Journal of Behavior Therapy and Experimental Psychiatry 78 (2023) 101773

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Journal of Behavior Therapy and Experimental Psychiatry

journal homepage: www.elsevier.com/locate/jbtep

Dr. Jack Rachman’s contributions to our understanding and treatment of

obsessive-compulsive disorder
Christine Purdon
Department of Psychology, University of Waterloo, Waterloo, ON, N2L 3G1, Belgium

A R T I C L E I N F O A B S T R A C T

Keywords: Background and objectives: This paper reviews the development of the cognitive-behavioural model of obsessive-
OCD compulsive disorder (OCD) through the work of Dr. Jack Rachman and the research his ideas inspired or shaped.
Obsessions Methods: A narrative review of Rachman’s work and important developments in related areas was conducted.
Compulsions
Results: Rachman was highly responsive to theoretical and empirical developments in the field, and continuously
Cognitive behaviour therapy
developed his model of OCD over the course of his career. Key developments in his thinking and of those in
related areas are described.
Limitations: This is a narrative review that highlights important developments in the cognitive behavioural model
of OCD only.
Conclusions: The CBT model of OCD has strong empirical support and CBT treatment is the most effective psy­
chotherapy. Continued development in our understanding of attachment and in the persistence of compulsions is
warranted.

1. The internal logic of OCD: A review
Until recently, obsessive-compulsive disorder (OCD) was identified
by the World Health Organization as one of the top ten leading causes of
disability worldwide (Murray, 1996), even though its lifetime preva­
lence rate is low, at 1% in men and 1.6% in women (Fawcett, Power, &
Fawcett, 2020). The behaviour of people with OCD is often inscrutable
to non-sufferers. Highly educated people doubt they have read a para­
graph properly, kind and gentle people fear they will grievously harm
others, loving parents refuse to hug their children, otherwise rational
people cannot function if their socks are uneven, and otherwise sensible
people cannot drive a short distance without repeatedly going back to
check that they haven’t hit someone without realizing it. Many historical
figures, famous for their genius, are thought to have suffered from OCD,
such as Samuel Johnson, who was unable to walk down the street
without touching each post along the way (Boswell, 1986). Even more
perplexingly, most people with OCD are aware of the irrationality of
their thinking and behaviour, which itself is a source of distress (Rach­
man & Hodgson, 1980).
Dr. Jack Rachman devoted a good deal of his career to the systematic
study of obsessions and compulsions. Although Rachman gives credit to
Aaron Beck for marrying behavioural and cognitive therapies (Rach­
man, 2015), he implicated cognition as a key factor in the development
and persistence of OCD in his early theoretical papers. Rachman (1971)
argued that the development of a comprehensive psychological theory
of clinical obsessions must rest on the assumption of some degree of
continuity with normal, nonclinical phenomena. Rachman and de Silva
(1978) examined the nature and content of unwanted intrusive thoughts
in people without OCD and obsessions in people with OCD, observing
that most people experience thoughts that are obsession-like in nature,
the difference between clinical obsessions and nonclinical obsession-like
thoughts being one of degree rather than kind. Whereas most people are
able to ignore or dismiss such thoughts, some find them very distressing
(Rachman, 1971, 1976b; Rachman & Hodgson, 1980). He argued that
individual differences in the experience of these normal thoughts may
have roots in pre-dispositional factors, such as neuroticism, and in
particular family environments. Parents who are over-protective may
foster fearfulness in a child with pre-disposing factors, which may result
in the child resorting to excessive cleaning as a means of restoring safety
and avoiding punishment. Parents who are overly critical may foster a
meticulousness in their child that results in excessive checking to avoid
errors and, again, punishment (Rachman, 1976b).
Rachman further observed that excessive checking will only occur
when the person feels that they will be held responsible by others for
causing harm and therefore will be open to criticism. Thus, compulsions
are done not simply to accomplish a simple proximal goal (“get my

E-mail address: Christine.purdon@uwaterloo.ca.

https://doi.org/10.1016/j.jbtep.2022.101773
Received 22 June 2022; Accepted 9 August 2022
Available online 9 September 2022
0005-7916/© 2022 Elsevier Ltd. All rights reserved.
C. Purdon
hands clean”) but to avoid criticism and punishment. People prone to
OCD are more likely to perceive that the obsession will cause harm if left
unaltered, will experience distress and concomitant physiological
arousal, and sense that some action must be taken to pre-empt potential
harm (Rachman, 1976a, b). Finally, negative mood state will decrease
control over obsessions, making them difficult to dismiss and increasing
their duration (Rachman, 1971, 1976a).
Distress reduction is thus achieved through some form of restorative,
preventative, or reassurance seeking act, otherwise known as “neutral­
izing” or compulsions. The temporary reduction in distress afforded by
the neutralizing act has two important effects. First, it serves as negative
reinforcement for the expression of the disturbing thought, which in
turn increases the frequency of thought occurrences. Second, perfor­
mance of the neutralizing act immediately captures attention, thereby
shifting attention from the obsession and terminating exposure to it.
Continued performance of the neutralizing act in response to the
obsession ensures that habituation cannot occur. In fact, Rachman
(1976a) argued that brief exposure results in incubation of the anxiety in
much the same manner as brief exposure to a phobic stimulus incubates
the fear. Thus, the neutralizing act is retained by the individual as an
effective, albeit temporary, means of reducing anxiety. Further re­
currences of the distressing intrusion lead to a sense of helplessness and
enhance feelings of depression, which also increase thought frequency.
Rachman (1976a) recommended exposure to the obsession while
performance of the compulsion is prevented. This serves three purposes.
First, it breaks the link between the obsession and the compulsive act.
Second, forced exposure allows the individual to habituate to the
thought. This in turn reduces the fear, shame and guilt evoked by the
thought and ultimately strips it of its personal meaning. Third, by
learning to form the thought on demand the individual’s sense of control
over her/his thinking processes is restored. This alleviates helplessness
and subsequent dysphoria (Rachman, 1971, 1976a; Rachman & Hodg­
son, 1980). Thus, Rachman explicitly stated that a key benefit of a
behavioural intervention is new learning about the original appraisal of
the obsession.
1.1. Early elaborations of the model
Salkovskis’ (1985, 1989) seminal cognitive-behavioural model of
OCD took its lead from Rachman’s work. Salkovskis (1985, 1989, 1999;
Salkovskis, Richards, & Forrester, 1995) observed that people with OCD
tend to hold overvalued core beliefs about responsibility for harm, such
as “Failing to prevent (or failing to try to prevent) harm to self or others
is the same as having caused the harm in the first place,” “Responsibility
is not attenuated by other factors (e.g., low probability of occurrence),”
and, “Not neutralizing when an intrusion has occurred is similar or
equivalent to seeking or wanting the harm involved in that intrusion to
happen” (Salkovskis, 1985, p. 579). When an obsessional thought oc­
curs, beliefs about responsibility will evoke appraisal such as “It would
be immoral for me to ignore this thought”, “I must be 100% certain that
X will not happen before it is moral to go on to other things”, and “I must
stop and deal with this NOW, before anything else”.
Elaborating on Rachman (1976b), Salkovskis (1985, 1989) argued
that people with OCD are not as concerned about harm so much as being
responsible for harm; there is little anxiety if someone else is locking up
the house, even if they believe the probability of harm is the same.
Compulsions are thus done to avoid being responsible for harm. The
compulsion reduces distress and prevents new learning about the
appraisal of the obsession, as the non-occurrence of harm is attributed to
having neutralized. Salkovskis also identified other ways people evade
being responsible for harm, including seeking reassurance that harm has
not occurred and sharing responsibility for the potential harm by telling
others about the possibility of harm. A central development here is the
idea that contextual factors determine whether a safety behaviour such
as washing or checking, will be enacted. That is, the problem in OCD is
not that there is a general deficit responsible for compulsion persistence,
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Journal of Behavior Therapy and Experimental Psychiatry 78 (2023) 101773
such as memory or cognitive problems, but rather that the compulsion
has functionality under particular circumstances.
Meanwhile, Rachman and colleagues identified a type of appraisal
they labelled “thought-action fusion”. Rachman (1993, 1997; Rachman,
Thordarson, Shafran, & Woody, 1995) observed that in addition to be­
liefs about responsibility people with OCD are more likely to believe that
the more one has an unacceptable thought the more likely the negative
event represented in the thought is of coming true, and that having a
morally repugnant thought is the moral equivalent to committing a
morally repugnant deed. This sense of “thought action fusion” also
manifests in beliefs that “Obsessional thoughts indicate something sig­
nificant about oneself (e.g., that one is terrible, weird, abnormal)” and
“Negative intrusive thoughts must be important merely because they
have occurred” (Thordarson & Shafran, 2002 p. 15). Other examples
include: “This thought reflects my true evil nature,” “Having this
thought means I am a bad person,” “If I think this, I must really want it to
happen,” “Thinking this can make the event more likely to happen,” “If
others knew I thought this, they would think I am an evil person,” and
“Having this thought means I am likely to lose control over my mind or
my behaviour” (Rachman, 1997, p. 793). Rachman summarized this
development in the model very succinctly: the problem in OCD is a
“catastrophic misinterpretation of obsessions”.
Rachman (1994, 2004) also observed that people can experience a
feeling of contamination in the absence of physical contact which they
attempt to rectify by repeated washing. Rachman termed this “mental
pollution”. Mental pollution can arise as a result of repugnant images
and memories, receiving a nasty insult, unwanted physical contact, ac­
cusations, betrayal, and humiliations. He argued that because the source
of the contamination is another person rather than a substance, and that
the feeling is internal, symptoms will be less responsive to ERP. Mental
contamination can be evoked in the lab by having participants imagine a
non-consensual kiss, which evokes an urge to clean (e.g., Elliott &
Radomsky, 2009a, 2009b; 2012) . Rachman and his colleagues devel­
oped a manual for treatment of mental contamination that addresses
beliefs about the meaning and interpretation of the sources of contam­
ination, misinterpretations of the significance of the feelings of
contamination, and separating feelings of anger, aversion, and disgust
from mental contamination. In a case series Coughtrey, Shafran, and Lee
(2013) reported good treatment response.
Rachman (1998) continued to develop his theory of obsessions. In
this elaboration, he observed that the content of obsessions tends to
reflect moral systems. Thoughts inconsistent with moral systems will be
experienced as especially salient and distressing. The person fears they
are mad, bad, or dangerous, and capable of causing harm. They also start
to view the obsession as potentiating that loss of control or as a pre­
monition of loss of control (or, thought-action fusion). The compulsion is
an essential means of preventing this loss of control. Rachman also
suggested that attempts to suppress thoughts lead to a rebound in
thought recurrences, which will be taken as further evidence of the
thoughts’ importance.
In addition to mental avoidance of obsessions people will avoid
thoughts and thought triggers, which can generalize rapidly (e.g.,
avoidance of blood can generalize to avoidance of anything red). In
terms of treatment, he again advocates for CBT, targeting beliefs about
responsibility, about one’s potential to lose control and behave in
harmful ways, and that extreme caution is thus a moral imperative. He
also recommended starting treatment with psychoeducation, empha­
sizing that obsessions are on a continuum with normal thoughts, and
about how compulsions and avoidance maintain OCD.
1.2. Appraisal of unwanted intrusive thoughts/obsessions
The models proposed by Rachman and by Salkovskis were based on
the assumption that obsessions have their roots in unwanted intrusive
thoughts. Since Rachman and de Silva’s (1978) initial study, there is a
wealth of empirical evidence which suggests that most people report
C. Purdon
having thoughts that are obsessional in nature, the difference being in
frequency, intensity, and appraisal (Freeston, Ladouceur, Thibodeau, &
Gagnon, 1991, 1992; Freeston & Ladouceur, 1993; Freeston, Ladouceur,
Gagnon, & Thibodeau, 1993; Purdon & Clark, 1993, 1994b). Together,
this work generated substantial interest in the identification of the types
of negative appraisal of and beliefs about obsessional thoughts that
cause OCD to develop and persist; if the obsession can be de-toxified by
addressing the negative appraisal, the compulsion will become obsolete.
The Obsessive-Compulsive Cognitions Working Group (OCCWG) was
a large international group of researchers who formed to collaboratively
identify and define negative appraisal in OCD, and develop a common
means of assessing them. In addition to beliefs/appraisals of re­
sponsibility and thought-action fusion, this group identified beliefs/
appraisal of mental control (“If I exercise enough willpower, I should be
able to gain complete control over my mind,”), overestimation of threat/
intolerance of uncertainty (“Bad things are more likely to happen to me
than to other people”, “If I’m not absolutely sure of something, I’m
bound to make a mistake”), and perfectionism (“If I fail at something
then I am a failure as a person”). The OCCWG created a measure of
situational appraisal of obsessions (the Interpretation of Intrusions In­
ventory; III, OCCWG, 2001) and general beliefs about obsessional
thoughts (the Obsessive Beliefs Questionnaire; OBQ; OCCWG, 2001).
Research on the appraisal of obsessions proliferated, yielding ample
evidence that the beliefs and appraisal identified by the OCCWG are
associated with OCD symptoms (e.g., Wheaton, Abramowitz, Berman,
Riemann, & Hale, 2010), that the appraisal/beliefs have a direct impact
on urge to do compulsions (e.g., Haciomeroglu, 2020; Lopatka &
Rachman, 1995; Parrish & Radomsky, 2006) and that these beliefs
change as a function of successful treatment (e.g., Radomsky et al.,
2020; Wheaton et al., 2010), although it is important to note that these
beliefs and appraisals have not always been found to be specific to OCD
(e.g., Pozza & Dèttore, 2014). Cognitive behaviour therapy targeting
obsessions specifically was found to be efficacious (Freeston et al., 1997)
and cognitive therapy alone was found to be just as effective as exposure
with response prevention alone (e.g., McLean et al., 2001). The treat­
ment of choice for OCD became CBT or ERP, with or without medication.
1.3. The persistence of compulsions
In leading protocols both CBT and ERP focus on distress over the
obsession. In another critical development, Rachman turned his atten­
tion to the persistence of compulsions, articulating a cognitive (rather
than behavioural) model for the persistence of checking compulsions,
both within and across episodes. Rachman (2002) proposed that
“compulsive checking occurs when people who believe that they have a
special, elevated responsibility for preventing harm, mainly to others,
are unsure that the perceived threat has been reduced or removed” (p.
625). He identified three factors, or, “multipliers” that will influence the
duration and intensity of the checking compulsion, and are in fact
self-perpetuating mechanisms: increased responsibility, increased esti­
mates of the probability of harm, and increased estimates of the severity
of harm. These factors also interact; people with OCD are more likely to
believe that harm is more probable if they are responsible for stopping it,
and responsibility for preventing that harm increases the more they
check.
Rachman observed that people with OCD view themselves as having
a poor memory for whether they checked something properly, yet have
no deficits in memory in other, unrelated domains. Furthermore, con­
cerns about memory vary according to situational circumstances, such
as level of responsibility for harm (e.g., Radomsky & Rachman, 1999;
Radomsky, Rachman, & Hammond, 2001). He argued that checking
degrades, rather than improves, memory for the check, and across epi­
sodes this state lack of confidence will feed into a stable idea of oneself
as having poor memory, which in turn may evoke greater repetition in
situ. The reason memory confidence degrades is that checking is done in
a state of anxious arousal, which focuses attention on threat at the
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Journal of Behavior Therapy and Experimental Psychiatry 78 (2023) 101773
expense of details of the check. However, people demand of themselves
a clear, perceptual memory for the check. That their memory cannot
produce what they demand of it is also taken as evidence of incompe­
tence. Rachman’s model implicates overvalued responsibility and
appraisal of memory as key factors in the persistence of compulsions. He
noted that overvalued responsibility is less likely to be attenuated by
ERP, and again advocated for CBT as the first line intervention over ERP
alone.
Rachman’s model features several important developments. First,
although OCD has traditionally been referred to as the “doubting dis­
ease” this is one of the few models that explicitly invokes doubt as a key
element in the persistence of compulsions. Second, this model identifies
self-perpetuating factors in checking compulsions, thereby introducing
the idea that once they start factors other than the immediate appraisal
of and distress over the obsession may be in play. Third, Rachman has
helped us understand why people with OCD think of themselves as
having a poor memory. Fourth, he observed that checking is likely to be
associated with reassurance seeking as it is a form of checking (i.e.,
“checking-by-proxy”), meaning it needs to be targeted in treatment.
Finally, his model explains why checking compulsions do not reliably
yield a reduction in distress. The model is a substantial elaboration from
the two-factor theory of compulsions, which understands their persis­
tence as due to negative reinforcement from distress reduction.
Radomsky, Shafran, and Coughtrey (2010) presented an overview of
treatment geared specifically at OCD characterized by compulsive
checking.
Rachman’s observations that a) there is no terminus for the checking
behaviour and, b) people doubt whether the compulsion was done
properly were pivotal. Although he focused on checking compulsions
the first observation applies to any compulsion done to undo or prevent
harm, and the second to all compulsions, from whether one’s towels are
perfectly aligned to whether one has caused death. Radomsky and col­
leagues did an elegant series of studies on compulsions and memory
confidence. Radomsky and Rachman (1999) found that people with
OCD with contamination fears had superior memory for objects that
were “contaminated” than for neutral objects, which was not observed
in their sample of people without OCD. In two studies Radomsky, Dugas,
Alcolado, and Lavoie (2014) found that repetition degraded memory
confidence, vividness, and detail, as well as memory accuracy, but only
when participants were checking to prevent harm.
The ironic effect of repetition on memory, sensory, and cognitive
confidence has now been widely observed, and in a recent meta-
analysis, van den Hout and colleagues found a large effect size for the
influence of repetition on confidence (van den Hout, van Dis, van
Woudenberg, & van de Groep, 2019). Other researchers have found
repetition of checking behaviour to be associated with decreased con­
fidence in attentional processes and sensory perception (e.g., Hermans,
Martens, DeCort, Pieters, & Eelen, 2003; Hermans et al., 2008),
including in people with OCD, conducting their compulsions in vivo,
rather than in the lab (Bouvard, Fournet, Denis, Achachi, & Purdon,
2020; Bucarelli & Purdon, 2015; Dean & Purdon, 2021b). Inducing
memory distrust has been found to result in greater checking (Alcolado
& Radomsky, 2011). Drawing from research on how we process stimuli,
van den Hout and Kindt (2003) suggested that as we repeat an action, we
move from processing it perceptually to processing it semantically, or,
conceptually, and indeed conceptual processing inhibits perceptual
processing. This is the reason we can drive a well travelled route and
arrive at our destination without recalling the drive. However, the
person with OCD demands of themselves a vivid perceptual memory of
the compulsion.
Rachman’s model raises important questions about how people
know when to stop their compulsions (that is, their “stop rules”). In an
elaboration of his CBT model of OCD, Salkovskis (1999) observed that
when we perceive the stakes of a decision to be high (e.g., which house
to buy) we require more evidence that the decision is correct before
taking it than we do for small decisions (e.g., what to pack for lunch). In
C. Purdon
OCD the decision of when to stop will typically be viewed as high stake,
and thus people rely on a wider range of criteria to take the decision to
stop their compulsions. Salkovskis also observed that in the absence of
objective information that the behaviour has been done properly people
are more likely to rely on an internal, felt sense that it is okay to stop.
Wahl, Salkovskis, and Cotter (2008) used interview, self-report, and
in vivo observation to study stop rules in people with OCD who had
washing compulsions. They compared this sample to a sample of people
with OCD without washing compulsions and to a group of healthy
controls. They found that people with washing compulsions were unique
in reporting a greater reliance on internal criteria than the other groups
across all three assessment modalities. The two groups of participants
with OCD relied on more evidence to make the decision to stop, the
perceived importance of the decision was associated with elevated evi­
dence requirements, and the decision making was considered more
effortful. These findings were replicated by Salkovskis, Millar, Gregory,
and Wahl (2017).
The idea compulsions persist because there is no terminus for the
behaviour is highly engaging. Several models for compulsion persistence
have emerged which centre on the notion that it is impossible to prove a
null hypothesis and/or establish the state of something with perfect
certainty. O’Connor and Robillard (1995) argued that OCD is a state of
mind characterized by inferential confusion, in which people confuse
imagined possibilities with actual probabilities (e.g., “Another table like
this was dirty, therefore this table is dirty until I can prove with certainty
it is not”). This model has empirical support (e.g., Aadrdema, O’Connor,
& Emmelkamp, 2006; Wu, Aardema, & O’Connor, 2009). Szechtman
and Woody (2004) viewed OCD as a disturbance of security motivation.
They start with the observation that we have a system which is dedicated
to the evaluation of potential threat. The system is quick to gear up and
slow to wind down in the absence of a certain cue for safety. It is
impossible to know for certain that a threat has passed (e.g., germs are
invisible) so in the absence of a clear and salient cue for safety, people
rely on an internal feeling of knowing, or, “yedasentience” to decide
when to stop the safety behaviour. The problem in OCD is that people
are unable to achieve this feeling of knowing. Thus, OCD is a problem
with stopping, rather than starting. This model too has been supported
empirically (e.g., Hinds, Woody, Van Ameringen, Schmidt, & Szecht­
man, 2012).
Dar, Lazarov, and Liberman (2021) proposed that people with OCD
have attenuated access to their internal states, such as emotions, phys­
iological arousal, motivations, wishes, and memories. When they
encounter a question about an internal state, such as “Did I read that
correctly?” people with OCD are less able to answer with confidence.
They then either repeat an action in an attempt to access that internal
state or rely on an external proxy, such as rules (e.g., “I read it three
times so I must know it”). These propositions have empirical support (e.
g., Dar et al., 2019). De Haan, Rietveld, and Denys (2011) observed that
to feel certain we need to have trust in foundational knowledge. If we are
asked whether it is cloudy outside, to answer with confidence we need to
trust that our senses are relaying information accurately and that the
puffy grey shapes in the sky are clouds. We can generate infinite, and
increasingly fantastical reasons as to why something might not be true
(e.g., “maybe those shapes are UFOs”). de Haan et al. (2013) argued that
people with OCD lack the capacity to trust even the most implicit
knowledge. Collectively, these models assert that a central problem in
OCD is that people are unable to obtain desirable internal states and/or
trust their own judgement about the state of the world or their internal
states.
Purdon (2018) provided a descriptive model of the persistence of
compulsions meant to pull together these related, but separate areas of
research. Compulsion persistence starts with the occurrence of the
obsession, which is appraised as requiring immediate action, resulting in
a compulsion. However, if the person enters into the compulsion with a
high need for certainty, overestimation of the probability and severity of
harm, poor confidence in their memory, sensory, and cognitive
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Journal of Behavior Therapy and Experimental Psychiatry 78 (2023) 101773
processes, and is oriented to remote possibilities as to why the
compulsion may not have been done properly, they are prone to doubt
whether they did it properly and/or fail to feel satisfied it is okay to
move on. They then repeat, but now pay attention to specific details that
were missing from their recollection of the action or aspects of the
compulsion they think they got “wrong” the previous time. This will
come at the expense of attending to other details. They may parse the
behaviour into small actions, trying to get each one correct, and they
may rely on even more criteria to decide when to stop. This taxes
working memory, which can produce doubt. The compulsion may be
repeated, which increases the sense of responsibility for getting it done
properly and may result in conceptual, rather than perceptual, pro­
cessing of the action, which produces doubt.
1.4. Origins of negative appraisal
The CBT model of OCD pivots on negative appraisal of obsessions,
and many researchers have been concerned with the origins of that
appraisal. The two areas of focus have been on the relationship of ob­
sessions to the sense of self and on critical parenting and attachment.
1.5. Obsessions and the self
Rachman observed that obsessions tend to reflect moral themes,
thereby connecting obsessional content with the self. Clark and Purdon
(1993) argued that people with OCD may have fewer domains by which
they define themselves (e.g., being a moral person, being a caring per­
son, being a responsible person). Thoughts that contradict these do­
mains (e.g., the thought that you may have caused harm) thus
compromise self-worth to a larger degree than they might in other
people and are appraised as signalling urgent harm, which evokes at­
tempts to repair potential damage and compensate for the failings the
thought is perceived to reflect. Purdon and Clark (1999) further pro­
posed that thoughts that threaten the self view are internal threat stimuli
which will receive priority in attentional processing. Whereas most
people will then assimilate the thought into the self-view (“even a per­
son like me can have a thought like this”), those vulnerable to OCD
accommodate the thought by altering their self view (“maybe I am a
homicidal maniac at heart!”), resulting in the need for compensatory
action, including vigilance for the thought, avoidance of thoughts and
thought triggers, and compulsions. Rowa and Purdon (2003) compared
people’s most and least distressing unwanted intrusive thoughts, finding
that the former contradicted important values to a greater degree. Rowa,
Purdon, Summerfeldt, and Antony (2005) interviewed people with OCD
about their most and least upsetting obsessions, finding that the former
were evaluated as more meaningful or significant, contradicted valued
aspects of the self to a greater degree, and were more likely to be rele­
vant to current concerns (e.g., being a good parent).
Bhar and Kyrios (2007) proposed that people with OCD are ambiv­
alent about their self-worth, morality, and loveability. Unwanted
intrusive thoughts relevant to those areas will be experienced as threats
and compulsions are attempts to preserve self-worth. Aardema and
colleagues (Aardema et al., 2013) proposed that people with OCD have a
feared self; that is, they fear they might be someone they do not wish to
be, such as a person who harms, or is careless, etc. Aardema and Wong
(2020) proposed that OCD develops when people are not able to resolve
their identity (e.g., “I may be a bad person”), are prone to self-distrust,
and are highly sensitive to unseen possibilities. Under these conditions
they become hypervigilant for information relevant to this open ques­
tion, respond to relevant unwanted intrusive thoughts with fear, and use
compulsions to mitigate their feared self. Fear of self appears to be
characteristic of people with OCD who had repugnant obsessions (Aar­
dema, Moulding, Radomsky, Audet, & Purcell-Lalonde, 2018) and
treatment-related reductions in fear of self predicted reductions in OCD
symptoms (Aardema, Wong, Audet, & Melli, 2019).
Doron and Kyrios (2005) proposed that people with OCD may have
C. Purdon
anxious or avoidant attachment, which informs their view of the world
as both dangerous and controllable. Furthermore, they have highly
valued aspects of the self in which they do not feel competent, making
them “sensitive” self-domains. Unwanted thoughts that bespeak threat
to sensitive domains will be appraised negatively and will evoke anxiety.
The view that the world is dangerous and controllable will then evoke
strategies to reduce harm and vulnerability. There is strong empirical
support for the association between sensitive self domains and OCD
symptoms (e.g., Doron, Moulding, Kyrios, & Nedeljkavik, 2008; Doron,
Sar-El, & Mikulincer, 2012), and a recent review concluded that beliefs
implying a damaged or feared self are most strongly associated with
OCD symptoms in both clinical and analogue samples (Jaeger,
Moulding, David, Knight, & Norberg, 2021).
1.6. OCD, parenting styles, and attachment
Rachman (1976b) posited that people with OCD are more likely to
have grown up in an over-protective or critical environment, which
produces fearfulness or meticulousness, respectively. Several causal
links between parental criticism and OCD have been posited. There is
some agreement that parental criticism sends the message that one’s
worth is conditional on getting things “right” (e.g., Guidano & Liotti,
1983; Elliott & Radomsky, 2012). Salkovskis, Shafran, Rachman, and
Freeston (1999) suggested that parental criticism produces inflated re­
sponsibility and sends the message that it is highly costly to be “irre­
sponsible”. Purdon (2021) noted if people behave in ways that they feel
are reasonable and justifiable but find themselves criticized by author­
itative people, they may conclude that their own judgement and per­
ceptions are misleading, flawed, or otherwise untrustworthy, and the
emotional cost for this is high (parental disapproval, rejection). This
may compromise their ability to trust they have done something prop­
erly or that danger has passed.
Pace, Thwaites, and Freeston (2011) offered a comprehensive review
of the role of parental criticism in OCD. They concluded that there is
empirical evidence for a relationship between criticism in family of
origin and current family, OCD symptoms, and overvalued re­
sponsibility, although the literature is small and approaches to studying
the issue quite varied.
Over-protective and critical parenting are likely to influence
attachment. In a recent meta-analysis, van Leeuwen, van Wingen,
Luyten, Denys, and van Marle (2020) found a moderate to large effect
size for the relationship between OCD and attachment anxiety, and a
moderate effect size for the relationship between OCD and attachment
avoidance. Doron (2020) found that anxious and avoidant attachment
moderated the relationship between feared self and OCD symptoms in a
community sample. Seah, Fassnacht, and Kyrios (2018) found that
self-ambivalence partially mediated the relationship between anxious
attachment and OCD symptoms in a nonclinical sample. Taken together,
these findings offer support for the role of attachment in OCD.
1.7. Areas for further exploration
Our understanding of the persistence of OCD has grown considerably
in the past few decades, and the widespread use of ERP and CBT may be
the reason that OCD is no longer listed as a leading cause of disability by
the World Health Organization, as suggested by OCDUK (https://www.
ocduk.org/ocd/world-health-organisation/). However, it is noteworthy
that the efficacy of ERP and CBT is about the same, which, when
treatment refusal and drop out are taken into account, is about 50% (e.
g., Öst, Havnen, Hansen, & Kvale, 2015), meaning that there is still more
work to do. In particular, we need to ensure we are working from a fully
specified model.
1.8. Self-perpetuating aspects of compulsions
Rachman’s seminal paper on compulsions identified self-
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Journal of Behavior Therapy and Experimental Psychiatry 78 (2023) 101773
perpetuating factors in checking compulsions. In their diary study,
Bucarelli and Purdon (2015) found that distress over the obsession had
no relationship to compulsion length or repetition. In their follow up
diary study, Dean and Purdon (2021b) found that distress over the
obsession had no relationship with the duration of compulsions, and a
small, nonsignificant correlation with the number of repetitions (.30, p
< .09). This provides further support for the idea that once a compulsion
starts factors other than the obsession that evoked it cause it to persist.
Bucarelli and Purdon (2015) and Bouvard et al. (2020) found that
compulsions that were terminated because they achieved their goal
were associated with fewer repetitions and greater confidence in
memory, sensory, and cognitive processes than those terminated for
other reasons (e.g., had to stop or else would be late for work). Dean and
Purdon (2021b) found that participants with checking compulsions re­
ported that the more they repeated the compulsion, the more they
doubted, but this was not the case for those with washing compulsions.
However, they noted that washing compulsions were repeated an
average of 1.46 times, whereas checking compulsions were repeated
3.96 times, a significant difference.
Taylor and Purdon (2016) and Dean and Purdon (2021a) studied
hand washing in the lab. They had participants high and low in
contamination fears “contaminate” their hands and either prepare gift
bags for preschoolers (high responsibility) or sort newspapers for recy­
cling (low responsibility), in between which they washed their hands.
Taylor and Purdon found that under low harm conditions greater wash
duration was associated with greater certainty the wash had been done
properly, whereas under high harm conditions, greater wash duration
was associated with less certainty, but this was not replicated in Dean
and Purdon. In both studies, hand wash duration was not associated
with memory, sensory, and cognitive confidence in any group, in any
condition, in either study. However, Dean and Purdon (2021a) again
observed that people did not repeat their hand wash, nor even the steps
within it, meaning that it was characterized more by prolongation. Thus,
the ironic effect of repetition may not be as applicable to washing.
Another factor worth considering is the extent to which people with
OCD are strategic. Bucarelli and Purdon (2016) had people with OCD
with checking compulsions and people with generalized anxiety disor­
der conduct a stove checking task in a kitchen with a real stove while
their eye movements were tracked. Participants boiled a kettle of water,
turned the burner off, placed a pot of dry rice on the burner that had
been used, and joined the researcher several doors down. Around the
stove were threat items (e.g., paper towels on a rack, a box of matches,
paper coupons) and non threat items (e.g., salt and pepper shakers).
They found that greater visual attention to the stove during the checking
period was associated with greater post-task ratings of responsibility and
harm and with less certainty in and memory for the check - but only for
the AC group. However, people with OCD looked at threat items less
than did the GAD group.
Bucarelli and Purdon speculated that the people with OCD may have
recognized that looking at the threat items might introduce doubt. Given
that they were not ultimately responsible for the lab kitchen they may
have made a strategic decision to avoid looking at threat so as to avoid
later doubt. Merritt and Purdon (2022) conducted a follow up study in
an analogue sample of people high and low in checking. They found that
people high in checking reported greater motivation to avoid looking at
threat, but total time attending to threat did not differ from those low in
checking concerns. However, greater visual attention to threat predicted
lower post-check certainty in those with high checking concerns, but not
those with low checking concerns. This finding suggests that people may
know that attending threat can lock them into a doubt-repetition-doubt
cycle, but at the same time find it difficult to not to attend to threat.
Chiang and Purdon (2022a) interviewed people with OCD and peo­
ple with subclinical OCD about the time course of their obsessions and
compulsions, and about doubt. They found that both groups reported
using proactive strategies to lessen the severity of later doubt and avoid
having to do a compulsion. For example, they might do a very careful,
C. Purdon
prolonged hand wash before leaving work in anticipation of having
obsessional concerns about contaminating their home upon arrival.
Once home, when the obsessional concern does occur, they can reassure
themselves that harm was diminished by the previous hand wash and
may be able to stave off a prolonged, stressful hand wash. Thus, people
work hard to out-manoeuvre their OCD. Clinically the use of proactive
strategies should be assessed and addressed.
Chiang and Purdon (2022b) also asked participants to rate their
doubt on distress, interferences, difficulty dismissing, conviction,
excessiveness, ability to resist, likelihood of feared consequences if the
doubt were true, and severity of those consequences. They hypothesized
that the subclinical group would rate their doubt as lower on all di­
mensions. Contrary to expectations there were no differences across
groups in their ratings. The only difference across groups was that the
OCD group reported their compulsions as significantly more interfering
and as less able to resist. This suggests that compulsions may initially be
effective, but over time the doubt may grow, and perhaps lead to the
need for more complex compulsions, and less capacity to obtain the
“right” feeling. This warrants more research.
Finally, in their diary studies, Bucarelli and Purdon (2015) and
Bouvard et al. (2020) found that people stopped their compulsion
because they felt certain it had been done properly, felt satisfied, or felt
certain enough it was okay to stop in 54% and 75% of episodes,
respectively. This suggests that compulsions “work” over half the time,
which is a very powerful intermittent reinforcement schedule. Given at
least a 50/50 chance that doing a quick compulsion will terminate
distress, we can understand why people may find it hard to do exposure
in between sessions. This means that people are not inevitably locked
into a doubt-repetition-doubt cycle. It would be worthwhile in future
work to study the factors that vary whether a compulsion is terminated
vs. persistent.
1.9. Compulsion goals
It is generally assumed that compulsions are done to prevent harm
and/or reduce distress (e.g., APA, 2013), yet there has been surprisingly
little research on what people with OCD are trying to accomplish when
they perform a compulsion. In their hand washing study in the lab, Dean
and Purdon (2021a) stopped participants 30s into the wash and asked
them to state their hand wash goal, taking verbatim recordings. In their
diary study Dean and Purdon (2021b) asked participants to write,
verbatim, the goal of the compulsion. In both studies, the goal of the
behaviour was typically proximal and concrete (“wash dirt off”). How­
ever, Dean and Purdon (2021a) found that when the stakes of the
compulsion were higher (i.e., the high responsibility condition) the goal
was more likely to be expressed in terms that rendered it impossible and
unverifiable (“make sure I get rid of all the germs”), with no objective
terminus. In an interview-based study, Kobori et al. (2012) similarly
found that a key goal of reassurance seeking was to achieve a high de­
gree of certainty that harm had been averted. Identifying and exploring
proximal compulsion goals may be a very useful addition to psycho­
education about their persistence.
Another area for exploration may be an examination of the behav­
iours that comprise a compulsion. Boyer and Liénard (2006) observed
that when a behaviour is important it is often parsed into small actions
(e.g., pump the soap, rub hands, lather, rinse, etc.). Eilam, Zor, Fineberg,
and Hermesh (2012) drew from animal studies to code each such
behaviour in sequence. They had people with OCD perform their
compulsion (e.g., check a stove) and then had a paired control without
OCD perform the same behaviour. They then identified behaviours that
were shared between the two groups and those that were unique to
people with OCD. Each behaviour could then be coded in sequence as
shared or unique, like beads on a string. They found that the unique
behaviours tended to occur at the end of the action. This strategy for
parsing compulsions could offer a more nuanced means of assessing the
impact of psychological factors on compulsion than simply duration or
6
Journal of Behavior Therapy and Experimental Psychiatry 78 (2023) 101773
number of repetitions. Clinically, it could prove helpful for people to
recognize the excessive and superfluous aspects of the behaviour, and
begin cutting those out, as a starting point in treatment.
1.10. Compulsions and attachment
In their interview study Chiang and Purdon (2022a) asked about the
time course of obsessions and compulsions and the meaning and
importance of doubt. They used the downward arrow technique to
establish what was important about doubt, asking “What would it mean
about you if the doubt were true?” They found that doubt was connected
to negative core beliefs about the self, such as being incompetent,
dangerous, “bad”, untrustworthy, or incompetent; that is, being mad,
bad, or dangerous, consistent with Rachman (1998). This supports the
growing consensus that targeting negative beliefs about the self is an
important addition to CBT.
Rachman (1976b) proposed that compulsions are done to avoid
punishment by others. Although there has been a lot of research on
avoiding being responsible oneself, this specific idea has not been given
a lot of attention. In their diary study of compulsions, Dean and Purdon
(2021b) asked people with OCD to rate the importance of a range of
goals from 0 to 100. These goals included achieving a feeling of satis­
faction, doing the compulsion properly, avoiding harm, avoiding re­
sponsibility for harm, avoiding guilt, and avoiding being held
responsible for harm by others. Consistent with Rachman, they found
that the goal of avoiding being held responsible for harm by others was
as important as the goal of doing the compulsion properly, was signifi­
cantly more important than being responsible for harm, and was strik­
ingly more important than the goal of preventing harm. These results are
very consistent with Pozza et al. (2021) who found that in a large sample
of people with OCD need for approval was associated with OCD symp­
toms over and above beliefs about obsessions and other predictive
factors.
In a similar vein, Mancini and Gangemi (2015) proposed that people
with OCD are highly averse to deontological guilt, which is guilt arising
from feelings of unworthiness, and will choose inaction over taking the
risk of being responsible for wrongdoing or violation of social norms.
Empirical research indicates that deontological guilt is associated with
disgust and not just right experiences (for a review see Gangemi &
Mancini, 2017). Together these data lend considerable support to the
idea that compulsions have a higher purpose than simply meeting a
proximal goal and bespeak the level of investment in doing compulsions.
This helps us understand why it can be so challenging for people to
engage in ERP. It also bespeaks the potential utility of addressing
attachment issues in treatment.
Finally, researchers have started to explore the mechanisms by
which anxious and avoidant attachment lead to OCD, looking in
particular at ambivalent and feared selves. One potential factor is fear of
compassion. Joeng et al. (2017) found that self-compassion and fear of
compassion mediated the relationship between anxious and avoidant
attachment and low mood/anxious arousal. Merritt and Purdon (2020)
found that people with OCD and related anxiety disorders had higher
fears of self-compassion than nonclinical controls. Recent research in
our lab found that in a large student sample, fear of self-compassion
mediated the relationship between anxious attachment and OCD
symptoms, and fear of receiving compassion mediated the relationship
between avoidant attachment and OCD symptoms (McNeil & Purdon,
2022). It may be that addressing fears of compassion could be helpful in
treating OCD, and worth exploring further in research.
1.11. Summary
Rachman’s elegant, succinct, and cogent analyses of obsessions and
compulsions have helped explicate the internal logic of OCD and
inspired the research that has informed the most effective treatment of
OCD to date. The current CBT model for understanding and treating
C. Purdon
OCD could benefit from continued elaborations. Future directions
include a greater understanding of how compulsions evolve across time,
the persistence of washing and compulsions other than checking,
developing our understanding of compulsion goals, and identification of
the mechanisms by which anxious and avoidant attachment influence
OCD symptoms.
1.12. Personal reflection
I never worked directly with Jack Rachman, but my dissertation
supervisor, Dr. David A. Clark did. I grew up as an academic on Rach­
man’s works and he has been a silent mentor to me throughout my
career. Once Jack sent me a hand-written letter in appreciation of a
piece I had published and invited me to contribute an essay to Behaviour
Research and Therapy. This remains one of the most cherished honours I
have received. I deeply miss Jack’s presence in the academic world.
CRediT authorship contribution statement
Christine Purdon: Conceptualization, Writing – original draft,
preparation, Writing – review & editing.
Declaration of competing interest
I have no conflict of interest.
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