The effects of brief emotional acceptance instructions on emotional distress and compulsive urges of various obsessive-compulsive symptoms dimensions

Abstract

Background and Objectives: Emotion regulation (ER) deficits are increasingly implicated in obsessive-compulsive symptoms (OCS). The ER difficulty of ‘non-acceptance of emotions’ has been most consistently found to correlate with OCS – albeit not uniformly with all OCS dimensions. This study examined the causal relationships between the acceptance of emotions and four OCS dimensions: contamination, responsibility of harm, unacceptable thoughts and symmetry. Methods: Participants in this online study rated their baseline emotional distress and compulsive urges to OC scenarios corresponding to each OCS dimension. After completing questionnaires on ER, OCS, anxiety and depressive symptoms, participants were randomly assigned to two conditions and instructed to observe and accept their emotions (acceptance condition; n = 180) or observe their emotions (control condition; n = 185) as they re-read the scenarios. Participants then rated their post-manipulation emotional distress and compulsive urges to each scenario. Results: The instructions to accept emotions resulted in lower compulsive urges to the responsibility of harm scenario, for participants with lower baseline compulsive urges. There were no other group differences on post-manipulation measures. Conclusions: The current findings suggest that even brief instructions to accept one’s emotions reduced compulsive urges, pointing to the potential clinical utility of enhancing the acceptance of emotions.

Keywords

acceptance of emotions OCD symptom dimensions

Introduction

Obsessive-compulsive disorder (OCD) is characterised by obsessions (i.e., intrusive and recurrent thoughts, images or urges) and/or compulsions (i.e., ritualistic behaviours or mental acts; American Psychiatric Association, 2013). The cognitive model of OCD emphasises the role of misinterpretations of obsessions, as harmful to self or others, in causing psychological distress and compulsions (Salkovski, 2007). Exposure and response prevention (ERP), with or without cognitive interventions, which primarily targets these faulty cognitions, is the most effective available psychological intervention for OCD (Olatunji et al., 2012; Öst et al., 2015). Nevertheless, non-compliance, treatment refusal and dropout remain common barriers to ERP treatment (Abramowitz et al., 2003; Foa et al., 2005; Ong et al., 2016).

Theorists, in line with the emotion processing theory (Foa & Kozak, 1986), postulated that individuals with OCD cope with the psychological distress, engendered by obsessions, through engaging in compulsions (Calkins et al., 2013). This possibility that compulsions serve an emotion regulatory role and that OCD may be perpetuated at least partly by ER difficulties had received support from emerging research. ER difficulties were more commonly reported by patients with OCD than healthy controls (Fernandez de la Cruz et al., 2013; Yazici & Yazici, 2019). ER difficulties were also found to be correlated to the severity of obsessive-compulsive symptoms (OCS) across a number of studies (Berman et al., 2022; Eichholz et al., 2020; Fergus & Bardeen, 2014; Hong et al., 2022; McKenzie et al., 2020; Stern et al., 2014; Yazici & Yazici, 2019).

Our recent systematic review on ER difficulties in OCD found evidence suggesting various ER difficulties, including non-acceptance of emotions, lack of access to effective ER strategies, difficulties in impulse-control and difficulties engaging in goal-directed behaviours, to be related to OCS (See et al., 2022). In particular, the significant relationship between the non-acceptance of emotions and OCS was the most consistently and widely replicated among all domains of ER difficulties across a range of non-clinical and clinical samples (refer to See et al., 2022 for a comprehensive review). The non-acceptance of emotions was also found to be most strongly associated with OCS in several studies (Berman et al., 2018; Stern et al., 2014; Yap et al., 2018).

The non-acceptance of emotions was conceptualised as the rejection of one’s emotions or the tendency to experience negative secondary emotions to one’s negative emotions (Gratz & Roemer, 2004). It also referred to a lack of ability (Cougle et al., 2013; Macatee et al., 2013) or willingness to accept unpleasant emotions (Blakey et al., 2016). We found three studies examining interventions with treatment components that may help to enhance acceptance of emotions, such as psychoeducation about negative consequences of negative emotions and emotional exposure exercises (Allen & Barlow, 2009; Macatee & Cougle, 2015; Shaw et al., 2020). Results from these studies showed ER interventions to be promising in reducing OCS.

However, further investigations into the relationship between the non-acceptance of emotions and OCS may be necessary given the heterogeneous nature of OCD. OCD was thought to comprise multiple symptom dimensions (refer to Cervin et al., 2021 for a comprehensive review). Foa et al.’s conceptualisation of Foa et al.’s (2002) included six symptom dimensions, including checking, hoarding, neutralising, obsessing, ordering and washing. To reflect empirically supported dimensions of OCD and evidence of hoarding disorder as a distinct condition from OCD, Abramowitz et al. (2010) postulated that OCS fall on four dimensions: (1) contamination-related fears; (2) concerns about responsibility for causing harm; (3) unacceptable thoughts pertaining sex, morality, religion or violence; and (4) symmetry concerns.

Each of these OCS dimensions had been shown to differ in nature, aetiology and prognosis (Mataix-Cols et al., 2002; Rufer et al., 2006). The empirical literature also recently pointed to the likelihood of the non-acceptance of emotions being differentially related to each of the OCS dimensions (Berman et al., 2018; Khosravani et al., 2018; Yap et al., 2018). Amongst the various OCS dimensions, the non-acceptance of emotions was found to be most consistently related to responsibility of harm OCS and unacceptable thoughts OCS (Berman et al., 2018; Yap et al., 2018), as well as obsessing and neutralising symptoms (Cougle et al., 2011, 2012, 2013; Khosravani et al., 2018; Macatee et al., 2013) across various studies.

Foa et al.’s (2002) obsessing and neutralising symptoms referred to OCS associated with the themes of sex, morality, religion or violence and counting (e.g., repeating numbers and feeling that there are bad numbers) respectively. Hence, obsessing and neutralising symptoms likely overlap with Abramowitz et al.’s (2010) responsibility of harm and unacceptable thoughts symptom. As such, there was stronger cumulative evidence suggesting a relationship between non-acceptance of emotions with responsibility of harm and unacceptable thoughts OCS than that with the contamination and symmetry OCS.

Despite increased empirical attention to the links between the non-acceptance of emotions and OCS, our systematic review had highlighted several gaps and limitations in the literature that remained to be addressed. Firstly, apart from Hong et al.’s (2022) longitudinal study that found difficulties in ER to predict OCS better than OCS predicted difficulties in ER, almost all available research on ER and OCS adopted a cross-sectional study design. In particular, none of the identified studies had employed experimental designs to investigate the causal relationships between the non-acceptance of emotions and each of the four OCS dimensions. Experimental research in this area would help clarify if OCD treatment should incorporate components targeting the non-acceptance of emotions.

Secondly, there was a lack of understanding on how ER difficulties may change the manifestation of OCS due to the common use of composite measures for OCS. Measures with specific items for obsessions, compulsive urges and compulsive behaviours can shed light on how ER interventions impact each of these different symptoms. Additionally, most studies on ER difficulties and OCS relied on restrospective self-report measures, which could be prone to biases, including over-reporting and memory biases (Sato & Kawahara, 2011; Van den Bergh & Walentynowicz, 2016). Such errors can be minimised through adopting ecologically valid measures for OCS (e.g., in-the-moment measures of emotional distress and compulsive urges or behaviours).

The present study examined the causal relationships between the acceptance of emotions and the four OCS dimensions of contamination, responsibility of harm, unacceptable thoughts and symmetry. Specifically, we manipulated instructions to either accept or observe emotions in response to scenarios describing intrusive thoughts relating to the four OCS dimensions. We then measured the level of in-the-moment emotional distress and urges to engage in compulsive behaviour (i.e., compulsive urges) reported by participants at baseline and post-manipulation. We hypothesised that controlling for baseline emotional distress and compulsive urges, individuals in the acceptance condition will report lower post-manipulation emotional distress and compulsive urges to both the responsibility of harm and unacceptable thoughts scenarios, compared to control participants. In contrast, given limited and inconsistent empirical evidence of a relationship between non-acceptance of emotions and symmetry concerns, and that with contamination fears, we did not expect significant group differences in the post-manipulation emotional distress and compulsive urges between the acceptance and control condition for the contamination and symmetry scenarios.

Methods

Participants

The final sample consisted of 365 participants from the National University of Singapore. A total of 190 participants from the University’s Research Participation (RP) programme received course credits, and 175 participants recruited via an advertisement posted on the University’s research forum received $4 in reimbursement. The sample was predominantly female (n = 264; 72.3%), with a mean age of 21.28 years (SD = 3.26, range = 18–57). The majority of participants identified themselves as Chinese (n = 322; 88.2%), followed by Indian (n = 19; 5.2%), Malay (n = 10; 2.7%), Other racial groups (n = 10; 2.7%) and Eurasian (n = 4; 1.1%).

Materials

Obsessive-compulsive (OC) scenarios

A total of eight hypothetical scenarios (two for each OCS dimension) describing intrusive thoughts, images and urges that individuals may experience in day-to-day situations were created for this study (see Online Appendix A). The scenarios were pilot-tested with 30 pilot participants. Four scenarios (one for each dimension) were selected for higher ratings on relevance, ability to imagine given thought and/or urges to carry out neutralisation behaviours (see Online Appendix B for descriptive statistics of pilot responses).

In the contamination scenario, participants were instructed to imagine thinking that their shoulders were still dirty after cleaning off bird droppings with an antibacterial wipe. In the responsibility for harm scenario, participants had to imagine thinking that they might have forgotten to pay for an item at the self-checkout kiosk and the alarm might sound as they exit the supermarket. For the unacceptable thought scenario, participants were required to imagine thinking that they might have inappropriately touched a child while volunteering at a childcare. Finally, in the symmetry scenario, participants imagined thinking that the placement of the furniture was slightly crooked and just ‘not right’ while they were arranging it.

Difficulties in emotion regulation scale (DERS) – non-acceptance subscale

The non-acceptance subscale from the DERS (Gratz & Roemer, 2004) constitutes a trait measure of participants’ tendency to reject their emotions or experience secondary negative emotions to their negative emotions. Participants rated six items (e.g., When I’m upset, I become embarrassed for feeling that way) on this subscale using a 5-point Likert scale ranging from 1 (Almost never) to 5 (Almost Always). The total score for this subscale ranges from 5 to 30, with a higher score indicating greater non-acceptance of emotions. The DERS subscales demonstrated adequate internal consistency and good convergent validity with other measures of ER (Gratz & Roemer, 2004). The DERS non-acceptance subscale also had good internal consistency in the current study (α = .88).

Dimensional obsessive-compulsive scale (DOCS)

The DOCS (Abramowitz et al., 2010) is a 20-item self-report questionnaire, which assesses the severity of OCS (i.e., obsessions and compulsions) in terms of time spent on obsessions or compulsions, level of avoidance, resulting distress, disruption to daily routines and difficulties in disregarding obsessions or refraining from compulsions in the past month. The DOCS comprises four validated scales on contamination fears (e.g., About how much time have you spent each day thinking about contamination and engaging in washing or cleaning behaviours because of contamination?), responsibility for harm (e.g., To what extent have you avoided situations so that you did not have to check for danger or worry about possible harm or disasters?), unacceptable thoughts (e.g., When unwanted or unpleasant thoughts come to mind against your will how distressed or anxious did you become?) and symmetry concerns (e.g., To what extent has your daily routine (work, school and self-care, social life) been disrupted by the feeling of things being ‘not just right’ and efforts to put things in order or make them feel right?).

Each item on the DOCS will be rated on a 5-point Likert scale from 0 to 4. Scores for each subscale range from 0 (i.e., no symptoms) to 20 (i.e., extreme symptoms) and are summed to compute the total DOCS score, which ranges from 0 to 80. A composite score of 18 and above is suggestive of possible OCD. The DOCS was found to be a valid and reliable measure of OCS severity in both non-clinical and clinical populations (Abramowitz et al., 2010). The DOCS demonstrated excellent internal consistency in this study (α = .91).

Patient health questionnaire (PHQ-9)

The PHQ-9 (Kroenke et al., 2001) is a 9-item self-report measure of depressive symptom severity in the past fortnight. Participants rated the frequency of each symptom (e.g., little pleasure or interest in doing things) on a 4-point Likert scale from 0 (Not at all) to 3 (Nearly every day). Scores for the PHQ-9 range from 0 to 27, with scores higher than 5, 10 and 15 representing mild, moderate and severe depressive symptoms respectively. The PHQ-9 had demonstrated reliability (Kroenke et al., 2001; Kroenke & Spitzer, 2002) and validity in various samples (Gelaye et al., 2014; Kocalevent et al., 2013). This scale also had good internal consistency in this study (α = .89).

Generalised anxiety disorder scale (GAD-7)

The GAD-7 (Spitzer et al., 2006) is a 7-item self-report measure of anxiety symptoms experienced by the individual in the past fortnight. Participants rated the frequency of each symptom (e.g. not being able to stop or control worrying) on a 4-point Likert scale from 0 (Not at all) to 3 (Nearly every day). GAD-7 scores range from 0 to 21, with scores higher than 5, 10 and 15 indicating mild, moderate and severe anxiety symptoms respectively. The GAD-7 had shown excellent internal consistency in past research (Kertz et al., 2012) and the current study (α = .92). It also had good convergent validity with other measures of anxiety (Spitzer et al., 2006).

Demographics measure

Participants were asked for their age, gender and ethnicity.

Procedure

The study was approved by our institutional review board (IRB). Participants accessed all study materials remotely via Qualtrics, an online portal for surveys. After providing written informed consent, participants read each obsessive-compulsive (OC) scenario and completed the baseline measures corresponding to each scenario (see Online Appendix A). Specifically, they rated how much emotional discomfort they felt from imagining the stated thought, image, urges or sensation on a 7-point Likert scale from 1 (No discomfort at all) to 7 (Extreme discomfort). They also rated their compulsive urges to respond to the thought (i.e., how likely they would respond in the given scenario by cleaning, checking or re-arranging) on a similar Likert scale from 1 (Not at all likely) to 7 (Extremely likely). Next, participants completed the DERS non-acceptance subscale, DOCS, PHQ-9 and GAD-7.

Participants were then randomly assigned to the acceptance (n = 180) or control condition (n = 185) by the built-in computerised randomiser. Participants in the acceptance condition were instructed to observe, accept and not judge their emotions as they proceed to re-read and imagine the OC scenarios, while participants in the control condition were only instructed to observe their emotions. All participants then re-read and rated their post-manipulation emotional distress and compulsive urges to each of the OC scenarios. The order of the OC scenarios was counterbalanced. All participants were also reminded of the manipulation instructions after the first two OC scenarios. Next, participants completed a manipulation check, in which they rated how well they had adhered to the manipulation instructions on an 8-point Likert scale from 1 (Not at all able) to 8 (Extremely well). Participants then completed the demographics questionnaire, stated what they thought was the hypothesis of the study and whether their responses were affected by their perception of the hypothesis. Finally, all participants were debriefed about the purpose of the study and reimbursed. The study procedures are summarised in Figure 1.

Figure 1.

Study flowchart. Note. Difficulties in Emotion Regulation Scale (DERS); Dimensional Obsessive-Compulsive Scale (DOCS); Generalised Anxiety Disorder scale (GAD-7); Patient Health Questionnaire (PHQ-9); OC (obsessive-compulsive).

Analytic approach

Power analysis and sample size

Macatee and Cougle’s (2015) brief computerised intervention that aimed at improving ability to tolerate or accept distressing emotions had an estimated medium effect size (η² = .07) on participants’ neutralisation urges following an imaginal exposure. The G*Power 3.1 (Faul et al., 2007) was used to conduct an a priori power analysis for the two tail-tests of difference in post-manipulation emotional distress and compulsive urges between two independent groups, while controlling for baseline emotional distress and compulsive urges. The analysis revealed that a minimum sample size of 311 participants will be required to achieve a power of .95 given a medium effect size (Cohen’s f = .25) and a Bonferroni-adjusted alpha level of .00625. Given that online survey studies are prone to incomplete and careless or insufficient effort (C/IE) responses, we aimed for a more conservative sample of 400 participants to ensure that our final sample would be sufficiently powered after removing these responses.

Data screening

Incomplete responses were first excluded. To ensure the quality and validity of our online data, we adopted Curran’s (2016) multiple hurdles approach, which involves the sequential identification and removal of most-likely-invalid data according to several criteria, to identify C/IE responders in this online study. Firstly, we removed data with response time under the recommended cut-off of 2 seconds per item (Huang et al., 2012). Responses that were too slow were not removed as various factors may account for a very slow response time (e.g., participants taking a long time to read) and research had not examined the quality of such data (Curran, 2016). Next, data with strings of identical responses (e.g., selecting ‘agree’ to all items) for the entire scale, for three or more of the self-report measures (i.e., DERS non-acceptance subscale, DOCS, PHQ-9 or GAD-7) were also excluded from analyses. Additionally, individuals scoring lower than three on the manipulation check were also excluded from the analysis. Lastly, participants who correctly guessed the hypothesis and reported that they had intentionally responded contrary to or in line with the perceived hypothesis were also excluded.

Preliminary analyses

Statistical analyses were completed with the SPSS statistical software. Data were first screened for univariate outliers and concordance with statistical assumptions. Independent t-tests were used to examine baseline differences between the conditions on potential covariates, including the DERS non-acceptance subscale, DOCS, PHQ-9 and GAD-7.

Main analyses

Eight analyses of covariance (ANCOVAs) examined the hypothesised effect of condition on post-manipulation measures of emotional discomfort and compulsive urges for each OCS dimension scenario, with the corresponding baseline measure as the covariate. As planned analyses do not protect against familywise Type 1 error (Frane, 2015), the following analyses were conducted using Bonferroni-adjusted alpha levels of .00625 (i.e., non-adjusted alpha level of .05 divided by eight tests). Assumptions of the ANCOVA were tested before interpreting the results. The assumption of the homogeneity of variance for the ANCOVA was unlikely to be violated when the sample sizes across conditions were equivalent. The assumption of independence between the independent variable and the covariate was tested with independent t-tests. Lastly, the homogeneity of regression slopes assumption was tested by entering the independent variable, the covariate and the interaction term between these two variables in a regression model. The regression model was interpreted in place of the ANCOVA in cases where the interaction was significant, indicating that this final assumption was violated (Leppink, 2018). All analyses were replicated with the original uncleaned data. As there were no differences in the patterns of results, results ran on the cleaned data were presented.

Results

Data screening

Incomplete data from 25 participants were excluded from analysis. No individual was identified as a C/IE responder with the response-time criterion. Data from two individuals were excluded due to strings of identical responses on three or more scales. Data from 11 participants were also removed as they scored below three points on the self-report manipulation check. No participant correctly guessed the study hypothesis. The final sample included 365 participants.

Preliminary analyses

No univariate outliers were identified. The distribution of scores for all measures was within the acceptable range of skew (all values <2) and kurtosis (all values <3) according to Kline’s (2005) conventions. Descriptive statistics for all baseline self-reported measures were presented in Table 1. A notable 64.4% of the sample was scored at or above the clinical cut-off score of 18 on the DOCS, reflecting a high level of OCS in this sample. There were no group differences on the DERS non-acceptance subscale, DOCS, PHQ-9 and GAD-7 scores at baseline, ps > .09 (see Table 1).

Table 1.

Descriptive and inferential statistics for self-reported measures at baseline.

Measure	Acceptance Condition		Control Condition		t (363)	p
Measure	M	SD	M	SD	t (363)	p
DERS Non-acceptance	15.73	5.62	16.60	5.80	1.45	.15
DOCS	20.87	10.55	22.82	11.57	1.69	.09
DOCS Contamination	5.89	3.22	6.46	3.65	1.58	.11
DOCS Responsibility of harm	5.84	3.73	6.32	3.99	1.20	.23
DOCS Unacceptable thoughts	5.35	3.69	6.02	4.25	1.61	.11
DOCS Symmetry	3.78	3.65	4.01	3.81	0.58	.56
PHQ-9	9.82	5.90	10.37	6.56	0.84	.40
GAD-7	8.27	5.55	8.91	5.66	1.10	.27

Note. Difficulties in Emotion Regulation Scale (DERS); Dimensional Obsessive-Compulsive Scale (DOCS); Generalised Anxiety Disorder scale (GAD-7); Patient Health Questionnaire (PHQ-9).

Main analyses

The assumption of independence between the independent variable and covariate was met for all post-manipulation emotional distress and compulsive urges measures, ps > .29. The assumption of the homogeneity of regression slopes was met for all measures, ps > .15, except for the post-manipulation compulsive urges measure to the responsibility of harm scenario. Hence, we interpreted the regression of condition, baseline compulsive urges and the interaction between these variables on post-manipulation compulsive urges to the responsibility of harm scenario in place of the ANCOVA. The interaction between the condition and baseline compulsive urges on post-manipulation compulsive urges to the responsibility of harm scenario was significant, F (1,361) = 9.14, p = .003, MSe = 0.94, p < .003, ƞ_p² = .025. Among participants with lower baseline compulsive urge, those in the acceptance condition reported lower levels of post-manipulation compulsive urges compared to those in the control condition (see Figure 2). On the other hand, participants with higher baseline compulsive urges reported similar levels of post-manipulation compulsive urges across both conditions. There was no other significant main effect of condition on other post-manipulation measures at the Bonferroni-adjusted alpha level of .00625, after controlling for the respective baseline measure, ps > .04 (see Table 2).

Figure 2.

Scatter plot with regression lines indicating an interaction between condition and baseline compulsive urges on post-manipulation compulsive urges for the responsibility of harm scenario.

Table 2.

Group comparisons for post-manipulation emotional distress and compulsive urges controlling for the respective baseline measure for the various obsessive-compulsive symptom dimensions.

Variable	Acceptance Condition				Control Condition				F (1,361)	Non-adjusted p	ƞ_p²
	Baseline		Post-Manipulation		Baseline		Post-Manipulation
	M	SD	M	SD	M	SD	M	SD
Contamination
Emotional distress	5.51	1.42	5.36	1.46	5.53	1.28	5.44	1.39	.000	.99	.000
Compulsive urges	5.94	1.48	5.83	1.56	6.10	1.31	5.92	1.39	.000	.99	.000
Responsibility for harm
Emotional distress	4.82	1.56	4.66	1.68	4.79	1.55	4.87	1.58	4.265	.04	.012
Compulsive urges	5.48	1.63	5.32	1.64	5.46	1.71	5.55	1.57	12.879	<.001	.034
Unacceptable thoughts
Emotional distress	4.22	1.68	4.19	1.68	4.09	1.76	4.21	1.78	.592	.44	.002
Compulsive urges	4.71	1.67	4.62	1.74	4.59	1.81	4.53	1.85	.326	.57	.001
Symmetry
Emotional distress	3.69	1.53	3.96	1.62	3.82	1.66	3.90	1.67	.004	.95	.000
Compulsive urges	4.55	1.79	4.35	1.81	4.62	1.79	4.49	1.80	.307	.58	.001

Note. Bolded text indicates a significant p-value at the Bonferroni-adjusted alpha level of .00625.

Discussion

This study examined the causal relationships between the acceptance of emotions and the various OCS dimensions. The results partially supported our hypotheses. As predicted, participants in the acceptance condition reported lower post-manipulation compulsive urges to the responsibility of harm scenario than control participants, although this finding was limited to those who scored lower on baseline compulsive urges. Contrary to the hypothesis, participants in the acceptance condition did not report lower post-manipulation emotional distress to the responsibility of harm scenario compared to control participants. Unexpectedly, participants in the acceptance condition also did not report lower post-manipulation emotional distress or compulsive urges on the unacceptable thoughts scenario compared to control participants. Finally, as expected, the acceptance manipulation did not result in lower post-manipulation emotional distress or compulsive urges compared to the control group for the contamination and symmetry scenarios. The results from the current study built on past research in several ways.

Firstly, the results suggest that the acceptance of one’s emotions can reduce compulsive urges related to the responsibility of harm dimension for individuals with lower baseline compulsive urges. This positive finding is in line with past research that showed acceptance of emotions to be related to fewer responsibility of harm OCS (Cougle et al., 2011, 2012, 2013; Khosravani et al., 2018; Macatee et al., 2013; Yap et al., 2018). It also concurs with Macatee and Cougle’s (2015) finding that increased acceptance of emotions, through a brief computerised intervention, reduced urges to neutralise a distressing thought related to the responsibility of harm. The current result was in line with the theory that compulsions are attempts to regulate negative emotions caused by obsessions (Calkins et al., 2013; Foa & Kozak, 1986). Since the acceptance of emotions may remove the need for further regulation of emotions, it follows that individuals will experience less of an urge to engage in compulsive behaviours. Clinically, this result also points to the potential utility of verbally encouraging individuals with lower levels of OCS to accept their emotions during the preventative and staying-well stages of therapy, to help them further reduce their compulsive urges.

Unexpectedly, brief instructions to accept one’s emotions did not reduce compulsive urges to the responsibility of harm scenario for individuals with higher baseline compulsive urges. This result ostensibly contradicted Macatee and Cougle’s (2015) finding that a brief computerised intervention could increase acceptance of emotions, and in turn reduce neutralisation urges. However, although both our brief instructions and Macatee and Cougle’s intervention aimed to improve acceptance of emotions, it was noted that their intervention was more extensive and included components on psychoeducation on adaptive functions of negative emotions and negative consequences of avoiding emotions, as well as experiential emotional acceptance practices. In light of McMullen et al.’s (2008) finding that brief acceptance instructions combined with experiential exercises were more effective than brief instructions alone in improving tolerance to aversive physical stimuli (McMullen et al., 2008), it may be possible that their intervention was more effective in reducing compulsive urges in individuals with higher baseline compulsive urges than our brief instruction. Hence, future research should investigate whether the combination of brief acceptance instructions and acceptance experiential exercises can effectively reduce compulsive urges to obsessions related to the responsibility of harm for individuals with higher baseline compulsive urges.

Contrary to our initial predictions, the brief instructions to accept one’s emotions did not reduce participants’ emotional distress to the responsibility of harm scenario. This result was congruent with Macatee and Cougle’s (2015) findings that participants continued to experience anxiety in response to intrusive thoughts following their computerised intervention. On the whole, it appeared that the acceptance of emotions can reduce individuals’ compulsive urges to intrusive thoughts related to the responsibility of harm, without necessarily reducing individuals’ subjective distress to the experience. This may suggest that it is still important to intervene and correct the misinterpretations of obsessions in OCD, which, according to the cognitive model of OCD, directly lead to emotional distress (Salkovski, 2007). Another explanation may be that the acceptance of emotions was only associated with reduced subjective distress after a distressing experience (e.g., focussing on an unwanted thought and watching an emotion-provoking film) but not during the experience (Campbell-Sills et al., 2006; Najmi et al., 2009). A possible clinical implication of this result would be that the experience of emotional distress should not be interpreted as a sign of failure to accept one’s emotions.

The relationship between the non-acceptance of emotions and unacceptable thoughts OCS had been well-documented in correlational studies conducted with non-clinical (Cougle et al., 2011, 2012, 2013; Macatee et al., 2013) and clinical samples (Berman et al., 2018; Khosravani et al., 2018). Yet, our brief instruction to accept one’s emotions did not reduce post-manipulation emotional distress to the unacceptable thoughts scenario. This lack of group differences may similarly be due to the need to intervene in the misinterpretations of obsessions in order to reduce the resulting emotional distress (Salkovski, 2007) and/or the possibility that acceptance of emotions only reduces emotional distress after the distressing experience but not during the experience (Campbell-Sills et al., 2006; Najmi et al., 2009).

There are at least three plausible explanations to account for the lack of group differences in post-manipulation compulsive urges to the unacceptable thoughts scenario. First, acceptance of emotions and unacceptable thoughts may not be causally related (i.e., the relationship between the two were due to unknown confounding variable(s)). Second, the positive relationship between the non-acceptance of emotions and unacceptable thoughts OCS found in past research may refer to the relationship between the ER difficulty and unacceptable thoughts obsessions rather than compulsions. This may be possible given that past studies have quantified OCS using composite scores (e.g., Abramowitz et al., 2010; Foa et al., 2002; Goodman et al., 1989), which do not distinguish between obsessions, compulsive urges and behaviours. However, this was unlikely in light of the knowledge that obsessions and compulsions co-occur rather than exist independently (Williams et al., 2011).

Third, the current manipulation may be too brief to produce meaningful changes in compulsive urges. Correlational research had found moderate to large effect sizes for the relationship between non-acceptance of emotions and unacceptable thoughts OCS (Yap et al., 2018). This suggested that individuals with unacceptable thoughts OCS generally experience a high level of non-acceptance of emotions and may have significant difficulties simply accepting their emotions when instructed to. Additionally, research had also found that the fear individuals with unacceptable thoughts OCD experience were sometimes compounded by the emotion of disgust (Olatunji et al., 2005), which could further explain the limited effectiveness of our brief instruction manipulation. Future research should explore the effectiveness of experiential exercises in addition to acceptance instruction, which had been found to be more effective in reducing avoidance of aversive physical stimuli compared to brief instructions (McMullen et al., 2008), in reducing compulsive urges for this OCS dimension.

Our study did not find acceptance of emotions to be related to lower emotional distress or compulsive urges to the symmetry scenario. A positive relationship between acceptance of emotions and symmetry OCS was found in two studies (Khosravani et al., 2018; Yap et al., 2018). However, Yap et al. (2018) had relied on an online sample without identifying and removing potential C/IE responders. This limitation is concerning as it may result in spurious relationships between variables that are unrelated (Huang et al., 2015). Moreover, several other studies (e.g., Berman et al., 2018; Cougle et al., 2011; Macatee et al., 2013) also did not find a positive relationship between the non-acceptance of emotions and symmetry OCS. Overall, there seemed to lack consistent evidence supporting the role of non-acceptance of emotion in the aetiology of symmetry-related OCD.

There is also limited evidence suggesting a link between the acceptance of emotions and contamination OCS. The positive relationship between non-acceptance of emotions and contamination OCS found in Stern et al.’s (2014) study was not replicated in other studies, which controlled for potential confounding variables such as anxiety and/or depressive symptoms (Berman et al., 2018; Cougle et al., 2011; Khosravani et al., 2018; Yap et al., 2018). Consistent with this body of research, we also did not find reduced emotional distress or compulsive urges to the contamination scenario in the acceptance condition.

This lack of relationship between the acceptance of emotions and contamination OCS may be explained by the unique core emotion involved in contamination-related OCD. Although OCD has been conceptualised as an anxiety disorder, research has increasingly shown disgust, rather than anxiety, to be the key emotion implicated in contamination-related OCD (Moretz & McKay, 2007). Disgust is an emotion with a visceral physiological state of revulsion (Rozin & Fallon, 1987). From an evolutionary stance, disgust functions as a basic response to protect an individual from potential pathogens and toxins (Davey, 2011). Learned disgust was found to be resistant to extinction (Mason & Richardson, 2012) and it is much more difficult to disengage one’s attention from disgust, in comparison to anxiety (Cisler et al., 2009). These characteristics of disgust mean that it can be extremely challenging to simply accept the emotion of disgust once an individual experiences it. This may in turn explain why our brief instructions to accept one’s emotions did not reduce emotional distress or compulsive urges to the contamination scenario.

Strengths, limitations and future directions

This study had adopted several recommendations from our systematic review to enhance the quality of evidence in this research area (refer to See et al., 2022). Firstly, we used an experimental study design, which allowed for the investigation of the direction of causality between the acceptance of emotions and each OCS dimension. We also employed more ecologically valid measures of OCS by measuring self-reported levels of in-the-moment emotional distress and compulsive urges as participants read and imagined the given scenarios. Use of these measures allowed for a more nuanced understanding of how the acceptance of emotions can differently impact emotional distress and compulsive urges. The large sample recruited for this study also ensured that the study was sufficiently powered. Familywise error rate was also accounted for with the Bonferroni adjustments for alpha levels to ensure robust findings.

Nonetheless, the findings should be interpreted in the light of several limitations. First, a non-clinical convenience sample was used in this study. Nevertheless, non-clinical studies were still found to be relevant in the investigation of OCD, specifically for dimensional psychological constructs (Abramowitz et al., 2014), such as non-acceptance of emotions and OCS. This limitation may be further mitigated by the high level of OCS reported by the sample. However, replication of the current study with clinical samples is still highly recommended given that few clinical studies were conducted in this area (See et al., 2022). The second limitation pertained the use of an online study design. Fortunately, research had found online data collection methods to produce qualitatively and quantitatively similar results to paper-and-pencil data collection (Weigold et al., 2013). Furthermore, precautions were also taken in this study to reduce error variance by removing potential C/IE responders with empirically supported procedures (Curran, 2016).

Another limitation of this study was the use of very brief instructions to manipulate the acceptance of emotions. Given that past research had found experiential acceptance exercises to be pivotal to the effectiveness of experimental analogues of acceptance-based interventions (McMullen et al., 2008), it is possible that the employed manipulation was too brief to result in meaningful changes in emotional distress and compulsive urges to the various OC scenarios. The brevity of the acceptance manipulation may also explain why the manipulation only reduced compulsive urges to the responsibility of harm scenario for individuals with lower baseline compulsive urges, but not for those with higher baseline urges. Patients with OCD are likely to present with higher OCS at baseline. Hence, it is pertinent that future studies examine the effectiveness of more extensive acceptance interventions (e.g., interventions that include experiential exercises) in reducing compulsive urges to intrusive thoughts related to the responsibility of harm and unacceptable thoughts scenarios, especially for individuals with higher baseline compulsive urges. The current research had also included only one scenario for each OCS dimension. It is recommended that future studies replicate the current research with a wider range of scenarios or with participants’ idiosyncratic OC-related concerns. Although we have pilot-tested the OC scenarios, future research should attempt to replicate the current study with validated vignettes and outcome measures. Our study also relied on self-report measures of emotional distress and compulsive urges. Lastly, as reductions in compulsive urges may not translate into reductions in compulsive behaviours (Macatee & Cougle, 2015), future research should incorporate measures of compulsive behaviours.

Conclusion

The present research examined the causal relationships between the acceptance of emotions and the four OCS dimensions of contamination, responsibility of harm, unacceptable thoughts and symmetry. Instructions to accept one’s emotions led to lower post-manipulation compulsive urges to the responsibility of harm scenario, but only among individuals with lower baseline compulsive urges. The manipulation, however, did not lead to lower post-manipulation emotional distress to this scenario. Additionally, it also did not lead to lower post-manipulation emotional distress and compulsive urges to the unacceptable thoughts scenario. Emotional distress and compulsive urges to both the symmetry and contamination scenarios were unaffected by the manipulation.

Clinically, these findings suggest that even very brief instructions to accept one’s emotions can reduce compulsive urges among those with lower baseline compulsive urges. This points to the utility of verbal encouragements to accept one’s emotions during the preventative and staying-well stages of therapy. The ineffectiveness of the current acceptance instructions in reducing emotional distress may also suggest emotional distress to be a normative part of accepting one’s emotions, rather than a sign of failure. Finally, it remained to be investigated whether slightly more extensive acceptance interventions (e.g., acceptance instruction combined with experiential exercises) can help to reduce compulsive urges and behaviours even for individuals with higher baseline compulsive urges.

Supplemental Material

Supplemental Material - The effects of brief emotional acceptance instructions on emotional distress and compulsive urges of various obsessive-compulsive symptoms dimensions

Supplemental Material for the effects of brief emotional acceptance instructions on emotional distress and compulsive urges of various obsessive-compulsive symptoms dimensions by Cassandra C. H. See, Vanessa S. Y. Tan, Jia Min Tan and Oliver Sündermann in Journal of Experimental Psychopathology.

Footnotes

Acknowledgments

The authors wish to thank Ms Shi Yun Ho, Ms Ping Zheng Lee and Ms Rui Quek who proofread the manuscript.

Declaration of conflicting interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical statement

This study had been reviewed and approved by the National University of Singapore Institution Review Board under the reference code 2020-September-03.

ORCID iD

Cassandra C. H. See

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Cassandra C. H. See was a candidate in the Master of Psychology (Clinical) programme at the National University of Singapore. Her research interests included the role of emotions in psychopathology. Cassandra is a registered clinical psychologist with the Singapore Psychological Society (SPS).

Vanessa S. Y. Tan was a psychology honours student at the National University of Singapore, Faculty of Arts and Social Sciences.

Jia Min Tan was a psychology honours student at the National University of Singapore, Faculty of Arts and Social Sciences.

Oliver Sündermann, PhD and Dr, is a Clinical Psychologist and Cognitive Behavioural Therapist with over 15 years of experience in the mental health sector. He is the Clinical Director at Intellect, a Singapore-based modern mental health technology company, where he leads the clinical and research team. At the National University of Singapore, he supervises undergraduate research projects and Masters theses in Clinical Psychology. His research interests included obsessive-compulsive disorder, body dysmorphic disorder, digital mental health and proactive mental health care. Dr Oliver is a registered clinical psychologist and supervisor with the Singapore Psychological Society (SPS).

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