Shame and taboo in obsessive-compulsive disorder : implications for the cognitive-behavioural therapies

Section A This is a critical appraisal and narrative review of 11 quantitative studies, investigating the association between taboo obsessions in OCD and treatment outcomes following CBT/ERP.Sexual and religious obsessions were found to be associated with poorer outcomes following CBT/ERP (compared to OCD without such obsessions), with small effect sizes. The picture for violent obsessions was more complex, and synthesis was challenging due to methodological limitations of the reviewed studies. Research and clinical implications are discussed, including the possibility that these findings would be better explained by the covariation of taboo obsessions with feelings of shame. Section B This is an empirical study, using a grounded theory methodology to explore how CBT/ERP may proceed when OCD is characterised by high levels of shame. Twelve individual interviews, with 5 therapists and 7 experts-by-experience, led to the development of a preliminary grounded theory model. This introduces the concept of the "shame shield" to show how the presence of shame may function as a context which interrupts or slows down necessary therapeutic processes (which may proceed in different ways depending on the characteristics of the person and their therapist). Findings are discussed in relation to relevant theory and current clinical practice, considering study limitations and implications.