Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 2532

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Journal of Obsessive-Compulsive and Related Disorders

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

A qualitative study of the investigation of reassurance seeking

in obsessivecompulsive disorder
Osamu Kobori a,n, Paul M. Salkovskis b, Julie Read c, Naima Lounes c, Vivien Wong d
a

Centre for Forensic Mental Health, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba 2608670, Japan
University of Bath, UK
c
King College London, Institute of Psychiatry, London, UK
d
University College London, UK
b

a r t i c l e i n f o

abstract

Article history:
Received 4 July 2011
Received in revised form
21 September 2011
Accepted 22 September 2011
Available online 10 November 2011

Reassurance seeking is a common problem in clinically anxious populations, and is particularly obvious
in obsessivecompulsive disorder (OCD). This study seeks to examine the way individuals with OCD try
to seek reassurance and the perceived consequences of such reassurance seeking using a qualitative
analysis of the perspectives of individuals with OCD who seek reassurance from other people. A semistructured interview was employed to ask individuals with OCD to reect on occasions when they
sought reassurance, and its impact on themselves and others. Ten interviews were conducted,
transcribed, and analysed in detail using thematic analysis. Four overarching themes were identied
in terms of reassurance seeking; interrogating feelings to achieve a sense of certainty, ceaseless and
careful effort, reluctance to seek reassurance, and interpersonal concern. A thematic map was produced
to understand the relationship between themes and sub-themes.
& 2011 Elsevier Ltd. All rights reserved.

Keywords:
Thematic analysis
Obsessive-compulsive disorder
Reassurance seeking
Quality study

1. Introduction
1.1. Impact of OCD
Reassurance seeking is probably the most frequent interpersonal manifestation of OCD. When considering this common
symptom of OCD, Salkovskis (1985, 1999) suggests that from a
cognitive perspective reassurance seeking is best conceptualized
as a special type of checking behaviour. When asking for reassurance, the individual seeks not only to check with others that he or
she has done their best to prevent harm, but in doing so seeks to
implicitly disperse some of the responsibility for the feared
consequence by passing it to the person offering reassurance.
This aim is usually achieved because the person who offers
reassurance has, without necessarily meaning to, both acknowledged their own awareness of the danger and implicitly taken a
share of responsibility if harm were to occur by explicitly or
implicitly endorsing the idea that the person need not take
further action. Thus reassurance seeking is a super-safety seeking
behaviour as it serves both to reduce the perception of threat and
to transfer some of the responsibility for any danger (and therefore the possibility of being blamed) to another person. As a safety
seeking behaviour it also has the effect of maintaining pre-

Corresponding author. Tel.: 81 43 226 2586; fax: 81 43 226 2561.

E-mail address: chelsea@faculty.chiba-u.jp (O. Kobori).

2211-3649/$ - see front matter & 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jocrd.2011.09.001

occupation and preventing disconrmation of the feared

consequences.
Similarly, Rachman (2002) suggests that excessive reassuranceseeking resembles compulsive checking, construed as a strategy
aimed at exerting inuence over negative outcomes (i.e., reducing
threat), and thereby reducing ones perceived responsibility for
such outcomes. He observes that reassurance has another similarity
to compulsive checking; the reductions in perceived threat and
responsibility that follow repeated reassurance are at best temporary, and the attempt to be reassured may even be directly counterproductive by eroding condence in outcomes (Rachman, 2002;
Rachman & Hodgson, 1980; Salkovskis, 1999; van den Hout & Kindt,
2004). Thus, both the functions and the long-term consequences of
reassurance seeking and compulsive checking in OCD appear
similar. On this basis, reassurance seeking is routinely targeted in
response prevention treatments for OCD (see Clark, 2004; Marks,
1981; Salkovskis & Warwick, 1986; Steketee, 1993; Tolin, 2001).
1.2. Reassurance seeking in OCD
Repeated requests for reassurance are particularly common
among individuals with checking compulsions, but such reassurance seeking apparently occurs across the full range of OCD
presentations. For example, clinical experience tells us that
individuals with OCD may ask others whether something is clean,
whether they have done something properly, whether they are
truly religious/heterosexual and so on. People close to the person

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O. Kobori et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 2532

suffering from OCD may be asked to verbally reassure the

sufferer, to support or assist their rituals, or just to be with them
or watch them when they are doing something worrying. However, these clinical observations have yet to be systematically
veried. Parrish and Radomsky (2006) reported greater urges
both to check and to seek reassurance under conditions of high
(vs. low) responsibility/threat, suggesting that these two behaviours may be functionally equivalent and/or driven by similar
processes. Parrish and Radomsky (2010) also assessed factors
involved in the onset, maintenance and termination of reassurance seeking and repeated checking. They employed a semistructured interview with non-depressed obsessivecompulsive
disorder (OCD) respondents, clinically depressed individuals
without OCD, and healthy control participants. Findings showed
that whereas individuals with OCD reported seeking reassurance
primarily about perceived general threats (e.g., re and theft), the
depressed group reported seeking reassurance primarily about
perceived social threats (e.g., abandonment and loss of support).
1.3. The purpose of the present study
The current study employed a qualitative methodology in
order to gain a more in-depth understanding of the way individuals with OCD seek reassurance and the consequences of
reassurance seeking in terms of how they understand reassurance, the way in which they seek it, the way they experience the
effects of reassurance, and what motivates them to seek it. The
specic methodology employed was thematic analysis, a dynamic
research method that can be usefully applied to improve understanding of a phenomenon of interest, inform theory development and strengthen clinical practice (Silverstein, Auerbach, &
Levant, 2006).

2. Method
2.1. Design
In order to understand the nature of reassurance seeking behaviour, thematic
analysis was performed on interview transcripts of individuals with OCD. A semistructured interview schedule was developed with input from experienced
clinicians and service users. A preliminary version of the semi-structured interview was piloted with two individuals with OCD and one healthy control, and the
nal version was slightly modied to take account of their feedback. The structure
of the interview involved four loosely dened sections.
Firstly, the participants views of reassurance: What, in your opinion, is
Reassurance?; Is it good or bad to seek reassurance? Why? In each instance the
interviewer was enabled to ask further questions until he considered the answer
to be complete. Throughout the interview participants were encouraged to seek
clarication themselves if they were unsure of what was being asked.
Secondly, how reassurance was sought: Do you seek reassurance?; When do
you seek reassurance?; Who do you seek reassurance from?; How do you ask for

reassurance?; How long does it take until you stop asking?; How closely do you
listen to the person?; Do you ask the person to do things for you?; Do you seek
reassurance in more subtle ways?; Do you seek reassurance in hidden ways? The
range of reassurance seeking we attempted to identify in the interview was from
direct seeking from people (e.g., is it clean?), asking to assist in the ritual, asking to
do the ritual (e.g., asking his/her partner to wash hands in front of them), selfreassurance (e.g., telling themselves in their mind that it is clean?), to subtle or
hidden reassurance seeking (e.g., calling a friend to make an alibi of where they
were). However, we did not include seeking reassurance from external references
such as internet and medical dictionary.
Thirdly, the effect of being reassured: What happens to you after seeking
reassurance?; How do you feel when you have obtained reassurance?; What
happens to the person who you seek reassurance from?; Is there anything you try
to do for the person?; Is there anything you do to reduce the burden of
reassurance on the person?.
Fourthly, questions seeking to identify the reasons for seeking reassurance:
Are you aware of what the person would respond? If so, why ask?; What makes
reassurance from those people effective to you? Interviews were conversational
with the structure being only loosely superimposed.
2.2. Participants
Participants were 10 individuals who met DSM-IV criteria for a principal
diagnosis of obsessivecompulsive disorder and who reported seeking reassurance from others (i.e., not just self-reassurance). Nine participants were diagnosed
using the Structured Clinical Interview for DSM-IV (SCID, First, Spitzer, Gibbon, &
Williams, 1996) by trained psychologists, and one participant was diagnosed
locally (e.g., by General Practitioner or Primary Care Trust). For this participant
who was diagnosed locally, scoring more than 60 points on Obsessivecompulsive
Inventory distress scale (OCI; Foa, Kozak, Salkovskis, Coles, & Amir, 1998) was
used as a further inclusion criterion. The mean age of the participants was 37.85
years (med. 35, range 2553), and the mean baseline OCI score was 92.57 (med.
94, range 62149). Characteristics of the participants were summarised in Table 1.
2.3. Procedure
All participants of this study had participated in an experimental study about
reassurance seeking and completed OCI (Foa et al., 1998), RAS and RIQ (Salkovskis
et al., 2000), BDI (Beck & Steer, 1987), and BAI (Beck, Epstein, Brown, & Steer,
1988) prior to the semi-structured interview. Written information about the
studies was sent to potential participants in the post, and if they agreed to take
part, they returned the reply slip. After their eligibility for participation was
checked, an appointment was made for them to come to meet the investigators.
Written informed consent was obtained on their arrival, and the purpose of the
studies was explained. They performed an experimental task prior to the interview study. The interview adopted a non-interventionist approach. Interviews
were conducted by the rst author, who had also carried out other studies about
reassurance seeking over the past 2 years. It was believed that familiarity with the
research topic can enhance understanding of the interview response and coherence of the interpretation. Participants were offered a 20 gift voucher for their
participation in the research. The protocol of the current study was approved by
the Research Ethics Committee, as part of a larger study about reassurance seeking
behaviour.
2.4. Qualitative analysis
Audio-recordings of the interviews were transcribed verbatim by the third,
fourth, and fth authors; the current data set therefore comprised the 10

Table 1
Characteristics of the participants.
ID

Gender

Age

Ethnicity

Educational
qualication

Relationship
status

Employment
status

OCI
total

RAS

RIQ

BDI

BAI

1
2
3
4
5
6
7
8
9
10

Male
Female
Female
Male
Female
Female
Female
Female
Male
Female

27
53
25
43
34
27

Mixed
Caucasian
Caucasian
Caucasian
Caucasian
Black
Caucasian
Caucasian
Mixed
Caucasian

Secondary
Secondary
Secondary
Secondary
Secondary
Secondary

Single
Married
Dating
Married
Cohabiting
Single
Single
Cohabiting
Married
Married

Paid Work
On Sick Leave
Paid Work
Unemployed
Unemployed
Unemployed

86
116
112
72
94
113
94
81
139
62

144
128
102
81
107
142
124
159
151
113

66.87
68.75
45.63
28.12
65.00
73.75

6
22
24
23
13
20

6
20
33
31
19
20

30
40
35

Participant declined to provide information.

Postgraduate
a

Secondary

Paid Work
On Sick Leave
Unpaid Work

55.00
72.5
21.25

25
14
10

19
34
13

O. Kobori et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 2532

transcribed interviews, which were analysed in accordance with the established
conventions of theoretical thematic analysis (Braun & Clarke, 2006). Thematic
analysis allows for a degree of epistemological exibility (Braun & Clarke, 2006). It
is compatible with an inductive, data-driven approach whilst, at the same time,
allowing for the integration of prior theory and research. As such, it is appropriate
for use in a multi-method context in which the qualitative element of enquiry is
framed by prior work, consistent with the present study, which is embedded
within a larger quantitative research programme and thus attended by certain
analytic and epistemological constraints.
The procedure as used here involved multiple steps, which are described
below in chronological order. Firstly, each of the interview transcripts was actively
read and reread several times by a single assessor (the rst author), with notes
being made at the side of the transcripts searching for meanings and patters, and
identifying ideas for coding. The interview transcripts were then reread once
again, with full and equal attention given to each data item. Following that, codes
were given to all features highlighted on initial readings. Coded data were then
collated and grouped together in meaningful clusters into separate tables.
Aided by the tables, coded data and their interrelationships were carefully
considered in order to generate overarching themes. Themes were then compared
and either broken down in order to capture different nuances of meaning or
combined according to their commonalities. These differentiating and merging of
themes allowed the development of an analytic hierarchy in which abstract,
overarching themes were identied, composed of sub-themes that, in turn, were
descriptively close to the verbatim data. A thematic map was developed (Fig. 1) to
examine and characterise the inter-relationship between overarching themes and
sub-themes. The process of analysis involved a recursive movement back and
forth between transcription, extract and theme in order to ensure that the
identied structure of themes continued to be grounded in the original transcripts.
Overarching themes were determined by the relevance (to theory development),
prevalence (in more than 80% of the transcripts) and the perceived importance
(based on their potential theoretical and clinical implications) of the data.
Candidate overarching themes and sub-themes were then reviewed by reading
all the collated extracts to examine whether themes and the thematic map work
in relation to the extracts.
The audit of the themes was conducted in two ways. Firstly, the main
transcriber (the third author), who was highly familiar with the interview
transcripts, was consulted regarding the accuracy of the themes once they had
been extracted. Differences in opinions were resolved via discussion. Following
that, the second author (an experienced OCD researcher and therapist) was
provided with the raw transcripts, the coded data, the matrix of codes, the
thematic map, and rst draft of the results, in order to review the process and to
check that the interpretations made were warranted on the basis of the data. This
auditor was asked to pay attention to the appropriateness of the coding scheme,
the thematic map, and the interpretations made on the basis of it. Minor changes
to terminology were made on the basis of these audits. Finally, all transcripts were
reread in order to check that all relevant data had been coded, and to test whether
the thematic map works against the transcription.

3. Results
3.1. Overview
Four overarching themes were identied from the analysis of
the interview transcripts. These are shown with sub-themes and
codes in Table 2. The rst theme, Interrogating feelings to achieve
a sense of certainty, appears to be linked to the motivation of the
participants to seek reassurance in the rst place. The remaining
categories Ceaseless and careful effort, Reluctance to seek
reassurance, and Interpersonal concern represent the process
before, during, and after they seek reassurance. In the next
section, each overarching theme is described immediately followed by its subcomponents with specic examples from the
transcripts.

Table 2
Overarching themes and sub-themes.
Interrogating feelings to achieve a sense of certainty:
Need to feel certain/perfect
Need to feel right
Dispersing responsibility
Ceaseless and careful effort:
Seeking to be reassured in range of ways
Careful asking
Clarity and understanding of the reassurance given
Reluctance to seek reassurance:
Counterproductive effects of reassurance seeking
Limited effect of reassurance
Knowing its bad to seek
Interpersonal concern:
Embarrassment
Causing problems for others by reassurance seeking
Guilt, gratitude and compensation

Need to feel
certain/perfect

Need to feel right

27

Dispersing
responsibility

Interrogating feelings to achieve a

feeling of certainty

Seeking to be reassured
in range of ways

Careful asking
Clarity and understanding of
the reassurance given

Ceaseless and careful effort

Reluctance to seek
reassurance

Interpersonal
concern
Embarrassment

Limited effect of
reassurance
Knowing it's
bad to seek Counterproductive effect
of reassurance seeking

Straining others by
reassurance seeking

Fig. 1. Thematic map of themes and sub-themes.

Guilt, gratitude and

compensation

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O. Kobori et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 2532

3.2. Interrogating feelings to achieve a sense of certainty

This overarching theme describes participants perception of
the perceived function of reassurance in terms of their awareness
of subjective reasons for reassurance seeking and linked motivations. Overall, participants described trying to achieve a subjective sense of certainty, even if they already knew the answer.
They tried hard to make sure that nothing bad will occur to
themselves and/or others that they had done things properly to
prevent bad things from happening that they had gathered all the
information and looked at every option, and that they would not
be responsible if bad things were to occur.
3.2.1. Need to feel certain/perfect
Nine participants indicated that they felt the need to feel either
certain or perfect when they sought reassurance, and they thought
that their anxiety decreased when they became more certain. When
explaining why they sought reassurance, Participant 3 said:
To know that Ill be ok andy you knowynothing is going to
happen to me. And I thinkyyeah, thats why I do that.
Another participant was seeking reassurance to be certain that
she had done the preventative ritual properly:
Participant 2: If I say to him Have I washed my hands? and
hes seen me do it and he says yes, then I feel more certain
without having the compulsion to repeat.
Another participant said that she needed not only to ask her
boyfriend whether he had washed his hands, but also she needed
to look at his hand washing. Even though she knew that he
washed as soon as he comes home, reassurance increases her
feeling of certainty:
Participant 5: I think it does make me feel more condent that
hes washed his hands. Theres less uncertainty about whether
hes washed or not.
Finally, one participant thought that she needed to identify
mistakes by seeking reassurance rather than making sure it is
perfect. Therefore, she felt reassured (but only incompletely) after
spotting mistakes because they could be rectied:
Participant 6: Theres always a mistake. Always something
thats not done properly, I need to conrm that there are
mistakes. I dont think I can think of a situation in which I can
feel clean enough or relaxed or happy or comfortable.
3.2.2. Need to feel right
Four participants felt the need to feel right, safe, or comfortable when they sought reassurance. This tended to be contrasted
with knowing things were right; they were usually aware that the
situation is not dangerous and that they knew the answer the
other person would give, but they still felt compelled to ask until
they felt right. One participant explained the way he sought
reassurance from his wife in order to feel right about the letter he
wrote:
Participant 4: I might read the content of the letter to my wife
and she might say thats ne, thats absolutely ne and Ill go
right but Ill still feel as though maybe its not quite right and
so a bit later Ill say look, do you really thinky.

that. I know that if I move that box twenty times it not going to
make any difference to the box, its not going to make any
difference to me, but the feeling is that its not safe to progress
onto other thingsy
3.2.3. Dispersing responsibility
Three participants felt that they were dispersing responsibility
for harm when they sought reassurance. That is, they tried to make
sure that they would not be to blame when bad things happened.
One participant described it as fear of people saying, oh its all your
fault.
Participant 8: Its like an insurance policy, too. So if the worst
does happen its not all my fault. So although its partly my
fault its like not. So the worst could happen and it would be
awful because it would all be my fault, but the worst could
happen and it would still be awful but at least I could say well,
it wasnt just my own bad judgment.
Another participant mentioned the link between feeling better
and dispersing responsibility:
Participant 1: If something was to happen then Ive got someone to blame, someone to get my anger out on and blame.
I dont know, it just makes me feel better.
3.3. Ceaseless and careful effort
This second overarching theme represents participants constant
caution and cares to ensure that they made sufcient effort to nd
the right reassurance given by the right person in order to be sure
that they could trust the reassurance given. They described trying
very hard to obtain good quality reassurance, and made an effort to
minimise the chance of bad or ill-timed reassurance. They describe
the constant effort involved in seeking to obtain and understand
reassurance in different ways so as to maximise the effect when
doubt emerges after reassurance. They also seek, in a range of ways,
to compensate for the absence of reassurance or bad reassurance.
3.3.1. Seeking to be reassured in range of ways
Seven participants were employing range of different ways to
obtain reassurance in order to maximise their chance of being
reassured, and to consolidate the effect of any reassurance they
had obtained. For example, one participant initially sought to
achieve self-reassurance, then she asked for reassurance from
someone else, and she subsequently self-reassured again:
Participant 6: Are the plates clean? Ill ask myself a few times
and Ill be loud. First of all its in my head and then I have to
ask. Then when I get told very sternly or they dont want to
know, then again internally. Its in-out-in.
Often when participants failed to obtain good reassurance
from someone else, they started to seek reassurance from themselves. For example, one participant self-reassured when no one
was around to ask for reassurance:
Participant 9: Yes I have learnt to do it (self-reassurance)
because of many occasions you dont get someone to reassure
you. [y] Ill ask my mind or head and that person will tell me
Ok, its alright now.

He also explained the contrast between objectively knowing that

it was right and subjectively feeling right, safe, and comfortable:

However, some participants said that if no one was around to

ask for reassurance, they went for other neutralising acts such as
washing and checking:

Participant 4: Well, well, this is the frustrating thing about it. The
logic is always there but, you know, its black and white, its
obvious that somethings there or somethings right, you know

Researcher: So if your wife is away from home and you have to

lock the door, how do you seek reassurance?
Participant 9: Ill go back and do the door three times.

O. Kobori et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 2532

3.3.2. Careful asking

Half of the participants suggested that they became particularly careful when they asked for reassurance. This caution was
expressed in terms of the care used to choose people/experts they
can trust, carefully compose trick questions in order to draw out
the convincing reassurance they hoped for, careful examination of
whether the person was listening to them. This often involves
trying to seek reassurance in hidden ways so that others do not
realise what they are doing. The following participant describes
composed a question to guide her boyfriend to the answer she
wanted whilst maintaining the perceived reassuring value of a
spontaneous response:
Participant 8: Ill tell him a story and try and make him agree
with me. [y] Itll always be, you know, that sort of question
you do with children at school where youre like leading them
to what you want. You know, Oh I stepped on the blood but
its ne, it will have worn off by now, it wont still be there,
will it?
Some participants sought reassurance in hidden ways; one
tried to ensure that her friend did not recognizes her reassurance
seeking:
Participant 7: Ill phone a friend, if I am, like walking past a
school, or I am in a situation that I feel uncomfortable, I would
talk to them in a way that, they wont know that I am ringing
them, because I want an alibi to know where I am and what I
am doingy
3.3.3. Clarity and understanding of the reassurance given
Six participants described making a particularly strong effort
to understand when they received reassurance. They tried hard to
make sure that the person was seriously thinking about the
answer, then paid close attention to how the person answered,
and analysed whether the answer made sense or whether there
were mistakes or inconsistencies in the answer. The following
participant explained that not only did he pay attention to the
tone of voice his wife used, but he also controlled the environment so that he could listen carefully:
Participant 9: The radio will be off, because I start the car with
the radio on then to seek reassurance I switch it off or reduce
the volume. And just look at her, her tone.
Another participant told how he critically analysed the result
of a medical test, which he had been told was negative:
Participant 1: What goes through my head is whether theyve
made a mistake, or whether they got my blood mixed up with
someone else. If it comes back negative then I think maybe
they got my name mixed up with someone else name or
maybe when I rang up that time she made a mistake. So I had
to go in to double check.
3.4. Reluctance to seek reassurance
This third overarching theme reects participants hesitation,
ambivalence, and inhibitions when seeking reassurance. Although
they were motivated to seek reassurance by interrogating feelings
to achieve a subjective sense of certainty, some factors slowed
down or interfered with their reassurance seeking. They felt
reluctant because they were aware of the limitations and counterproductive effects of reassurance, and because they had understood from a range of sources that it is unhelpful to their OCD to
seek reassurance.

29

3.4.1. Limited effect of reassurance

Seven participants were aware of the intrinsic limitations of
reassurance. For example, they cannot believe reassurance when
they received it from someone who they do not trust. They also
knew that it works only temporarily at best. After a while, the
same doubts return and then they ask for reassurance again and
again, or they start worrying about other issues:
Participant 8: Yeah for a while. Yeah for a while. Ill feel ne
about it for a short time and then. And then yeah, I probably
would, might ask him again actually.
The following participant noted that he started worrying about
other issues soon after he was reassured by the medical test
result, which was negative:
Participant 1: But then I felt I was contaminated by the needle
they used to do the test. And then again I felt I had to ring up
the doctor to reassure me that the needle was clean and is
disposed of properly, but that obviously how I gain my
reassurance, by making sure something done medically or
scientically, by someone saying something like youre ok,
youre clean, I still dont believe it.
3.4.2. Counterproductive effects of reassurance seeking
Half of the participants mentioned the negative and counterproductive effects of reassurance seeking. They felt worse as a
result of seeking reassurance and/or became frustrated when
reassurance did not work or when the person did not answer.
They sometimes felt disappointed or misunderstood when the
person did not appear to take the question on board (or treat it
seriously). The following participant said she felt worse when her
boyfriend did not answer and then she needed to do rituals to
compensate:
Participant 8: Quite a lot of the time he doesnt [answer].
Which just makes me cross. [y] Then Im not happy till Ive
washed or cleaned or done whatever it is I need to do.
The following participant described the negative effect of illtimed reassurance:
Participant 4: When the compulsion is so strong, to get it to
feel right, [reassurance] feel[s] as in inverted commas, sort of
thing, [y] someone telling you that its right, it almost feels
like um youre being tripped up before youre trying to do.
3.4.3. Knowing its bad to seek reassurance
Three participants were aware that it is unhelpful for them to
seek reassurance. Some of them learned that it is bad for their
recovery from OCD, while others thought seeking reassurance
meant that they were dependent on others. The following
participant learned, from treatment and her own experience that
it is bad to seek reassurance because it is unstoppable:
Participant 7: I think it is bad, but only because I am undergoing treatment that I know that this prolongs the effects
really, cos you feel better in the short term, but then you want
it more and more and you are never satised. And then even
somebody I trust reassures me, I am still not even then
complete satised always, as I want more.
The following participant thought that seeking reassurance
meant that she was not controlling her anxiety:
Participant 6: It teaches you to rely on other people to stop you
from worrying and I suppose ultimately you need to learn to
control it yourself.

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O. Kobori et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 2532

3.5. Interpersonal concern

The participants were selected from those who sought reassurance from other people, so interpersonal processes are inevitably involved in reassurance seeking. This overarching theme
reects the tension between the compulsion to seek reassurance
and the appropriate concern over having a negative impact on
their relationship with the other person. For example, they were
afraid of seeking reassurance for fear that others may think they
are mad or weak. Although they were desperate to be reassured,
they were concerned that they were straining others by reassurance seeking, and they believed it likely that they would elicit
negative reactions from others. As a result, refrained from
reassurance seeking in order to protect their relationship or
sought to nd other ways of compensating for asking for
reassurance.
3.51. Embarrassment
Half of the participants mentioned the concern that they
would feel embarrassed if they directly asked for reassurance
from other people. The following participants thought that seeking reassurance would reveal them to be weak or as having
difculties, and other people may think negatively or even
ridicule them as a consequence. In some participants, this also
carried a threat to them in terms of their obsessional fears:
Participant 6: I didnt want to draw attention to the fact that
Im concerned. I feel my concern is a weakness. And if you see
my concern you might deceive me and I dont have room
for that.
Participant 8: Um, well, you sort of open up the fact to people
that you nd it difcult to do certain things. I know Ive had
incidents where people, I say ahh, is it clean? and they say no
and they think its really funny. And that just sends me into
overdrive.
The following participant said that he sought reassurance in
subtle and hidden ways because of embarrassment:
Participant 4: So you see the way I would subtly introduce,
you know?
Researcher: So the reason for subtle reassurance isy?
Participant 4: Well its embarrassment. Yes OCD can be very
embarrassing.
3.5.2. Causing problems for others by reassurance seeking
Six participants said that they were bothering, straining and
even draining other people by their persistent reassurance seeking, and usually perceived a negative reaction in the other person:
Participant 3: sometimes hes ne and other times hes
annoyed, cos I asked him a lot of the time, he got fed up with it.
Participant 8: Sometimes I know its going to really annoy him.
And hell get cross.
The following participant described how the person became
frustrated:
Participant 7: Ill feel really contaminated, I would like to wash
that washing again. But hell ask me to stop it, stop being so
stupid kind of thing. Or he would not bother at all, and hell
just get quite angry, sometimes.
The following participant said she emotionally threatened her
boyfriend when he was reluctant to provide reassurance:
Participant 5: Id get quite agitated and ask him to do it until
he got fed up with me keeping on. Otherwise I would get upset

inwardly. [y] If Im really wound up I might say Im going to

cut my arms.
3.5.3. Guilt, gratitude, and compensation
Half of the participants felt guilty about straining others, felt
grateful that other people sought to provide their support, or
actively tried to compensate for asking for reassurance. The
following participant felt guilty about the impact on her boyfriends life and on their relationship:
Participant 7: I feel guilty that my problem is impacting on his
life, and our relationship. I feel cross about that that I cant
always control them, how I am feeling or what I want to do cos
I often feel compelled to do something again and again, even
though I try to stopy
The following participant acknowledged the stress he imposed
on his wife, and he tried to show his appreciation for her care:
Participant 4: I permanently reassure her about how I feel
about her as a person, and what a good person she is, that sort
of thing. Do you understand what I mean? I want her to know
that I do really appreciate what she does, the care and that for
my condition.

4. Discussion
The purpose of the present study was to identify patients
report of the phenomenology of reassurance seeking, including
both their view of the motivation to seek it, and their reactions
once it was provided. In addition, the strategies used were
elaborated, and we sought to clarify the interpersonal consequences of reassurance seeking from the perspective of the
sufferer. The results that are obtained are consistent with the
view that reassurance seeking is motivated by the need for
certainty, with a common theme being the person with OCD
responding to reassurance provision by interrogating their feelings in reaction to reassurance to achieve a sense of certainty
about their obsessional fears. When they seek reassurance,
individuals with OCD are mostly (but not entirely) certain about
the answer. However, they experience lingering doubts, mostly
fuelled by the obsessional thoughts themselves (what if???) and
thus feel that they are not subjectively certain that bad things are
not going to occur or that they would not be entirely responsible
if bad things were to occur.
Reassurance thus has the same function as checking, which is
to remove all elements of uncertainty regarding the occurrence of
harm and their personal responsibility for it. Reassurance seeking
is another type of attempt to resolve intolerance of uncertainty
regarding the possibility of responsibility for harm to themselves
or other people. This manifests in the qualitative analysis in term
of OCD patients describing the function of reassurance in terms of
active, motivated attempts to achieve feelings of certainty, of
being perfect, of being right, feeling comfortable with the situation they are in and the actions they have taken and so on.
When they are driven by those motivations to seek reassurance, individuals with OCD become extremely careful, manifest in
the present study as consistent reports of consciously and
deliberately making a ceaseless effort to be certain/sure before,
during, and after they seek reassurance. They also seek reassurance in range of ways, which are either intended to maximise the
effects of their previous compulsive behaviour or compensate for
failed ritualising and reassurance seeking. They describe paying
careful attention to the reassurance provider in the course of their
seeking reassurance, but also describe the seeking of reassurance
in subtle/hidden ways, including the use of trick questions.

O. Kobori et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 2532

They describe the care taken in terms of scrutinising the persons

face, analysing their tone of the voice, and critically examining the
answer they obtained, sometimes subjecting the responses to
supplementary self-reassurance.
Although it is clear that the motivation to seek reassurance is
strong, individuals with OCD also experience hesitation, ambivalence, and inhibitions, which can interferes with their reassurance
seeking. These seem to stem from aspects of insight, that is, their
awareness not only of the potential counter-productive effects of
reassurance through increasing their discomfort both in the short
and longer terms in the same way as overt washing and checking
can do, but also because once they had begun to seek reassurance,
there is the risk that reassurance might increase doubts and fears as
the wrong responses are given. Some participants understand that
reassurance seeking, like other forms of compulsive behaviour, is
part of the problem rather than any kind of solution. Clearly,
however, as with obsessional ritualising, the experience of obsessional fear can overwhelm their resolve not to seek reassurance.
Another key factor identied in this study is the patients
concern regarding the other persons reaction to reassurance,
either because seeking it reveals embarrassing fears or because
the repetitive and illogical nature of repeatedly asking odd
questions opens them to ridicule and/or hostilityy.. Why are you
bothering me with this?
Fig. 1 seeks to depict the relationship between the overarching
themes and sub-themes and the inter-relationship between different
overarching themes. Ceaseless and careful effort can be linked their
reluctance to seek reassurance because they persons suffering from
OCD is aware that there are limits on their opportunities to obtain
good reassurance. Asking for reassurance carefully is linked to
attempt to avoid counterproductive effects of careless or unnecessarily repetitive reassurance seeking, such as receiving unhelpful or
contradictory reassurance. There is a further link to interpersonal
concern in terms of asking for reassurance carefully, particularly in
hidden/subtle ways, as a way of minimising embarrassment or
hostility. In addition, the seeking of clarity (certainty regarding
content) can itself impose strain not only on the person with OCD
but also the person giving reassurance; some OCD sufferers were
aware of the problem of themselves showing frustration when they
receive bad reassurance.
Seeking reassurance is, of course, a normal phenomenon not
conned to people suffering from OCD. It is closely linked to the
experience of anxiety and attempts to relieve or dilute it. Thus,
the question is not simply why people might seek reassurance,
but why they do so persistently and in ways, which become
counter-productive. The present ndings shed light on this issue.
Firstly, as discussed above, reassurance has the same function as
other types of obsessional checking. Thus, reassurance seeking is
employed to resolve intolerance of uncertainty regarding the
possibility of responsibility for harm to themselves or other
people. Secondly, reassurance seeking can be utilised as an
alternative more acceptable strategy in order to feel safe particularly when checking or other types of compulsions are prohibited. In other words, some individuals with OCD are not aware of
the counterproductive nature of reassurance seeking, and they
turn to reassurance as a solution. Thirdly, because individuals
with OCD seek reassurance in subtle or hidden ways in order to
draw out convincing answers and/or so that other people do not
notice reassurance seeking, it is sometimes difcult for carers and
even therapists to spot it. Moreover, individuals with OCD may
seek reassurance without noticing that they are seeking it,
because actions are automatic or proceduralised. For example,
they seek reassurance by watching another persons reaction to
OCD related statements. It was beyond the scope of the present
study to evaluate such reassurance, which is being investigated in
studies following on from the present one. Finally, individuals

31

with OCD are mostly aware that seeking reassurance bothers,

strains, and drains other people. However, they try hard to keep
sources for reassurance by seeking reassurance in hidden ways,
by compensating other people for asking for reassurance, by
employing self-reassurance.
Another strand of research has addressed this issue with respect
to both checking and washing in OCD. The cognitive behavioural
model of OCD (Salkovskis, 1999) proposes the use of potentially
counterproductive stop criteria as a common response to fears of
being responsible for harm. The person actively seeks to achieve a
particular subjective or emotional state such as sense of satisfaction or completeness and just right feelings, as way of deciding
that it is appropriate to stop behaviour. The use of just right and
other subjective states to decide on the termination of an action
could be regarded as an example of the operation of Elevated
Evidence Requirements (Tallis, Eysenck, & Mathews, 1991; Wahl,
Salkovskis, & Cotter, 2008). Two overarching themes identied
here in terms of the occurrence of repetitive reassurance seeking,
which is difcult to curtail (Interrogating feeling to achieve a sense
of certainty and Ceaseless and careful effort) can be readily linked
to difculty stopping other types of compulsions (Salkovskis, 1999;
Wahl et al., 2008).
An implication of the active use of elevated evidence requirements is that the decision making process is controlled in the
sense that it requires mental effort, is deliberate and conscious
(McNally, 1995). This can be contrasted with the termination of
non-compulsive behaviours (such as hand washing or door locking in people who do not suffer from OCD), which are almost
invariably automatic or proceduralised, i.e., involve little or no
conscious effort and are not deliberately terminated. Wahl et al.
(2008) noted both in a questionnaire study and in a laboratory
setting those obsessional washers experienced the decision making process as more deliberate and as requiring more mental
effort than controls. Termination of reassurance seeking might be
understood as another example of the counter-productive application of elevated evidence requirements, because they perceive
the feared outcomes linked to their reassurance seeking to be so
important, individuals with OCD consciously and carefully seek to
achieve subjective feelings of certainty, perfect, right, comfortable
in the way that others would do for life and death decisions.
Note that declarations of complete certainty are easier to obtain
by interrogating others as opposed to oneself.
Consistent with the present ndings, Parrish and Radomsky
(2010) found that individuals with OCD and depression often report
terminating reassurance seeking as a result of interpersonal concerns such as fears of embarrassment, causing others to become
angry/frustrated and so on. They also found that the function of
reassurance for individuals with OCD is to reduce anxiety and to
prevent general harm (i.e., ensure safety). The present ndings
support the hypothesis that compulsive checking and reassurance
seeking are functionally equivalent in the context of OCD, suggesting
that reassurance seeking is more likely to function as a type of
verication rather than as restitution (such as in washing rituals).
Thematic analysis, which was employed in the present study,
recognizes the input from both the participants being interviewed
and the researcher who conducts the analysis. Hence, results of the
present study represent not only how the individuals with OCD
made sense of their own experience, but also how the researchers
interpreted the participants description of the way they made sense
of their reassurance seeking. Efforts were made to minimise
researchers biases and to increase the transferability and integrity
of the data interpretation, for example, the audits on the coding and
interpreting of the data and the inclusion of direct quotations from
the participants.
Qualitative studies of the type reported here can be criticized
for their focus on narratives provided by a small sample of

32

O. Kobori et al. / Journal of Obsessive-Compulsive and Related Disorders 1 (2012) 2532

participants. The themes that were identied from the present

study may not be generalisable to the broader OCD population.
There may also be a discrepancy between narratives and actual
reassurance seeking in real life. However, the current study had as
its primary aim a rich and in-depth exploration of reassurance
seeking, and is intended to inform other quantitative studies at a
later stage of the research programme. Acknowledging the limitations of this qualitative methodology, we are currently carrying
out quantitative studies (descriptive and experimental) in order
to validate the ndings of this study and further enhance the
understanding of reassurance seeking in OCD. Firstly, our questionnaire study compares individuals with OCD, individuals with
other anxiety disorders, and healthy controls in terms of how
frequently they seek reassurance, how much trust they put in
various sources to seek reassurance, how many times they seek
reassurance until they stop, and how carefully they seek reassurance. We also ask them how anxious, reassured, guilty, etc. they
would feel in the short term and in the long term after reassurance, and when they receive bad reassurance and no reassurance.
The experimental study investigates the effect of reassurance in
the short term and in the long term. We ask individuals with fear
of contamination to touch an anxiety provoking (contaminating)
stimulus, wash their hands, and seek reassurance from either
someone who understands them or someone who does not
understand them, in order to manipulate the trust in reassurance.

5. Conclusion
In conclusion, the present study sought to qualitatively investigate reassurance seeking in anxiety disorders. Main results
suggest that the reduction of uncertainty is a key perceived
motivation for reassurance seeking in OCD. Sufferers attempt to
ensure the validity of reassurance whilst they frequently seek to
minimise the negative impact of reassurance seeking and the
linked interpersonal problems.
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