous studies included religiosity as a variable of interest. By including a fourth variable in the moderation model in current study, there may have been insufficient power to detect statistically significant findings.

Regarding the experimental data, it was hypothesized that there would be an immediate enhancement effect (i.e., increased frequency of intrusions during time period

1) for the thought suppression group in comparison to the monitor-only, and that religiosity would have an effect on this difference. The immediate enhancement hypothesis was not supported, and religiosity was not found to account for a significant amount of the variance in the differences between coping strategies. Previous research on the immediate enhancement effect has had mixed findings. Some studies have found evidence of an immediate enhancement effect (Lavy & van den Hout, 1990; Marcks &

Woods, 2005; Muris & Merckelbach, 1991; Salkovskis & Campbell, 1994; Trinder &

Salkovskis, 1994). However, similar to the current study, there have been many studies that have not found an this effect (Belloch, Morillo, & Gimenez, 2004; Janeck &

Calamari, 1999; Kelly & Kahn, 1994; Koster et al., 2003; Purdon & Clark, 2001; Purdon et al., 2005). Possible reasons for the discrepancies in findings will be discussed later in this section. This is the first study to look at how religiosity may impact the effectiveness 54 of coping strategies. The results of this study suggest that religiosity does not have an effect on the effectiveness of thought suppression.

It was also hypothesized that there would be a rebound effect in terms of frequency of intrusive thought for the thought suppression group compared to the monitor-only group. It was predicted that there would be a stronger relationship (positive correlation) between religiosity and changes in frequency of intrusive thought in the thought suppression group compared to the monitor-only group. This hypothesis was not supported. Thus, the current study did not provide evidence of a rebound effect, and religiosity did not impact the change in frequency of intrusions. This finding is in line with the vast majority of studies that have not found evidence of the rebound effect

(Belloch, Morillo, & Gimenez, 2004; Janeck & Calamari, 1999; Kelly & Kahn, 1994;

Marcks & Woods, 2005; Merckelbach et al., 1991; Muris et al., 1992; Purdon & Clark,

2001; Purdon et al., 2005; Salkovskis & Campbell, 1994). Therefore, the current study’s findings are consistent with the majority of research on the rebound effect.

Regarding anxiety levels and negative appraisals, it was hypothesized that participants in the thought suppression group would have greater anxiety and more negative appraisals than those in the monitor-only group. It was also hypothesized that the thought suppression group would have a greater increase in anxiety across the time periods as compared to the monitor-only group (i.e. experience a rebound effect in anxiety). None of these hypotheses were supported. Religiosity did not have a significant effect on the differences between the groups, and the coping strategies were not significantly different from one another, regardless of religiosity, in terms of their effects 55 on anxiety and appraisal ratings. These findings are inconsistent with previous research that suggests thought suppression leads to more anxiety and more negative mood states

(Koster et al., 2003; Marcks & Woods, 2005; Purdon & Clark, 2001; Trinder &

Salkovskis, 1994).

It was hypothesized that participants in the acceptance group would have less anxiety and less negative appraisals than those in the monitor-only group. It was also expected that the acceptance group would have a greater decrease in anxiety across the two time periods as compared to the control group, with religiosity having a significant effect on this difference. None of these hypotheses were supported. Prior research has found that an acceptance based strategy results in decreased anxiety associated with intrusive thoughts (Marcks & Woods, 2005; Marcks & Woods, 2007) and greater willingness to have the intrusive thought (Marcks & Woods, 2007) compared to a monitor-only condition. Thus, these findings are in contradiction to prior research. A possible explanation for this is that the acceptance group reported putting forth similar amounts of effort in using suppression compared to the actual thought suppression group.

Therefore, it does not appear that the acceptance group followed the experimental instructions to the fullest extent, and thus it is not surprising that this hypothesis was not supported.

Due to the unexpected findings, additional exploratory analyses were performed to examine the relationship between religiosity, effort put forth suppressing, and the dependent variables, for the thought suppression group. These analyses revealed the more effort one used to suppress, the more intrusive thoughts he/she had, the greater the 56 anxiety, the less change in intrusive thought frequency and anxiety levels over time, the more guilt, the greater the sense of moral wrongness about having the intrusive thought, and the greater the urge to do something to reduce the effects of thinking about the car accident. Although the overall model was significant in each of these cases, thought suppression effort was in fact the only unique predictor of these variables. Thus, religiosity was not predictive in any of these models. These findings support previous correlational research that have also found that suppression is related to more intrusive thoughts (Muris et al., 1996; Purdon & Clark, 1994).These result s are also in line with previous findings on how thought suppression is related to higher levels of anxiety

(Koster et al., 2003; Muris et al., 1996; Rafnsson & Smari, 2001; Rassin & Diepstraten,

2003; Trinder & Salkovskis, 1994), as well as more negative appraisals (Koster et al.,

2003; Rassin & Diepstraten, 2003; Muris et al., 1996). It is important to note that religiosity was not related to any of these variables when suppression was included in the model, which calls into question the role of religiosity in the escalation of intrusive thoughts.

To summarize, religiosity was not found to be a moderator in the relationship between thought suppression tendencies, TAF fusion beliefs, and OC symptoms. Also, there was no evidence found of the paradoxical effects of thought suppression on frequency of intrusions, and no evidence suggesting the detrimental effects of thought suppression on anxiety and negative appraisals. Exploratory analyses did provide some support for thought suppression being associated with negative outcomes though. Due to spontaneous suppression in the acceptance group, it is unclear whether such an approach 57 could be beneficial for individuals dealing with distressing thoughts and images. It is also important to note that religiosity did not have an impact on any of the analyses with the exception of it being related to OC symptoms.

Since some of the current study’s experimental results are discrepant from previous findings, it is important to consider factors that may have led to these deviations.

Only one previous study on thought suppression (Marcks & Woods, 2007) utilized the same intrusive thought induction as the current study. Instead, most of the prior studies used either an intrusive thought that the participant created for him/herself or one in which the participant selected from a list of intrusive thoughts, such as the Revised

Obsessive Intrusions Inventory (ROII) (Purdon & Clark, 1994) (e.g., Belloch et al., 2004;

Kelly & Kahn, 1994; Marcks & Woods, 2005; Muris et al., 1996; Purdon & Clark, 2001;

Purdon et al., 2005; Salkovskis & Campbell, 1993; Trinder & Salkovskis, 1994). In studies that used the ROII to generate the target intrusive thought, the participant selected the personal intrusive thought that they experienced most frequently. Indeed, of studies that used personal intrusive thoughts, a number of them found a strong, positive relationship between thought suppression and negative appraisals (Marcks & Woods,

2005; Muris et al., 1996; Purdon & Clark, 2001; Purdon et al., 2005; Trinder &

Salkovskis, 1994). Thus, the personal nature of the intrusive thought and a participant’s prior experience with his/her thought may make such a thought particularly salient, more anxiety-provoking, and evoke stronger efforts to suppress during a thought suppression study. Given that the intrusive thought used in the current study was not a personal intrusive thought, it is likely that participants in the study had never had a thought like the 58 one used in the induction, and thus they may not have been able to come up with an image of a loved one in a car accident as readily as they would a personal intrusive thought. Thus, it could be the case that having the participants generate or choose their own intrusive thought may make for a better manipulation (i.e. more anxiety provoking) than having participants think of an experimenter generated thought (e.g., loved one in a car accident) or neutral target thought, although no comparisons have been done between these target thoughts. It does seem though that having participants use a personal intrusive thought may be more clinically relevant and may better capture the idiosyncratic nature of intrusive thoughts and obsessions in OCD.

There are several limitations that should be taken into consideration while interpreting the results of the current study. One limitation is the nature of the sample that was used for the study. Only undergraduate university students were included, which could impact the generalizability of the study’s findings. However, it should be noted though that the vast majority of past studies on thought suppression have also been conducted in undergraduate samples. Another limitation is that the sample was not ethnically diverse, with 87.8% of the participants being Caucasian. Only a few of the participants were Atheist/Agnostic (16.7%), with the rest endorsing some type of

Christianity. This likely impacted the variability in terms of level of religiosity for the study’s sample, which as discussed earlier, could have impacted the findings. Also, an unexpectedly large proportion of the sample was Catholic, which may have affected the results too. Much of the previous research has focused on Protestant Christians, which only made up 14.4% of Christian individuals in the current study, while 41.1% of 59 participants were Catholic. Indeed, previous research has indicated that Protestant

Christians may experience higher levels of moral TAF and may be more bothered by intrusive thoughts (Berman et al., 2010; Cohen, 2003; Cohen & Rankin, 2004; Cohen &

Rozin, 2001; Siev, Chambless, & Huppert, 2010). Thus, it is possible that individuals who endorse other Christian denominations may not experience as much TAF as

Protestant Christians, which could have impacted the findings from the current study.

Indeed Rassin and Koster (2003) found that there was a stronger relationship between religiosity and moral TAF in Protestant individuals than in Catholic individuals. Future studies should compare differences across more religious groups, other than Protestant

Christians and Atheist/Agnostics, as this would allow researchers to examine the relationship between religiosity and OC symptoms more broadly. Also, a measure of rigidity of religious beliefs may be beneficial to include. It is possible that it is not the religious belief itself that is problematic in scrupulosity, but rather the uncompromising nature of the religious belief. Unfortunately the current study did not include such a measure.

Another limitation to consider is the strength of the TAF induction. Although this induction method has been utilized by numerous researchers (e.g., Marcks & Woods,

2007; Rachman et al., 1996; Rassin, 2001; van den Hout et al., 2002; van den Hout et al.,2001; Zucker et al., 2002), the instructions do not specify the type or severity of accident the participant must visualize. Thus, there is no way to know what kind of car accident the participants visualized. Although the study included induction check ratings, participants could think of any type of accident they wanted. For instance, one 60 participant reported that he had intentionally thought of a cartoonish and unrealistic car accident, while another participant reported that the loved one envisioned in the car accident had gotten into many car accidents in his/her lifetime and was a “terrible driver.”

Some participants also endorsed that they purposefully tried not to think about the car accident during the intrusive thought induction, potentially as a way to manage their associated anxiety. Indeed, the mean score on this manipulation check rating (“How hard did you try not to think about the car accident?”) was a 50.13 (SD = 30.59), which means that participants may not have been putting their full effort toward visualizing the car accident, although no group differences were found on this item.

Although many studies have used the car accident induction in the past, most of these studies were focused on neutralization efforts, rather than religiosity and coping strategies (Rachman et al., 1996; van den Hout et al., 2001; van den Hout et al., 2002;

Zucker et al., 2002). Also, Rachman and colleagues (1996), as well as van den Hout and colleagues (2001; 2002) prompted participants to imagine a more anxiety provoking car accident if they indicated less than a 50 on a 0 to 100 scale of anxiety. Indeed, it seems very likely that the participants in the current study were not thinking of very serious car accidents, given that the mean anxiety rating was a 44.02 (SD = 29.12). This can be compared to a mean of 47.66 (SD = 28.21) in Marcks and Woods (2007). In Rachman and colleagues (1996) study, the mean anxiety rating was 67.20, and although van den

Hout and colleagues (2001; 2002) used the same procedure as Rachman and colleagues

(1996), the mean anxiety ratings in both studies were only 58 and 38.33, respectively.

Even though van den Hout and colleagues (2001; 2002) prompted participants to think of 61 a more severe car accident if they endorsed low levels of anxiety, it does not seem that this was enough to bring up the average anxiety rating across all participants. It is quite possible that participants in the current study may not have felt the urge to suppress the car accident thought, since on average, they endorsed only a mild to moderate level of anxiety. In future studies, if this induction is utilized, it may be advantageous to give participants a more standardized scenario, instead of allowing them to come up with their own car accident scene. This would allow for the car accident scene to be more similar across participants, and hopefully give the experimenter’s more control in terms of the effects of the induction procedure.

Future studies may also consider using a more religiously relevant intrusive thought. In particular, one in which a choice is made. For example, in Cohen and Rozin

(2001), the participants read a vignette about an individual who had thoughts of committing adultery. A manipulation such as Cohen and Rozin’s may elicit more TAF beliefs because a personal choice is being made, instead of in the car accident manipulation where it is probably assumed by most participants that the person involved in the car accident did not choose for it to happen.

It is also important to consider the way in which intrusive thought frequency was measured in the current study. The frequency counter was used in order to count the number of car accident related thoughts the participants experienced. If a participant had only one instance of the intrusive thought, it is possible that the intrusive thought lasted the entire time period or it could have been of very short duration. In both scenarios, it would have been recorded as one intrusive thought. Clearly there is a qualitative 62 difference between these two scenarios, which was not captured in the current study.

Future studies may consider having participants describe their experience after a 5 minute thought monitoring period so that researchers can gain insight into what exactly might be happening to the participants. This may also help researchers in considering ways in which to limit participants’ ability to spontaneously suppress the intrusive thought, which is what occurred in the acceptance group of the current study.

The results of the current study suggest that the relationship between OC symptoms and experiences and religiosity may be more complicated and nuanced than originally proposed. Future studies should focus on the ways in which religiosity specifically impacts OC symptoms and experiences. For example, the current study does not lend evidence to a moderation model, however perhaps a different model may be appropriate whereby religiosity acts as a mediator in the relationship between OC experiences and OC symptoms instead. Future studies may also examine the possibility that religiosity may have a non-linear relationship with OC experiences and symptoms.

Religiosity should also be looked at in more specific terms as well. For example, there has been some research that has found that certain religious affiliations may experience more OC symptoms than others (Berman et al., 2010; Cohen, 2003; Cohen & Rankin,

2004; Cohen & Rozin, 2001; Siev, Chambless, & Huppert, 2010). There should be additional studies conducted to compare different religious beliefs on OC experiences, such as TAF beliefs and thought suppression use. Indeed, there has been little to no research done on Eastern religions, such as Hinduism and Buddhism, on OC experiences.

This type of research would broaden the scope of the literature’s current focus on 63

Christianity and Judaism. It could also be helpful in developing treatments for scrupulosity that presents in different cultures. Also, there has been very little research done on acceptance related to religiosity. There may be certain religious beliefs in which acceptance of thoughts and feelings is an important feature, thus making such an approach as ACT a potentially good fit.

The current study provides contributions to our understanding of how religiosity,

TAF beliefs, and thought suppression may impact how intrusive thoughts escalate, as well important methodological issues to consider when studying this topic. The current study is one of the first studies to use religiosity as a covariate in analyses involving different coping strategies. Although the current study did not find evidence supporting the role of religiosity in the escalation of intrusive thoughts, prior research has provided some support for the relationship between religiosity and TAF, thought suppression, and

OC symptoms. Thus, given the discrepant findings, additional research is needed on the topic. This study was also the first study to use an acceptance based approach while considering religiosity’s effects on using that strategy to cope with an intrusive thought.

Unfortunately spontaneous suppression in acceptance group made interpreting the findings problematic. Nonetheless, given prior research on the utility of acceptance based approach for intrusive thoughts, additional research on this strategy specifically related to religiosity is warranted. Once a successful experimental manipulation can be achieved and better measurements of religiosity are implemented, this methodology and approach may ultimately lead to significant clinical implications relevant to both cognitive-behavioral and acceptance-based interventions. 64

References

Abramowitz, J. S. (1997). Effectiveness of psychological and pharmacological treatments

for obsessive–compulsive disorder: A quantitative review. Journal of Consulting

and Clinical Psychology, 65, 44–52.

Abramowitz, J. S. (2001). Treatment of scrupulous obsessions and compulsions using

exposure and response prevention: A case report. Cognitive and Behavioral

Practice, 8, 79–85.

Abramowitz, J. S., Deacon, B. J., Woods, C. M., & Tolin, D. F. (2004). Association

between Protestant religiosity and obsessive–compulsive symptoms and

cognitions. Depression and Anxiety, 20(2), 70 - 76.

Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., & Furr, J. M. (2003). Symptom

presentation and outcome of cognitive-behavioral therapy for obsessive-

compulsive disorder. Journal of Counseling and Clinical Psychology, 71(6),

1049-1057.

Abramowitz, J. S., Huppert, J. D., Cohen, A. B., Tolin, D. F., & Cahill, S. P. (2002).

Religious obsessions and compulsions in a non-clinical sample: the Penn

Inventory of Scrupulosity (PIOS). Behaviour Research and Therapy, 40, 825–

838.

Abramowitz, J. S., Whiteside, S., Kalsy, S. A., & Tolin, D. F. (2003). Thought control

strategies in obsessive-compulsive disorder: A replication and extension.

Behaviour Research and Therapy, 41, 529–540.

Agorastos, A., Muhtz, C., Kellner, M., Jellinek, L., & Moritz, S. (2010). Religiosity

correlates significantly with paranormal beliefs and magical ideation in patients

with anxiety disorders. European Psychiatry, 25, 326.

Aiken, L. S., & West, S. G. (1991). Multiple regression: Testing and interpreting

interactions. Newbury Park, CA: Sage.

Alonso, P., Menchon, J. M., Pifarre, J., Mataix-Cols, D., Torres, L., Salgado, P., &

Vallejo, J. (2001). Long-term follow-up and predictors of clinical outcome in

obsessive-compulsive patients treated with serotonin reuptake inhibitors and

behavioral therapy. Journal of Clinical Psychiatry, 62(7), 535-540.

Allport, W. R. & Ross, M. J. (1967). Personal religious orientation and prejudice. Journal

of Personality and Social Psychology, 5(4), 432-443.

Altın, M., & Gençöz, T. (2011). How does thought-action fusion relate to responsibility

attitudes and thought suppression to aggravate the obsessive-compulsive

symptoms? Behavioural and Cognitive Psychotherapy, 39, 99-114.

Amir, N., Cashman, L. A., & Foa, E. (1997). Strategies of thought control in obsessive-

compulsive disorder. Behaviour Research and Therapy, 35, 775–777.

Antony, Downie, & Swinson, (1998). Diagnostic issues and epidemiology in obsessive-

compulsive disorder. In: R. P. Swinson, & A. M. Martin (Eds.), Obsessive-

compulsive disorder: Theory, research, and treatment (pp. 3–32). New York, NY:

Guilford Press. 66

Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to

prevent the rehospitalization of psychotic patients: A randomized controlled trial.

Journal of Consulting and Clinical Psychology, 70, 1129–1139.

Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in

social psychological research: Conceptual, strategic, and statistical considerations.

Journal of Personality and Social Psychology, 51(6), 1173-1182.

Barrett, P. M., & Healy, L. J. (2003). An examination of the cognitive processes involved

in childhood obsessive-compulsive disorder. Behaviour Research and Therapy,

41, 285–300.

Belloch, A., Morillo, C., & Gimenez, A. (2004). Effects of suppressing neutral and

obsession-like thoughts in normal subjects: Beyond frequency. Behaviour

Research and Therapy, 42, 841-857.

Belloch, A., Morillo, C., Lucero, M., Cabedo, E., & Carrió, C. (2004). Intrusive thoughts

in non-clinical subjects: The role of frequency and unpleasantness on appraisal

ratings and control strategies. Clinical Psychology and Psychotherapy, 11, 100-

110.

Berle, D., & Starcevic, V. (2005). Thought-action fusion: Review of the literature and

future directions. Clinical Psychology Review, 25, 263-284.

Berman, N. C., Abramowitz, J. S., Pardue, C. M., & Wheaton, M. G. (2010). The

relationship between religion and thought-action fusion: Use of an in vivo

paradigm. Behaviour Research and Therapy, 48, 670-674.

Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K.,

Waltz, T., & Zettle, R. D. (2011) Preliminary psychometric properties of the

Acceptance and Action Questionnaire – II: A revised measure of psychological

flexibility and acceptance. Behavior Therapy, 1-38.

Bourke, J. (2009). Divine madness: The dilemma of religious scruples in twentieth-

century America and Britain. Journal of Social History, 42(3), 581-603.

Bouvard, M., Cottraux, J., Mollard, E., Arthus, M., Lachance, S., Guerin, J. et al. (1997).

Validity and factor structure of the Obsessive Compulsive Thoughts Checklist.

Behavioural and Cognitive Psychotherapy, 25, 51-66.

Bowers, K. S., & Woody, E. Z. (1996). Hypnotic amnesia and the paradox of intentional

forgetting. Journal of Abnormal Psychology, 105, 381-390.

Burns, G. L., Keortge, S. G., Formea, G. M., & Sternberger, L. G. (1996). Revision of the

Padua Inventory of obsessive compulsive disorder symptoms: Distinctions

between worry, obsessions, and compulsions. Behaviour Research and Therapy,

34, 163-173.

Canda, E. R. (2001). Transcending through disability and death: Transpersonal themes in living with cystic fibrosis. In E.R. Canda & E. D. Smith (Eds.). Transpersonal Perspectives on Spirituality in Social Work (pp. 109-134). New York: Haworth Press.

Canda, E. R. (2002). The significance of spirituality for resilient response to chronic

illness: A qualitative study of adults with cystic fibrosis. In D. Saleebey (Ed.). The

Strengths Perspective in Social Work Practice (pp. 63-79). Boston: Allyn &

Bacon. 68

Clark, D. A., & de Silva, P. (1985). The nature of depressive and anxious intrusive

thoughts: Distinct or uniform phenomena? Behaviour Research and Therapy, 23,

383-393.

Clark, D. A., & Purdon, C. (1993). New perspectives for a cognitive theory of obsessions.

Australian Psychologist, 28, 161-167.

Clark, D. M., Ball, S., & Pape, D. (1991). An experimental investigation of thought

suppression. Behaviour Research and Therapy, 29(3), 253–257.

Clark, D. M., Winton, E., & Thynn, L. (1993). A further experimental investigation of

thought suppression. Behaviour Research and Therapy, 31 (2), 207-210.

Cohen, A. B. (2003). Religion, likelihood of action, and the morality of mentality.

International Journal for the Psychology of Religion, 13, 273–285.

Cohen, A. B., & Rankin, A. (2004). Religion and morality of positive mentality. Basic

and Applied Social Psychology, 26, 45–57.

Cohen, A. B., & Rozin, P. (2001). Religion and the morality of mentality. Journal of

Personality and Social Psychology, 81, 697–710.

Corcoran, K. M. & Woody, S. R. (2009). Effects of suppression and appraisals on

thought frequency and distress. Behaviour Research and Therapy, 47, 1024-1031.

Darii Rafnsoon, F., & Smári, J. (2001). Chronic thought suppression and obsessionality:

The relationships between the white bear suppression inventory and two

inventories of obsessive-compulsive symptoms. Personality and Individual

Differences, 30, 159-165.

Deacon, B. & Nelson, E. A. (2008). On the nature and treatment of scrupulosity.

Pragmatic Case Studies in Psychotherapy, 4(2), 39-53.

Diduca, D., & Joseph, S. (1997). Schizotypal traits and dimensins of religiosity. British

Journal of Clinical Psychology, 36(4), 635-638.

Edwards, S., & Dickerson, M. (1987). On the similarity of positive and negative

intrusions. Behaviour Research and Therapy, 25, 207-211.

Ehlers, A., & Steil, R. (1995). Maintenance of intrusive memories in posttraumatic stress

disorder: A cognitive approach. Behavioural and Cognitive Psychotherapy, 25,

217-249.

Ehntholt, K. A., Salkovskis, P. M., & Rimes, K. A. (1999). Obsessive–compulsive

disorder, anxiety disorders, and self esteem: An exploratory study. Behaviour

Research and Therapy, 37, 771–781.

Evans, D. W., Milanak, M. E., Medeiros, B., & Ross, J. L. (2002). Magical beliefs and

rituals in young children. Child Psychiatry and Human Development, 33, 43–58.

Fallon, B. A., Liebowitz, M. R., Hollander, E., Schneier, F. R., Campeas, R. B.,

Fairbanks, J. Papp, L. A., Hatterer, J. A., & Sandberg, D. (1990). The

pharmacotherapy of moral or religious scrupulosity. Journal of Clinical

Psychiatry, 51(12), 517-521.

Faul, F., Erdfelder, E., Buchner, A., & Lang, A. (2009). Statistical power analyses using

G*Power 3.1: Tests for correlation and regression analyses. Behavior Research

Methods, 41(4), 1149-1160.

Foa, E. B., & Kozak, M. J. (1995). DSM-IV field trial: Obsessive-compulsive disorder.

American Journal of Psychiatry, 152, 90–96.

Forrester, E., Wilson, C., & Salkovskis, P. M. (2002). The occurrence of intrusive

thoughts transforms meaning in ambiguous situations: An experimental study.

Behavioural and Cognitive Psychotherapy, 30, 143–152.

Freeston, M. H., & Ladouceur, R. (1993). Appraisal of cognitive intrusions and response

style: Replication and extension. Behaviour Research and Therapy, 31, 181-191.

Freeston, M. H., & Ladouceur, R. (1997). What do patients do with their obsessive

thoughts?. Behaviour Research and Therapy, 35, 335-348.

Freeston, M. H., Ladouceur, R., Thibodeau, N., & Gagnon, F. (1991). Cognitive

intrusions in a non-clinical population. Response style, subjective experience, and

appraisal. Behaviour Research and Therapy, 29, 585–597.

Freud, S. (1907). Obsessive actions and religious practices. In J. Strachey (Ed.), The

Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. IX

(116–39). London: W. W. Norton.

Genest, M., Bowen, R. C., Dudley, J., & Keegan, D. (1990). Assessment of strategies for

coping with anxiety: Preliminary investigations. Journal of Anxiety Disorders, 4,

1-14.

Gorsuch, R. L., & Venable, D. G. (1983). Development of an “Age Universal” I-E scale.

Journal for the Scientific Study of Religion, 22(2), 181-187.

Greenberg, D., & Huppert, J. D. (2010). Scrupulosity: a unique subtype of obsessive-

compulsive disorder. Current Psychiatry Reports, 12(4), 282 – 289. 71

Greenberg, D., & Witztum, E. (1994). The influence of cultural factors on obsessive

compulsive disorder: Religious symptoms in a religious society. Israel Journal of

Psychiatry and Related Sciences, 31(3), 211-220.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment

therapy: An experiential approach to behavior change. New York: Guilford

Press.

Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D.,

Polusny, M., A., Dykstra, T. A., Batten, S. V., et al. (2004). Measuring

experiential avoidance: A preliminary test of a working model. The Psychological

Record, 54, 553-578.

Hodgson, R. J., & Rachman, S. (1977). Obsessional-compulsive complaints. Behaviour

Research and Therapy, 15, 389-395.

Holmbeck, G. N. (2002). Post-hoc probing of significant moderational and mediational

effects in studies of pediatric populations. Journal of Pediatric Psychology, 27(1),

87-96.

Huppert, J. D., & Siev, J. (2010). Treating scrupulosity in religious individuals using

cognitive-behavioral therapy. Cognitive and Behavioral Practice, 17, 382-392.

Huppert, J. D., Siev, J., & Kushner, E. S. (2007). When religion and obsessive-

compulsive disorder collide: treating scrupulosity in ultra-orthodox jews. Journal

of Clinical Psychiatry, 63(10), 925-941.

Janeck, A. S., & Calamari, J. E. (1999). Thought suppression in obsessive-compulsive

disorder. Cognitive Therapy and Research, 23 (5), 497-509. 72

Karekla, M., & Constantinou, M. (2010). Religious Coping and Cancer: Proposing an

Acceptance and Commitment Therapy Approach. Cognitive and Behavioral

Practice, 17, 371-381.

Kelly, A. E., & Kahn, J. H. (1994). Effects of suppression of personal intrusive thoughts.

Journal of Personality and Social Psychology, 66(6), 998-1006.

Koenig, H. G., Meador, K., Parkerson, G. (1997). Religion index for psychiatric research:

A 5-item measure for use in health outcome studies. American Journal of

Psychiatry, 154, 885-886

Koster, E. H. W., Rassin, E., Crombez, G., & Naring, G. W. B. (2003). The paradoxical

effects of suppressing anxious thoughts during imminent threat. Behaviour

Research and Therapy, 41(9), 1113–1120.

Ladouceur, R., Rheaume, J., Gagnon, F., Thibodeau, N., Freeston, M. H., Dugas, M. J., et

al. (2000). Strategies used with intrusive thoughts: A comparison of OCD patients

with anxious and community controls. Journal of Abnormal Psychology, 109,

179–187.

Lopatka, C., & Rachman, S. (1995). Perceived responsibility and compulsive checking:

An experimental analysis. Behaviour Research and Therapy, 33, 673-684.

Lavy, E. H., & van den Hout, M. A. (1990). Thought suppression induces intrusions.

Behavioural Psychotherapy, 18, 251–258.

Mahgoub, O. M., & Abdel-Hafeiz, H. B. (1991). Pattern of obsessive-compulsive

disorder in eastern Saudi Arabia. The British Journal of Psychiatry, 158, 840-842.

Marcks, B. A., & Woods, D. W. (2005). A comparison of thought suppression to an

acceptance-based technique in the management of personal intrusive thoughts: A

controlled evaluation. Behaviour Research and Therapy, 43, 433–445.

Marcks, B. A., & Woods, D. W. (2007). Role of thought-related beliefs and coping

strategies in the escalation of intrusive thoughts: An analog to obsessive–

compulsive disorder. Behaviour Research and Therapy, 45(11), 2640-2651.

Mataix-Cols, D., Marcks, I. M., Greist, J. H., Kobak, K. A., & Baer, L. (2002).

Obsessive-compulsive symptom dimensions as predictors of compliance with and

response to behaviour therapy: Results from a controlled trial. Psychotherapy and

Psychosomatics, 71(5), 255-262.

McNally, R. J., & Ricciardi, J. N. (1996). Suppression of negative & neutral thoughts.

Behavioural and Cognitive Psychotherapy, 24(1), 17-25.

Merckelbach, H., Muris, P., van den Hout, M., & de Jong, P. (1991). Rebound effects of

thought suppression: Instruction-dependent? Behavioural Psychotherapy, 19,

225-238.

Miller, C. H., & Hedges, D. W. (2008). Scrupulosity disorder: An overview and

introductory analysis. Journal of Anxiety Disorders, 22, 1042-1058.

Moore, E. L., & Abramowitz, J. S. (2007). The cognitive mediation of thought-control

strategies. Behaviour Research and Therapy, 45, 1949-1955.

Morillo, C., Belloch, A., & García-Soriano, G. (2007). Clinical obsessions in obsessive–

compulsive patients and obsession-relevant intrusive thoughts in non-clinical,

depressed and anxious subjects: Where are the differences? Behaviour Research

and Therapy, 45, 1319-1333.

Muris, P., Meesters, C., Rassin, E., Merckelbach, H., & Campbell, J. (2001). Thought-

action fusion and anxiety disorders symptoms in normal adolescents. Behaviour

Research and Therapy, 39, 843–852.

Muris, P., & Merckelbach, H. (1991). The effect of thought suppression: A quasi-

experiment. Directieve Therapie, 11, 119–126.

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.

Muris, P., Merckelbach, H., van de Hout, M., & de Jong, P. (1992). Suppression of

emotional and neutral material. Behaviour Research and Therapy, 30, 639-642.

Nelson, E. A., Abramowitz, J. S., Whiteside, S. P., & Deacon, B. J. (2006). Scrupulosity

in patients with obsessive-compulsive disorder: Relationship to clinical and

cognitive phenomenon. Journal of Anxiety Disorders, 20, 1071-1086.

Niler, E. R., & Beck, S. J. (1989). The relationship among guilt anxiety and obsessions in

a normal population. Behaviour Research and Therapy, 27, 213-220.

Obsessive Compulsive Cognitions Working Group. (2003). Psychometric validation of

the Obsessive Beliefs Questionnaire and the Interpretation of Intrusions

Inventory: Part I. Behaviour Research and Therapy, 41, 863–878. 75

Osarchuk, M., & Tatz, S. J. (1973). Effect of induced fear of death on belief in afterlife.

Journal of Personality and Social Psychology, 27(2), 256-260.

Parkinson, L., & Rachman, S. (1981). Part II. The nature of intrusive thoughts. Advances

in Behaviour Research and Therapy, 3, 101-110.

Plante, T. G., & Boccaccini, M. T. (1997). The Santa Clara strength of religious faith

questionnaire. Pastoral Psychology, 45, 375-387.

Purdon, C. (2004). Empirical investigations of thought suppression in OCD. Journal of

Behavior Therapy and Experimental Psychiatry, 35, 121-136.

Purdon, C., & Clark, D. A. (1993). Obsessive intrusive thoughts in nonclinical subjects.

Part 1. Content and relation with depressive, anxious and obsessional symptoms.

Behaviour Research and Therapy, 31(8), 713–720.

Purdon, C., & Clark, D. A. (1994a). Obsessive intrusive thoughts in non-clinical subjects.

Part II. Cognitive appraisal, emotional response and thought control strategies.

Behaviour Research and Therapy, 32, 403-410.

Purdon, C., & Clark, D. A. (1994b). Perceived control and appraisal of obsessional

intrusive thoughts: A replication and extension. Behavioural and Cognitive

Psychotherapy, 22, 269-285.

Purdon, C., & Clark, D. A. (2001). Suppression of obsession-like thoughts in nonclinical

individuals: Impact on thought frequency, appraisal and mood state. Behaviour

Research and Therapy, 39, 1163–1181. 76

Purdon, C., & Clark, D. A. (2002). The need to control thoughts. In R. O. Frost, & G.

Steketee (Eds.), Cognitive approaches to obsessions and compulsions: Theory,

assessment, and treatment (pp. 29–44). London: Elsevier Science.

Purdon, C., Rowa, K., & Antony, M. M. (2005). Thought suppression and its effects on

thought frequency, appraisal and mood state in individuals with obsessive-

compulsive disorder. Behaviour Research and Therapy, 43, 93-108.

Rachman, S. (1976). The modification of obsessions: A new formulation. Behaviour Research and Therapy, 14, 437–443. Rachman, S. (1993). Obsessions, responsibility and guilt. Behaviour Research and Therapy, 31, 149–154. Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793–802. Rachman, S. (1998). A cognitive theory of obsessions: Elaborations. Behaviour and

Research Therapy, 36(4), 385-401.

Rachman, S. (2003). The treatment of obsessions. Oxford: Oxford University Press.

Rachman, S., & de Silva, P. (1978). Abnormal and normal obsessions. Behaviour

Research and Therapy, 16, 233–248.

Rachman, S., & Hodgson, R. J. (1980). Obsessions and compulsions. Englewood Cliffs,

NJ: Prentice Hall.

Rachman, S.,Shafran, R.,Mitchell, D.,Trant, J.,&Teachman, B. (1996). How to remain

neutral: An experimental analysis of neutralization. Behaviour Research and

Therapy, 34, 889-898.

Rachman, S., Thordarson, D. S., Shafran, R., & Woody, S. R. (1995). Perceived

responsibility: Structure and significance. Behaviour Research and Therapy, 33,

779–784.

Rassin, E. (2001). The contribution of thought-action fusion and thought suppression in

the development of obsession-like intrusions in normal participants. Behaviour

Research and Therapy, 39, 1023-1032.

Rassin, E., Cougle, J. R., & Muris, P. (2007). Content difference between normal and

abnormal obsessions. Behaviour Research and Therapy, 45, 2800-2803.

Rassin, E., & Diepstraten, P. (2003). How to suppress obsessive thoughts. Behaviour

Research and Therapy, 41, 97–103.

Rassin, E. & Koster, E. (2003). The correlation between thought-action fusion and

religiosity in a normal sample. Behaviour Research and Therapy, 41(3), 361.

Rassin, E., Merckelbach, H., Muris, P., & Spaan, V. (1999). Thought-action fusion as a

causal factor in the development of intrusions. Behaviour Research and Therapy,

37, 231–237.

Rassin, E., & Muris, P. (2007). Abnormal and normal obsessions: A reconsideration.

Behaviour Research and Therapy, 45, 1065–1070.

Rassin, E., Muris, P., Schmidt, H., & Merckelbach, H. (2000). Relationships between

thought–action fusion, thought suppression and obsessive–compulsive symptoms:

A structural equation modeling approach. Behaviour Research and Therapy, 38,

889–897.

Rippere, V. (1979). Scaling the helpfulness of antidepressive activities. Behaviour

Research and Therapy, 17, 439-449.

Rowa, K., & Purdon, C. (2003). Why are certain intrusive thoughts more upsetting than

others? Behavioural and Cognitive Psychotherapy, 31, 1-11.

Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural

analysis. Behaviour Research and Therapy, 23, 571–583.

Salkovskis, P. M. (1989). Cognitive-behavioural factors and the persistence of intrusive

thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677-682.

Salkovskis, P. M. (1998). Psychological approaches to the understanding of obsessional

problems. In R. P. Swinson, M. M. Antony, S. Rachman, & M. A. Richter (Eds.),

Obsessive–compulsive disorder: Theory, research and treatment (pp. 33–50).

New York: Guilford.

Salkovskis, P. M., & Campbell, P. (1994). Thought suppression induces intrusion in

naturally occurring negative intrusive thoughts. Behaviour Research and Therapy,

32 (1), 1-8.

Salkovskis, P. M., & Forrester, E. (2002). Responsibility. In R. O. Frost & G. Steketee

(Eds.), Cognitive approaches to obsessions and compulsions: Theory, assessment,

and treatment (pp. 45-62). London: Elsevier Science.

Salkovskis, P. M., & Harrison, J. (1984). Abnormal and normal obsessions: A replication.

Behaviour Research and Therapy, 22, 549-552.

Salkovskis, P., Shafran, R., Rachman, S., & Freeston, M. (1999). Multiple pathways to

inflated responsibility beliefs in obsessional problems: Possible origins and

implications for therapy and research. Behavior Research and Therapy, 37, 1055-

1072.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. (2002). Mindfulness-based cognitive

therapy for depression: A new approach to preventing relapse. New York:

Guilford Press.

Shafran, R. (1997). The manipulation of responsibility in obsessive-compulsive disorder.

British Journal of Clinical Psychology, 36, 397-407.

Shafran, R., & Rachman, S. (2004). Thought-action fusion: A review. Journal of

Behavior Therapy and Experimental Psychiatry, 35, 87-107.

Shafran, R., Thordarson, D. S., & Rachman, S. (1996). Thought–action fusion in

obsessive compulsive disorder. Journal of Anxiety Disorders, 10(5), 379–391.

Sica, C., Novaro, C., & Sanavio, E. (2002). Religiousness and obsessive–compulsive

cognitions and symptoms in an Italian population. Behaviour Research and

Therapy, 40, 813–823.

Siev, J. & Cohen, A. (2007). Is thought-action fusion related to religiosity? Differences

between christians and jews. Behaviour Research and Therapy, 45, 829-837.

Siev, J., Chambless, D. L., & Huppert, J. D. (2010). Moral thought–action fusion and

OCD symptoms: The moderating role of religious affiliation. Journal of Anxiety

Disorders, 24, 309-312.

Smári, J., & Hólmsteinsson, H. E. (2001). Intrusive thoughts, responsibility attitudes,

thought–action fusion, and chronic thought suppression in relation to obsessive–

compulsive symptoms. Behavioural and Cognitive Psychotherapy, 29, 13–20.

Sternberger, L. G., & Burns, L. G. (1990). Maudsley obsessional-compulsive inventory:

obsessions and compulsions in a nonclinical sample. Behaviour Research and

Therapy, 28(4), 337-340.

Thordarson, D. S., & Shafran, R. (2002). Importance of thoughts. In R. O. Frost, & G.

Steketee (Eds.), Cognitive approaches to obsessions and compulsions: Theory,

assessment, and treatment (pp. 15–28). Oxford: Pergamon/Elsevier.

Tolin, D. F., Abramowitz, J. S., Kozak, M. J., & Foa, E. B. (2001). Fixity of belief,

perceptual aberration, and magical ideation in obsessive–compulsive disorder.

Journal of Anxiety Disorders, 15(6), 501-510.

Trinder, H., & Salkovskis, P. M. (1994). Personally relevant intrusions outside the

laboratory: Long-term suppression increases intrusion. Behaviour Research and

Therapy, 32(8), 833–842. van den Hout, M., Kindt, M., Weiland, T., & Peters, M. (2002). Instructed neutralization,

spontaneous neutralization and prevented neutralization after an obession-like

thought. Journal of Behavior Therapy and Experimental Psychiatry, 33, 177-189. van den Hout, M., van Pol, M., & Peters, M. (2001). On becoming neutral: Effects of

experimental neutralizing reconsidered. Behaviour Research and Therapy, 39,

1439-1448.

Veale, D. (2004). Psychopathology of obsessive-compulsive disorder. Psychiatry, 3(6),

65-68.

Wang, A., & Clark, D. A. (2002). Haunting thoughts: The problem of obsessive mental

intrusions. Journal of Cognitive Psychotherapy: An International Quarterly,16,

193–208.

Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief

measures of positive and negative affect: The PANAS scales. Journal of

Personality and Social Psychology, 54 (6), 1063-1070.

Wegner, D. M. (1994). White bears and other unwanted thoughts: Suppression,

obsession, and the psychology of mental control. New York: Guilford Press.

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(1), 5–

13.

Wegner, D. M., & Zanakos, S. (1994). Chronic thought suppression. Journal of

Personality, 62(4), 615–640.

White, J., Joseph, S., & Neil, A. (1995). Religiosity, psychoticism, and schizotypal traits.

Personality and Individual Differences, 19(6), 847-851.

Yee, P. L., & Vaughan, J. (1996). Integrating cognitive, personality, and social

approaches to cognitive interference and distractibility. In I. G. Sarason, G. R.

Pierce, & B. R. Sarason (Eds.), Cognitive interference: Theories, methods, and

findings (pp. 77-97). Mahwah, NJ; Erlbaum.

Yorulmaz, O., Gençöz, T., & Woody, S. (2009). OCD cognitions and symptoms in

different religious contexts. Journal of Anxiety Disorders, 23, 401-406.

Zucker, B. G., Craske, M. G., Barrios, V. & Holguin, M. (2002). Thought action fusion:

Can it be corrected? Behaviour Research and Therapy, 40, 653-664. 83

Table 1 Descriptive Statistics for Demographic Variables by Group

Group Thought Monitor-only Acceptance suppression M SD M SD M SD Age 19.67 1.58 19.57 1.25 19.70 1.05 Completed Years of 13.20 1.13 13.27 1.28 13.47 1.04 Education

Percent Percent Percent Gender Female 53.3% 60% 63.3% Male 46.7% 40% 36.7% Ethnicity African American 10% 0% 0% Asian 0% 3.3% 0% Caucasian 76.7% 93.3% 93.3% Hispanic 0% 3.3% 3.3% Multiracial 3.3% 0% 3.3% Native American 0% 0% 0% Other 10% 0% 0% Marital status Single 100% 96.7% 100% Married 0% 3.3% 0% Divorced 0% 0% 0%

Table 2 Percentages of Participants’ Religious Affiliation by Group

Group Thought Monitor-only Acceptance suppression Percent Percent Percent Current Religion Christian 80% 90% 80% Atheist/Agnostic 20% 10% 20% Current Christian Affiliation Not Christian 20% 10% 20% Protestant 20% 13.3% 10% Catholic 33.3% 50% 40% Mormon 0% 0% 0% Jehovah’s Witness 0% 0% 0% Orthodox 0% 6.7% 0% Other 26.7% 16.7% 30% No response 0% 3.3% 0% Past Religion Religion never changed 86.7% 93.3% 80% Christian 13.3% 6.7% 20% Atheist/Agnostic 0% 0% 0% Past Christian Affiliation Never Christian 3.3% 3.3% 6.7% Protestant 26.7% 16.7% 20% Catholic 33.3% 53.3% 50% Mormon 0% 0% 0% Jehovah’s Witness 0% 0% 0% Orthodox 0% 6.7% 0% Other 36.7% 16.7% 23.3% No response 0% 3.3% 0%

Table 3 Descriptive Statistics for Religiosity Measures

M SD α Questionnaires and Subscales

Santa Clara Strength of Religious 25.51 7.83 0.95 Faith Questionnaire Duke Religion Index Organizational religiosity 3.08 1.24 NA Non-organizational religiosity 2.38 1.62 NA Intrinsic religiosity 8.71 3.41 0.89 Total score 14.17 5.48 0.88

Table 4 Descriptive Statistics for Coping Strategy Affect Measures

M SD α Questionnaires and Subscales

White Bear Suppression Inventory 50.80 9.89 0.89 Acceptance and Action Questionnaire 17.70 7.23 0.87 Positive and Negative Affect Scale Positive Affect 24.73 8.14 0.89 Negative Affect 13.16 4.23 0.82

Table 5 Descriptive Statistics for Obsessive-Compulsive Related Beliefs and Symptoms Measures

M SD α Questionnaires and Subscales Thought-Action Fusion Scale Moral 19.12 9.26 0.85 Likelihood Self 2.86 3.02 0.94 Likelihood Other 1.81 2.82 0.96 Likelihood Total 4.67 5.18 0.93 Total 27.79 11.87 0.87 Penn Inventory of Scrupulosity Fear of God 6.57 5.75 0.91 Fear of sin 10.21 7.80 0.91 Total 16.78 12.77 0.94 Padua Inventory- WA State University Revision Obsessional Thoughts about Harm to 3.00 4.25 0.84 Self/Others Obsessional Impulses to Harm Self/Others 1.83 3.52 0.88 Contamination Obsessions and Washing 7.31 7.11 0.91 Checking Compulsions 8.32 7.65 0.91 Dressing/Grooming Compulsions 1.94 2.65 0.84 Total 22.41 20.74 0.95

Table 6 Descriptive Statistics for Thought-Action Fusion Induction Check and Appraisal Ratings

M SD Visual Analogue Scale Ratingsa Thought-Action Fusion Induction Check Vividness of accident scene 65.61 21.74 Severity of accident 54.44 30.70 Effort put forth visualizing accident 64.69 22.35 Level of engagement 63.58 22.61 Believability of accident scene 61.57 28.35 Appraisal Ratings Anxiety 44.02 29.12 Guilt 39.03 29.70 Effort to not think about the accident 50.13 30.59 Moral wrongness 48.30 34.01 Perceived control over the accident 18.57 24.10 Likelihood of accident occurring in next 24 hours 13.97 16.50 Urge to do something to reduce or cancel the effects 47.17 34.35 Willingness to further think about accident 26.93 26.05 a Ratings on a 100 mm visual analogue scales (0 mm = “not at all” to 100 mm = “extremely ”)

Table 7: Hierarchical Multiple Regression Analysis for the Interactions of Religiosity and Obsessive-Compulsive Beliefs in Predicting Obsessive-Compulsive Symptoms

ΔF Variable B SE B β sr² R² ΔR² (dfs) Block 1 (OC Beliefs & 4.67** Religiosity) 0.14 0.14 (3,86)

TAFS -0.06 0.18 -0.03 0.001

WBSI -0.64 0.21 -0.31** 0.10

SCSRF 0.44 0.27 0.17 0.03

Block 2 (Interactions) 0.19 0.05 1.39

TAFS x WBSI -0.05 0.08 -0.27 0.005

TAFS x SCSRF -0.03 0.02 -0.44 0.02

WBSI x SCSRF -0.06 0.03 -0.71 0.04

TAFS x WBSI x SCSRF 0.002 0.003 0.24 0.004 ** p < .01 90

Table 8 Descriptive Statistics for Appraisal Ratings Across Time Periods 1 and 2 By Group Time 1 Time 2

Appraisal Thought Acceptance Monitor-only Thought Acceptance Monitor-only rating a suppression suppression M SD M SD M SD M SD M SD M SD Anxiety 33.27 25.95 35.80 31.17 23.70 24.44 20.63 19.45 21.03 21.44 15.73 19.73 Guilt 28.47 24.36 27.83 27.33 26.00 32.09 16.07 15.10 18.30 21.43 18.33 24.66 Effort to not 67.63 27.35 56.23 29.06 50.63 31.86 49.63 33.87 44.20 30.48 39.33 31.97 think about Moral 39.43 33.77 37.60 35.26 40.97 31.99 33.13 35.47 30.13 34.99 37.03 30.28 wrongness Perceived 21.00 27.42 18.77 26.17 18.27 23.83 14.67 22.98 20.97 28.70 12.83 18.66 control Likelihood 15.07 17.88 11.37 15.04 16.33 19.36 12.50 16.40 7.67 10.40 13.50 17.25 Urge to do 48.67 35.10 36.73 31.33 33.63 31.96 43.80 35.77 35.80 33.11 30.00 34.54 something Willingness 29.37 26.33 25.37 27.52 24.37 22.03 26.50 25.57 20.87 25.92 19.27 21.12 a Ratings on a 100 mm visual analogue scales (0 mm = “not at all” to 100 mm = “extremely ”)

Table 9 Unique Predictor of Obsessive-Compulsive Experiences: Effort Suppressing Intrusive Thought t β sr²

Intrusive Thought Frequency (Time Period 1) 3.05* 0.56 0.25 Anxiety (Time Period 1) 2.66* 0.49 0.19 Change in Intrusive Thought Frequency -3.05* -0.56 0.25 Change in Anxiety -2.66* -0.48 0.19 Appraisal Ratings (Time Period 1) Guilt 2.67* 0.48 0.18 Moral wrongness 2.12* 0.37 0.11 Likelihood of accident occurring in next 24 hours 2.07* 0.41 0.13 Urge to do something to reduce or cancel the effects 3.16** 0.55 0.25

* p < .05 ** p < .01

Appendix A: Demographics Questionnaire

We would like to ask you a few questions about yourself. The questions ask about your gender, age, marital status, educational background, and ethnicity. This information will assist us in our study. Please answer all the questions as completely as possible by circling the appropriate response or by providing the necessary information.

1. What is your gender? 1=female 2=male

2. What is your marital status? 1=single 4=separated 2=married 5=remarried 3=divorced 6=widowed

3. What is your age? ______

4. What was the highest grade of school you completed? High School 9 10 11 12

Post High School (vocational/technical) 1 2 3 4

College 1 2 3 4 degree?______

Graduate/Professional 5 6 7 8 degree?______

5. What is your ethnicity/race? 1=African American 2=Asian American 3=Caucasian 4=Hispanic 5=Multiracial 6=Native American 7=Other (please specify)______

6. What is your current religious affiliation? 1=Christian IF CHRISTIAN, specify the denomination below: A = Protestant B = Catholic C = Mormon D = Jehovah's Witness E = Orthodox (e.g., Greek, Russian, Other) F = Other Christian (please 93

specify):______

2=Jewish 3=Muslim 4=Hindu 5=Buddhist 6=Atheist/Agnostic 7=Other (please specify)______

7. What was your religious affiliation in the past? 0=My religious affiliation has never changed 1=Christian

IF CHRISTIAN, specify the denomination below A = Protestant B = Catholic C = Mormon D = Jehovah's Witness E = Orthodox (e.g., Greek, Russian, Other) F = Other Christian (please specify):______

2=Jewish 3=Muslim 4=Hindu 5=Buddhist 6=Atheist/Agnostic 7=Other (please specify)______

Appendix B: SCSRFQ

Please answer the following questions about religious faith using the scale below. Indicate the level of agreement (or disagreement) for each statement.

1 = strongly disagree 2 = disagree 3 = agree 4 = strongly agree

_____ 1. My religious faith is extremely important to me.

_____ 2. I pray daily.

_____ 3. I look to my faith as a source of inspiration.

_____ 4. I look to my faith as providing meaning and purpose in my life.

_____ 5. I consider myself active in my faith or church.

_____ 6. My faith is an important part of who I am as a person.

_____ 7. My relationship with God is extremely important to me.

_____ 8. I enjoy being around others who share my faith.

_____ 9. I look to my faith as a source of comfort.

_____ 10. My faith impacts many of my decisions.

Appendix C: DRI

Directions: Please answer the following questions about your religious beliefs and/or involvement. Please indicate your answer with a checkmark.

(1) How often do you attend church or other religious meetings?

1. More than once/wk

2. Once a week

3. A few times a month

4. A few time a year

5. Once a year or less

6. Never

(2) How often do you spend time in private religious activities, such as prayer, meditation or Bible study?

1. More than once a day

2. Daily

3. Two or more times/week

4. Once a week

5. A few times a month

6. Rarely or never

The following section contains 3 statements about religious belief or experience. Please mark the extent to which each statement is true or not true for you.

(3) In my life, I experience the presence of the Divine (i.e., God).

1. Definitely true of me

2. Tends to be true

3. Unsure

4. Tends not to be true 96

5. Definitely not true

(4) My religious beliefs are what really lie behind my whole approach to life.

1. Definitely true of me

2. Tends to be true

3. Unsure

4. Tends not to be true

5. Definitely not true

(5) I try hard to carry my religion over into all other dealings in life.

1. Definitely true of me

2. Tends to be true

3. Unsure

4. Tends not to be true

5. Definitely not true

Appendix D: TAFS

Please read each statement and respond by providing the appropriate number to the left of each item using the scale below. 0 1 2 3 4 disagree strongly disagree neutral agree agree strongly

___ 1. Thinking of making an extremely critical remark to a friend is almost as unacceptable to me as actually saying it. ___ 2. Having a blasphemous thought is almost as sinful to me as a blasphemous action. ___ 3. Thinking about swearing at someone else is almost as unacceptable to me as actually swearing. ___ 4. When I have a nasty thought about someone else, it is almost as bad as carrying out a nasty action. ___ 5. Having violent thoughts is almost as unacceptable to me as violent acts. ___ 6. When I think about making an obscene remark or gesture in church, it is almost as sinful as actually doing it. ___ 7. If I wish harm on someone, it is almost as bad as doing harm. ___ 8. If I think about making an obscene gesture to someone else, it is almost as bad as doing it. ___ 9. When I think unkindly about a friend, it is almost as disloyal as doing an unkind act. ___10. If I have a jealous thought, it is almost the same as making a jealous remark. ___ 11. Thinking of cheating in a personal relationship is almost as immoral to me as actually cheating. ___ 12. Having obscene thoughts in a church is unacceptable to me.

TAF-LO ___ 1. If I think of a relative/friend losing their job, this increases the risk that they will lose their job. ___ 2. If I think of a relative/friend being in a car accident, this increases the risk that he/she will have a car accident. ___ 3. If I think of a friend/relative being injured in a fall, this increases the risk that he/she will have a fall and be injured. ___ 4. If I think of a relative/friend falling ill this increases the risk that he/she will fall ill.

TAF-LS ___ 1. If I think of myself being injured in a fall, this increases the risk that I will have a fall and be injured. ___ 2. If I think of myself being in a car accident, this increases the risk that I will have a car accident. ___ 3. If I think of myself falling ill, this increases the risk that I will fall ill.

Appendix E: WBSI

This survey is about thoughts. There are no right or wrong answers, so please respond honestly to each of the items below. Be sure to answer every item by circling the appropriate number beside each.

1 2 3 4 5 Strongly disagree Disagree Neutral Agree Strongly agree

1 2 3 4 5 1. There are things I prefer not to think about.

1 2 3 4 5 2. Sometimes I wonder why I have the thoughts I do.

1 2 3 4 5 3. I have thoughts that I cannot stop.

1 2 3 4 5 4. There are images that come to mind that I cannot erase.

1 2 3 4 5 5. My thoughts frequently return to one idea.

1 2 3 4 5 6. I wish I could stop thinking of certain things.

1 2 3 4 5 7. Sometimes my mind races so fast I wish I could stop it.

1 2 3 4 5 8. I always try to put problems out of mind.

1 2 3 4 5 9. There are thoughts that keep jumping into my head.

1 2 3 4 5 10. There are things that I try not to think about.

1 2 3 4 5 11. Sometimes I really wish I could stop thinking.

1 2 3 4 5 12. I often do things to distract myself from my thoughts.

1 2 3 4 5 13. I have thoughts that I try to avoid.

1 2 3 4 5 14. There are many thoughts that I have that I don’t tell anyone.

1 2 3 4 5 15. Sometimes I stay busy just to keep thoughts from intruding on my mind.

Appendix F: AAQ-II

Below you will find a list of statements. Please rate how true each statement is for you by circling a number next to it. Use the scale below to make your choice.

1 2 3 4 5 6 7 Never Very seldom Seldom Sometimes Frequently Almost Always true true true true true always true true

It’s OK if I remember something unpleasant. 1 2 3 4 5 6 7

My painful experiences and memories make it difficult for me to live a life that I would value. 1 2 3 4 5 6 7

I’m afraid of my feelings. 1 2 3 4 5 6 7

I worry about not being able to control my worries and feelings. 1 2 3 4 5 6 7

My painful memories prevent me from having a fulfilling life. 1 2 3 4 5 6 7

I am in control of my life. 1 2 3 4 5 6 7

Emotions cause problems in my life 1 2 3 4 5 6 7

It seems like most people are handling their lives better than I am. 1 2 3 4 5 6 7

Worries get in the way of my success. 1 2 3 4 5 6 7

My thoughts and feelings do not get in the way of how I want to live my life. 1 2 3 4 5 6 7

100

Appendix G: PI-WSUR

The following statements refer to thoughts and behaviors which may occur to everyone in everyday life. For each statement, circle the reply which best seems to fit you and the degree of disturbance which such thoughts or behaviors may create.

Not A Quit A Very at all littl e lot much e a lot 1 I feel my hands are dirty when I touch money. 0 1 2 3 4 2 I think even the slightest contact with bodily secretions (perspiration, saliva, 0 1 2 3 4 urine, etc.) may contaminate my clothes or somehow harm me. 3 I find it difficult to touch an object when I know it has been touched by 0 1 2 3 4 strangers or by certain people. 4 I find it difficult to touch garbage or dirty things. 0 1 2 3 4 5 I avoid using public toilets because I am afraid of disease and contamination. 0 1 2 3 4 6 I avoid using public telephones because I am afraid of contamination and 0 1 2 3 4 disease. 7 I wash my hands more often and longer than necessary. 0 1 2 3 4 8 I sometimes have to wash or clean myself simply because I think I may be dirty 0 1 2 3 4 or “contaminated”. 9 If I touch something I think is “contaminated”, I immediately have to wash or 0 1 2 3 4 clean myself. 10 If an animal touches me, I feel dirty and immediately have to wash myself or 0 1 2 3 4 change my clothing. 11 I feel obliged to follow a particular order in dressing, undressing, and washing 0 1 2 3 4 myself. 12 Before going to sleep, I have to do certain things in a certain order. 0 1 2 3 4 13 Before going to bed, I have to hang up or fold my clothes in a special way. 0 1 2 3 4 14 I have to do things several times before I think they are properly done. 0 1 2 3 4 15 I tend to keep on checking things more often than necessary. 0 1 2 3 4 16 I check and recheck gas and water taps and light switches after turning them 0 1 2 3 4 off. 17 I return home to check doors, windows, drawers, etc., to make sure they are 0 1 2 3 4 properly shut. 18 I keep checking forms, documents, checks, etc., in detail to make sure I have 0 1 2 3 4 filled them in correctly. 19 I keep on going back to see that matches, cigarettes, etc., are properly 0 1 2 3 4 extinguished. 20 When I handle money, I count and recount it several times. 0 1 2 3 4 21 I check letters carefully many times before posting them. 0 1 2 3 4 22 Sometimes I am not sure I have done things which in fact I knew I have done. 0 1 2 3 4 23 When I read, I have the impression I have missed something important and 0 1 2 3 4 must go back and reread the passage at least two or three times. 24 I imagine catastrophic consequences as a result of absent-mindedness or minor 0 1 2 3 4 errors which I make. 25 I think or worry at length about having hurt someone without knowing it. 0 1 2 3 4 26 When I hear about a disaster, I think it is somehow my fault. 0 1 2 3 4 27 I sometimes worry at length for no reason that I have hurt myself or have some 0 1 2 3 4 disease. 28 I get upset and worried at the sight of knives, daggers, and other pointed 0 1 2 3 4 objects. 29 When I hear about a suicide or crime, I am upset for a long time and find it 0 1 2 3 4 difficult to stop thinking about it. 30 I invent useless worries about germs and disease. 0 1 2 3 4 31 When I look down from a bridge or a very high window, I feel an impulse to 0 1 2 3 4 throw myself into space. 32 When I see a train approaching, I sometimes think I could throw myself under 0 1 2 3 4 its wheels. 33 At certain moments, I am tempted to tear off my clothes in public. 0 1 2 3 4 34 While driving, I sometimes feel an impulse to drive the car into someone or 0 1 2 3 4 101

something. 35 Seeing weapons excites me and makes me think violent thoughts. 0 1 2 3 4 36 I sometimes feel the need to break or damage things for no reason. 0 1 2 3 4 37 I sometimes have an impulse to steal other people’s belongings, even if they 0 1 2 3 4 are of no use to me. 38 I am sometimes almost irresistibly tempted to steal something from the 0 1 2 3 4 supermarket. 39 I sometimes have an impulse to hurt defenseless children or animals. 0 1 2 3 4

102

Appendix H: PIOS

Instructions: The following statements refer to experiences that people sometimes have. Please indicate how often you have these experiences using the following key: 0=never; 1=almost never; 2=sometimes; 3=often; 4=constantly.

____ 1. I worry that I might have dishonest thoughts

____ 2. I fear that I might be an evil person

____ 3. I fear I will act immorally

____ 4. I feel urges to confess sins over and over again

____ 5. I worry about heaven and hell

____ 6. I worry I must act morally at all times or I will be punished

____ 7. Feeling guilty interferes with my ability to enjoy things I would like to enjoy

____ 8. Immoral thoughts come into my head and I can’t get rid of them

____ 9. I am afraid my behavior is unacceptable to God

____ 10. I fear I have acted inappropriately without realizing it

____ 11. I must try hard to avoid having certain immoral thoughts

____ 12. I am very worried that things I did may have been dishonest

____ 13. I am afraid I will disobey God’s rules/laws

____ 14. I am afraid of having sexual thoughts

____ 15. I worry I will never have a good relationship with God

____ 16. I feel guilty about immoral thoughts I have had

____ 17. I worry that God is upset with me

____ 18. I am afraid of having immoral thoughts

____ 19. I am afraid my thoughts are unacceptable to God

103

Appendix I: PANAS

This scale consists of a number of words that describe different feelings and emotions. Read each item and then mark the appropriate answer in the space next to that word. Indicate to what extent you feel this way right now, that is, at the present moment. Use the following scale to record your answers.

1 2 3 4 5 very slightly a little moderately quite a bit extremely or not at all

_____ interested _____ irritable _____ distressed _____ alert _____ excited _____ ashamed _____ upset _____ inspired _____ strong _____ nervous _____ guilty _____ determined _____ scared _____ attentive _____ hostile _____ jittery _____ enthusiastic _____ active _____ proud _____ afraid

104

Appendix J: Appraisal Ratings

Please place a vertical mark on the lines to answer the questions below.

1. How anxious/distressed do you feel right now?

Not at all Extremely

0 50 100

2. How much guilt do you feel right now?

Not at all Extremely

0 50 100

3. How hard did you try to not think about the car accident?

Not at all Extremely

0 50 100

4. How morally wrong was it to think about the car accident?

Not at all Extremely

0 50 100

5. How much control do you feel you have over the car accident occurring?

Not at all Extremely

0 50 100

6. What is the likelihood of the car accident occurring in the next 24 hours?

Not at all Extremely

0 50 100

7. How strong is your urge to do something to reduce or cancel the effects of thinking about the car accident?

Not at all Extremely

0 50 100

8. How willing are you to further think about the car accident?

Not at all Extremely

0 100

105

Appendix K: Intrusive Thought Induction Check

Please place a vertical mark on the lines to answer the questions below.

1. How vivid were the thoughts and images of the car accident?

0% 100%

2. How severe of a car accident did you imagine??

Not at all Extremely

0 50 100

3. How much effort did you put forth in attempting to visualize the car accident?

Not at all Extremely

0 50 100

4. What was your level of engagement with your thoughts and images of the car accident?

Not at all Extremely

0 50 100

5. How believable was the car accident?

Not at all Extremely

0 50 100

106

Appendix L: Coping Strategy Manipulation Check

Please place a vertical mark on the lines to answer the questions below.

Suppression Group Time Period 1

How hard did you try to suppress thoughts and images of the car accident?

Not at all Extremely

0 50 100

Acceptance Group Time Period 1

How hard did you try to watch your thoughts and images of the car accident without arguing with them or trying to make them go away?

Not at all Extremely

0 50 100

Monitor-Only Group Time Period 1

How hard did you try to think about anything you wanted to?

Not at all Extremely

0 50 100

All Groups Time Period 2

How hard did you try to think about anything you wanted to?

Not at all Extremely

0 50 100

All Groups Both Time Periods

How hard did you try to not think about the car accident?

Not at all Extremely

0 50 100

107

Appendix M: Selection of Target Individual Form

1. Please write down the name of a person whom you feel close to in the space provided. This person could be a friend, parent, significant other, relative, or any other loved one: ______

2. Please circle the response that best describes the nature of your relationship with this person (i.e., this person is my … parent, friend, etc):

Parent Sibling Relative outside immediate family (e.g., grandparent, cousin, aunt, uncle) Husband/Wife Boyfriend/girlfriend Child Friend Other (please specify):______

3. Please place a vertical mark on the line to answer the following question:

How close would you rate your relationship with this person?

Not at all Extremely

0 50 100

108

Appendix N: Sentence Copy Form

Please read the following statement and fill in the blank with the name of a living person close to you. Then copy the completed sentence in the space provided below.

I hope ______will soon be in a car accident.

______.

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

Thesis and Dissertation Services ! !