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Oxford Guide to
the Treatment of Mental
Contamination
Oxford Guides in Cognitive Behavioural Therapy

Oxford Guide to Low Intensity CBT Interventions

Bennett-Levy, Richards, Farrand, Christensen, Griffiths, Kavanagh,
Klein, Lau, Proudfoot, Ritterband, Williams, and White

Oxford Guide to Imagery in Cognitive Therapy

Hackmann, Bennett-Levy, and Holmes

Oxford Guide to Metaphors in CBT

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Oxford Guide to Surviving as a CBT Therapist

Mueller, Kennerley, McManus, and Westbrook

Oxford Guide to the Treatment of Mental Contamination

Rachman, Coughtrey, Radomsky, and Shafran

Also published by Oxford University Press

Oxford Guide to Behavioural Experiments in Cognitive Therapy
Bennett-Levy, Butler, Fennell, Hackmann, Mueller, and Westbrook
Oxford Guide to
the Treatment
of Mental
Contamination

Stanley Rachman
Anna Coughtrey
Roz Shafran
Adam Radomsky

1
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
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© Oxford University Press 2015
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First Edition published in 2015
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and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
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ISBN 978–0–19–872724–8
Printed in Great Britain by
Clays Ltd, St Ives plc
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
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Links to third party websites are provided by Oxford in good faith and
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contained in any third party website referenced in this work.
 Dedication
To Emily Rachman, Tina Shafran, Doreen Radomsky, Nikolas Dixon,
and the Nightall Family.
 Acknowledgments

It is with pleasure that we acknowledge the assistance and advice of many

colleagues. Several of the earliest and most intriguing cases were treated
in collaboration with Dr M. Whittal of the Anxiety Disorders Clinic at
the University Hospital in Vancouver. Her contribution to the evolving
ideas about contamination was invaluable. Other colleagues who made
helpful contributions were Dr P. McLean, and Dr Clare Philips. Corinna
Elliot, Eva Zysk, P. de Silva and Melanie Marks on OCD and trauma,
and Paul Rozin’s writings on the topic of disgust, were significant influ-
ences in the development of the concept of mental pollution.
 Contents

Part 1 Contamination Fears

1 Clinical Fears of Contamination 3
Case illustration of fear of contamination in OCD 19

2 Feelings and Features of Contact and Mental

Contamination 23
Case illustrations of contamination 37

3 Forms of Mental Contamination 43

Case illustrations of different forms of mental contamination 51

4 A Cognitive Theory of Contamination Fears and Compulsive

Washing 55

Part 2 Cognitive-Behavioral Treatment of Mental

Contamination
5 Assessment and Formulation of Mental Contamination 83
6 Overview of Cognitive Behavioral Treatment of Mental
Contamination 95
Case illustrations of cognitive behavioral methods 110

7 Contamination After Physical or Psychological

Violations 117
Case illustrations of treatment of contamination after physical or psychological
violations 122

8 Self-Contamination 125
Case illustrations of the treatment of self-contamination 130

9 Morphing 137
Case illustrations of the treatment of morphing 144

10 Visual Contamination 155

Case illustrations of treatment of visual contamination 156

11 Case Series 159

12 Implications of Cognitive Behavioral Therapy for Mental
Contamination 169
x CONTENTS

Part 3 Toolkit: Appendices

1 VOCI (Contact) Contamination Subscale Items 175
2 VOCI Mental Contamination Scale (VOCI-MC) 177
3 Contamination Thought–Action Fusion Scale 179
4 Contamination Sensitivity Scale 181
5 Personal Significance Scale (Intrusive Thoughts) 183
6 Contamination Standardized Interview Schedule 187
7 Treatment for OCD: Information for Patients 191
8 Morphing: Information for Patients 193
9 Self-Contamination: Information for Patients 197

References 199

Index 207

Part 1

Contamination Fears

1 Clinical Fears of Contamination 3

2 Feelings and Features of Contact and Mental
Contamination 23
3 Forms of Mental Contamination 43
4 A Cognitive Theory of Contamination Fears and
­Compulsive Washing 55
 Chapter 1

Clinical Fears of Contamination

Recognition of the occurrence of mental contamination raised the need

for methods to treat this disorder and the purpose of this book is to
describe the nature of mental contamination and how it is treated.
The book comprises three parts. The first describes the nature of men-
tal contamination and how to recognize it. The second provides details
of general treatment procedures, followed by specific methods for man-
aging the various manifestations of mental contamination. This part
also gives a detailed account of how to assess mental contamination and
how to evaluate the progress of therapy. The clinical implications of the
concept of mental contamination are discussed. The final part provides
a toolkit for therapists to use in their therapeutic practice. The mani-
festations of mental contamination and treatment techniques are illus-
trated by numerous case histories throughout the book. Exercises that
are designed to give patients and therapists a sense of what contamin-
ation feels like are included in the text. The terms “patient,” “client,” and
“participant” are used as appropriate.

1.1 Contamination in obsessive compulsive

disorder (OCD)
Fears of contamination are important because they feature so prominently
in the serious psychological disorder, OCD. They are the driving force that
compels people to wash repeatedly. Cleaning compulsions are the second
most common form of OCD compulsion, exceeded only by compulsive
checking/doubt. In a sample of 560 people with OCD, Rasmussen and
Eisen (1992) found that 50% had fears of contamination, very similar to
an earlier figure of 55% compiled from a series of 82 patients seen at the
Maudsley and Bethlem Hospitals in London by Rachman and Hodgson
(1980). Comparable figures on the incidence of compulsive cleaning have
been reported in a number of studies (Antony et al., 1998).
4 Contamination Fears

The cleaning compulsions are out of control, bizarre, and unadaptive.

Over time, the cleaning turns robotic and stereotyped. It is not uncommon
for patients to complain that they have forgotten how to wash normally,
and even ask for demonstrations to remind them. Compulsive washing
is so obviously abnormal that it has become almost definitional of OCD.
Compulsive washing usually involves vigorous, repeated cleaning of one’s
hands because most of our contacts with the external world, including
contacts with dirty or dangerous substances, are through our hands.
The compulsive behavior is an attempt to clean away a perceived con-
taminant in order to reduce or remove a significant threat. Contam-
ination can threaten to harm one’s physical health, mental health, and
social life. The contaminants fall into four broad classes: disease, dirt/
pollution, harmful substances, and mental contaminants.
In addition to the familiar contamination, contact contamination,
which is caused by touching a dirty or dangerous contaminant, such
as waste products, blood, or bloody items such as bandages, decaying
foods, or pesticides, there is another less obvious form of contami-
nation fear—mental contamination. The “mental” form arises from
experiencing psychological or physical violation. The source of the con-
tamination is a person, not contact with an inert inanimate substance.
In contact contamination the site of the feelings of contamination is
localized, usually on the hands, and is therefore accessible. In mental
contamination, however, the feelings of dirtiness and pollution are dif-
fuse, mainly internal and difficult to localize.

1.2 The nature of contamination fear

The fear of contamination is complex, powerful, probably universal, eas-
ily provoked, intense, difficult to control, extraordinarily persistent, vari-
able in content, evident in all societies, often culturally accepted and even
prescribed, and tinged with magical thinking. Usually the fear is caused
by physical contact with a contaminant and spreads rapidly and widely.
A fear of contamination can also be established mentally and without
physical contact. Fears of contamination are more complex and subtle
than they appear to be, and the concept of mental contamination opens
wide the door. See Box 1.1.
 Clinical Fears of Contamination 5

Box 1.1 Four key qualities of fear of contamination

◆ Rapid acquisition
◆ Non-degradability
◆ Contagious
◆ Asymmetric

In most instances of contact contamination, the feelings of contami-

nation are acquired rapidly, indeed instantly, after touching a tangible
inanimate object or substance, or a contaminated person. The feelings
spread rapidly from object to object, from person to person, from per-
son to objects, and from objects to persons. The contagious quality of
contamination is most evident among patients who fear that they are in
serious danger of contracting an illness. The fear of being contaminated
by a contagious illness is itself contagious.
People who are frightened by the wide spread of contamination live
in a pervasively dangerous world. One patient described his constricted
world in this way: “As soon as I walk out of my front door it is Vietnam.”
Once the fear takes grip, their vigilance and precautionary behavior can-
not keep pace with the spreading contamination, and if left untreated
the fear compels them to avoid more and more places and people. There
is no spontaneous braking mechanism to prevent the spread of the con-
tamination. Entire cities can become contaminated.
Contamination is generally transmitted at full strength, and a small
amount of contamination goes a long way (in both senses). However,
there is a curious asymmetry in the spread of contamination. A tea-
spoonful of contaminated fluid is sufficient to spoil an entire barrel of
clean water, but a teaspoonful of clean water will do absolutely nothing
to cleanse the contents of a barrel of contaminated water.
Asymmetry is also observed in the transmission of contamination
from person to person, or even from group to group. A person from
a group believed to be sullied or polluted, such as an “untouchable” in
6 Contamination Fears

India, can contaminate someone of a higher and purer status by mere

proximity (Anand, 1940). The reverse rarely occurs; a person of high
status cannot “cleanse” an untouchable person by direct or indirect con-
tact. The entry of a contaminated person into an unsullied group will
contaminate the group, but the entry of a clean person into a “contami-
nated” group will not cleanse the group.
In large part, contamination becomes pervasive because it does not
easily degrade. The qualities of non-degradability, contagion, and per-
vasiveness are evident in the rooms that severely affected patients keep
locked for years and years in order to seal off the contamination. Intense
feelings of contamination seldom degrade spontaneously, and even
under treatment can be slow to diminish. Moreover, contaminants can
leave traces even after the contaminated item has been removed. Tolin
et al. (2004) demonstrated that contamination passes from object to
object with virtually no loss of intensity. A contaminated pencil was used
to touch neutral pencils, and the same level of contamination was trans-
ferred from pencil to pencil without loss of intensity. This demonstra-
tion is consistent with reports made by patients experiencing feelings
of contamination. Objects that were felt to be contaminated 5, 10, even
20 years earlier retain their original level of contamination. It has now
been demonstrated that feelings of mental contamination can be trans-
ferred in a similar manner to Tolin’s pencil experiment (Coughtrey et al.,
2014a), and we describe an exercise to demonstrate the phenomenon of
mental contagion to help patients learn about the qualities of contamina-
tion (see Activity 2.4 on page 42).
“Spontaneous” inflations of the feelings of contamination sometimes
occur, especially in cases of mental contamination. Changes in the patient’s
perceptions, memories, and cognitions about the person who is the prima-
ry source of the contamination, the violator, can inflate the contamination.
Changes in the perception of secondary sources of contamination can also
do it, but the largest effects occur in response to the primary source.

1.3 Memory
“I can never seem to find my keys, but I can surely tell you where
the germs are in my home.”
 Clinical Fears of Contamination 7

Most patients have an enhanced memory for contaminating cues and

events and can retain a precise memory of the nature and exact where-
abouts of contaminated material, even going back as far as 20 years or
more. For example, a patient was able to recall the exact spot in the hos-
pital parking lot where he had seen a discarded stained band-aid 10 years
earlier. He was still avoiding the tainted area. Characteristically he was
able to describe in detail the original stained band-aid, its exact location,
and the position of his car.
An OCD participant in an experiment on memory said that he could
recall the “location of every chair at work (a restaurant) that has been con-
taminated, the type of contaminant involved, a description of the person
sitting there, and what cleaners were used to remove the contaminant, over
the last five years” (Radomsky and Rachman, 1999, p.614). Others will
recall the exact spot on a shelf on which a container of pesticides was
briefly placed years earlier, and so forth. In these common instances, one
observes a familiar combination of the non-degradable quality of the con-
taminant and an enhanced memory. If an item is contaminated and pre-
sents an unchanged threat, remembering its location makes good sense.
The results of this experiment by Radomsky and Rachman (1999) are
consistent with clinical experience in showing that people with fears of
contamination display superior recall of contaminated objects, relative
to anxious participants and non-clinical controls who do not have this
particular fear. The OCD participants with a fear of contamination dis-
played a superior memory for those items which had been touched by
a “contaminated” cloth in an array of 50 items, half of which were free
of contact with the contaminant. There were no differences between the
three groups of participants on standard tests of memory.
The clinical observations and experimental findings which indicate
superior memory among people with OCD, under specifiable conditions,
are difficult to reconcile with the idea that these patients suffer from a
memory deficit, probably attributable to biological abnormalities (Clark,
2004; Rachman, 1998, 2004; Radomsky and Rachman, 1999; Tallis, 1997).
In OCD, memory problems are usually caused by a loss of confidence in
one’s memorial capacity rather than a biological deficit (Radomsky et al.,
2003, 2006; Tolin et al., 2004; van den Hout and Kindt, 2003).
8 Contamination Fears

1.4 Normal and abnormal feelings of contamination

As with virtually all human fears, there is a continuum of fears of con-
tamination, ranging from the mild and circumscribed, to moderate
fears, and ultimately to those which are abnormally intense, abnormally
extensive, and abnormally sustained by belief and conduct. Abnormal-
ly strong fears of contamination are unyielding, expansive, persistent,
commanding, contagious, and resistant to ordinary cleaning.
Not all feelings of contamination are excessive, irrational, and una-
daptive. Contamination by contact with disgusting or dangerous mater-
ial is a common, probably universal, experience. However, the sense of
contamination does not arise until the person passes through the earli-
est years of childhood. Young children attempt to touch or even eat
matter that is known by everyone else to be dangerous or disgusting.
Naturally they are ignorant of possible sources of infection, and the con-
cept of infection. They do not avoid infectious people or materials and
display no disgust even in contact with excrement. Further, people are
tolerant of their own bodily products, and those of their infants, but are
disgusted by those of other people. Contact with the bodily products of
other people or animals usually produces feelings of disgust contam-
ination and strong urges to clean oneself. As a rule, people believe that
anything which the body excretes must not be allowed to re-enter one’s
body (Douglas, 1966).

1.5 What causes a fear of contamination?

As there is no a priori reason to assume that the fear of contamination
is fundamentally different from other fears, the question of causation is
approached from one of the prevailing theories of the development of
human fears, namely the three pathways of theory of fear acquisition
(Rachman, 1978, 1990). According to this theory, the three pathways
consist of conditioning, vicarious acquisition, and the transmission of
fear-inducing information. A powerful illustration of the informational
genesis of intense fear is provided by recurrent epidemics of koro in S.E.
Asia (Rachman, 2002). Rumours of an outbreak of koro, a fear of male
genital shrinkage and impending death, can cause panic. An epidemic
 Clinical Fears of Contamination 9

of koro was set off in Singapore by a rumour that the Vietcong had con-
taminated the food supply.
Each of the pathways can be illustrated by clinical examples.
In most cases it is possible to construct a cause and a path of develop-
ment for the particular fear. The fear of contamination by contact with
a person with HIV started for a highly sensitive person after he shared
a wine glass and cigarettes with an unfamiliar person at a large, well-
lubricated, rowdy, all-night party. The fear of picking up unspecified
but pervasive germs led another patient to live a secluded life and wash
compulsively. She had been raised by an extremely anxious mother who
was constantly watchful for dangers and every day warned her to avoid
touching suspect items. Clothing was washed three or four times before
use, the kitchen was scrubbed down with disinfectants every day, and
travel was treacherous. A reclusive patient had a dread of dirt that kept
her virtually housebound. The problem arose when she had a prolonged
bout of digestive problems in early adulthood and developed a fear of
losing control of her bowels in public and/or exuding unpleasant smells
in public. For many years, long after the digestive difficulties had been
overcome, she showered compulsively and limited her excursions to a
minimum. The patient carried out her shopping at unsocial hours, usu-
ally late at night. She feared a social catastrophe and attempted to avert
the threat by compulsive cleaning and wide avoidance. An 18-year-old
man developed a fear of touching pesticides, anti-freeze fluid, and then
most other chemical products. It began when he heard that the father of
a friend had committed suicide by drinking anti-freeze and was found
dead in his garage. He was so shocked and frightened that he became pre-
occupied with the story, even though it may well have been inaccurate,
and took to washing his hands intensively. He avoided all contact with
chemicals and places where chemicals were stored. Because of the fear,
he avoided garages and had to arrange for other people to refuel his car.
A highly responsible woman was caring for her infant granddaughter,
as promised, despite feeling ill. She had what seemed to be a bad cold
(actually flu) and was sneezing and coughing but persisted in carrying
out her obligations. Late that night the parents realized that the baby
was struggling to breathe and rushed her to emergency. She had such a
10 Contamination Fears

serious fever and respiratory difficulties that she was admitted to hospi-
tal for intensive treatment. The cause of the infant’s illness was medically
unclear, but the grandmother interpreted it as her fault, feeling that she
had transmitted her flu to the child. As a result she developed a strong
fear of disease contamination and took to washing repeatedly and inten-
sively with the aid of disinfectants. She was preoccupied by the fear that
she was at risk of becoming contaminated and might die. Unsurpris-
ingly, she was terrified of transmitting diseases to her family.
Another patient developed a vicarious fear of disgust contamination
after witnessing a friend slip and fall into a deep puddle of pig manure
during a holiday in the countryside. The friend screamed as she fell into
the puddle and after climbing out was filthy and distressed for hours.
Shortly after this event the patient became highly sensitive to dirt and
began washing vigorously and frequently, especially before leaving her
home. Another patient developed a fear of being contaminated by dan-
gerous substances after erroneously being told that someone had died
after drinking from a bottle that contained brake fluid.
These cases illustrate the three pathways to fear—by conditioning,
observational learning, and absorbing threatening negative informa-
tion. The patient who dreaded touching anything even remotely con-
nected to AIDS had developed a conditioned fear; the person who had
a pervasive fear of germs was exposed to a frightened model through-
out her life and was given a daily diet of frightening information; the
reclusive patient’s fear was a combination of conditioning and negative
information that she had picked up when attempting to cope with her
medical problem; the person who avoided contact with chemical prod-
ucts developed a fear of chemical contamination as a result of disturbing
negative information.
A full account of the status of the fear-acquisition theory is provided
elsewhere (Rachman, 1990, 2004, 2013) and for present purposes three
points merit attention. First, a fear of being contaminated by contact
with a suspect item can be generated by the transmission of threatening
information. Second, a fear of contamination assuredly can be gener-
ated by observing the frightened reactions of other people to actual or
threatened contact with a notorious contaminant. Third, conditioning
 Clinical Fears of Contamination 11

processes can establish disgust-reactions in a manner comparable to

conditioned fear reactions. It is probable that fear and disgust can be
simultaneously conditioned. Recognition of the occurrence of mental
contamination, a fear of being harmed by contamination, which results
from a psychological or physical violation, requires the addition of a
fourth pathway to the acquisition of fear—namely via physical or psy-
chological violation. Psychological/emotional violation, in which “no
skin is broken,” can be as damaging as physical abuse.
It has been proposed that certain fears, such as a fear of deep water,
might arise without any relevant learning experiences; they have always
been present. Poulton and Menzies (2002) set out a plausible case for some
of these “non-associative” fears (see Craske, 2003, for a critical view).

1.6 The consequences of a fear of contamination

The strength and depth of contamination fears is evident from the wide-
ranging consequences which follow the emergence of such fears. The con-
sequences are cognitive, emotional, perceptual, social, and behavioral.
Affected people construe the world and themselves in a changed fashion.
They become highly sensitive to possible threats of contamination, and
the result is hypervigilance. The parameters of danger are expanded and
the areas of safety are newly constrained. Memories of contamination-­
relevant situations or events are enhanced. They believe that they are
especially vulnerable to contamination and its anticipated effects.
In cases of contact contamination, elevated attention is concentrated
predominantly on external cues, such as dirty bandages, but can include
the scanning for internal cues of contamination, dirt/infection. “Am I
now entirely, certainly, safely clean? Does my body feel absolutely clean?”
As with other fears, it gives rise to consistent overpredictions of both the
likelihood of experiencing fear and the intensity of the expected fear
(Rachman, 2004). “If I visit my relative in hospital I am certain to feel
extremely frightened of becoming contaminated.”
A fear of contamination can lead to intense social anxiety and avoid-
ance. Patients who fear their own bodily pollution can become acutely
sensitive to the effects of their pollution on other people. Given their
beliefs about the pollution, it is not unreasonable for them to dread how
12 Contamination Fears

people will react to it, and they anticipate rejection. People who are espe-
cially sensitive to negative evaluations are likely to be particularly vul-
nerable. Another social threat, seen most strongly among people with an
inflated sense of responsibility, is the dread of passing the contamination
on to other people and therefore endangering them. In these instances
the usual fear and avoidance is accompanied by guilt.
In cases of mental contamination the elevated vigilance focuses on the
violator, people, and places that are closely associated with him/her and
can also include internal scanning of the body to try to detect signs of
persisting contamination. In cases of morphing, anyone who possesses
and/or displays the undesirable characteristics that the patient dreads he
might acquire, or worse that might intrude into his mind or personality,
is strictly avoided. The consequences of feelings of self-contamination
include guilt, self-criticism and doubt, and concealment.

1.7 Methods of coping

In cases of contact contamination the fear of being contaminated gener-
ates powerful urges that can dominate other considerations. Affected
people try to avoid touching anything until they have cleaned them-
selves. Attempts to clean oneself, and one’s possessions such as vehi-
cles and clothing, are compulsive in that they are: driven by powerful
urges, commanding, very hard to resist, repetitive, and recognized by
the affected person to be extreme and at least partly irrational. The most
common form of compulsive cleaning is repeated handwashing, which
typically is meticulous, ritualistic, unchanging, difficult to control, and
so thorough that it is repeated again and again, even though it abraids
the skin. There are instances in which patients continue washing despite
the reddening of the water caused by their bleeding hands.
Paradoxically, the compulsive washing causes dryness of the skin
because it removes natural oils and the person’s skin becomes blotchy,
dry, and cracked, especially between the fingers. If the core fear is that
one’s health might be endangered by contact with contamination mate-
rial, it is common to overuse disinfectants, supposedly anti-bacterial
soaps, and very hot water.
 Clinical Fears of Contamination 13

In addition to the need to remove a present threat of contamination by

cleaning it away, compulsive cleaning is carried out in order to prevent
the spread of the contamination. “If I do not clean my hands thoroughly
I will spread the contamination throughout the house.” Other attempts
to prevent contamination include the use of protective clothing (e.g.,
gloves, keeping outdoor clothing and indoor clothing separated, using
tissues to handle faucets, door handles, and toilet handles) and taking
care to remove sources of potential contamination, such as pesticides
and anti-freeze fluid.
In the process of avoiding contamination the person steadily sculpts
a secure environment, establishing some sanctuaries. As the number
of safe places shrinks, one’s own room tends to evolve into a personal
sanctuary and great care is taken to ensure that it remains uncontami-
nated. The home as a whole is safe but less safe than one’s room because
other members of the family do not share the patient’s super-sensitivity
to contamination, and care less about taking precautions. At the other
extreme of the continuum there are highly contaminated places, such as
public lavatories and clinics for the care of people with sexually trans-
mitted diseases.
The fear of contamination generates elaborate and vigorous attempts
to avoid coming into contact with perceived contaminants. An otherwise
well-adjusted woman developed an intense fear of being contaminated
by any bodily waste matter, animal or human. She became hypervigilant
and avoidant, but on one fateful day she woke up to find that a dog had
defecated on the lawn directly outside her front door. She was shocked
and felt thoroughly contaminated. Repeated showers relieved her not,
and within days she dreaded leaving or returning to her house (now
using only the back door).The fear became so intense that she sold her
house and moved into a rented home in another suburb. As this failed
to help her, she decided to move to another city, and forever avoided
going anywhere near the city in which the trigger event had occurred;
she regarded the entire city as contaminated. Her extreme avoidance
illustrates the rapid and uncontrolled spread of dreaded contamination.
Among people who have an inflated sense of responsibility, a major
factor in many instances of OCD (Salkovskis, 1985), their fear of
14 Contamination Fears

contamination, is manifested in the usual compulsive cleaning, but they

also exert special efforts to prevent the spread of contamination. They
are strongly motivated to protect other people from the dangers of con-
tamination and strive to maintain a contamination-free environment.
They try to ensure that the kitchen and all eating implements are totally
free of germs, dirt, and tainted food. One father insisted on steriliz-
ing his baby daughter’s feeding bottles at least ten times before re-use.
Affected people try to ensure that their hands are completely free of con-
tamination before touching other people or their possessions. If they
feel that they have not been sufficiently careful, anxiety and guilt arise.
They try to recruit the cooperation of relatives and friends in preventing
and avoiding contamination, but seldom succeed in persuading adults
to comply with their excessive and irrational requests.
People who feel that their cleaning and avoidance behavior have not
ruled out the threat from contamination resort to neutralizing behav-
ior and/or a compulsive search for reassurance. Coping with a fear of
mental contamination, however, presents some problems. The con-
tent and intensity of the fear can be changeable and puzzling because
of the obscurity of the contaminants. What is provoking the feelings
and how does the contamination arise even without touching dirt or
germs? Repeated cleaning is the most common attempt at coping, and
can achieve temporary relief but is ultimately futile because the contam-
ination is not confined to one’s hands; it is not localized. Therefore the
patients resort to other means of neutralizing their feelings and fears.
These tend to take the form of internal neutralizing, and include count-
ing, praying, or repetitious phrases. In some cases of mental contamin-
ation, attempts to cleanse one’s mind are added to the familiar methods
of escape and avoidance and some patients drink water to flush out the
perceived dirt.
Feelings of mental pollution/contamination often have a moral ele-
ment, and theologians who recognized “mental pollution” hundreds of
years ago are the experts in this domain. When pollution occurs after an
objectionable impure thought or act, or contact with an impure place/
material/person, the religious advice or requirement is that the person
carries out a ritualistic cleansing of one’s body, and secondarily of one’s
 Clinical Fears of Contamination 15

possessions and surroundings. The religious tactics to overcome or at

least subdue the feelings of mental pollution include prayers, pardons,
offerings, resolutions, disclosures, compensations, acts of charity, acts
of service, confessions, inhibition, exorcism, repentance, and renuncia-
tions. This list is not immediately familiar to clinicians.

1.8 Disgust, fear, and contamination

Fear and disgust are intense and unpleasant emotions. With a few excep-
tional instances of pleasurable fear, these emotions are aversive and peo-
ple exert considerable efforts to escape from or avoid them. Laboratory
research shows that disgust and a fear of contamination are moderately
associated (Deacon and Olatunji, 2007; Woody and Teachman, 2000),
and an overlap between fear and disgust is observed in some instances
of OCD. In an experiment with non-clinical participants, Edwards and
Salkovskis (2005) found that an induced increase in fear of spiders was
followed by an increase in disgust. However, an increase in disgust left
the level of fear unaffected. They concluded that “disgust reactions are
magnified by fear, but fear is not magnified by disgust.” There are excep-
tions in cases of mental contamination in which disgust inflates a fear
of the violator.
In both fear and disgust the emotion can be provoked by direct or
indirect contact with a perceived contaminant. In both instances the
observed consequences—cognitive, behavioral, and perceptual—are
similar and, most prominently, both disgust and contamination-fear
generate compulsive cleaning. If it is disgust contamination then soap
and hot water will do, but if there is a threat of infection by contami-
nation, disinfectants might be added. In both instances the aim is to
remove the contaminant. In both instances it is believed that after con-
tact the contamination can be spread, and in both of them attempts are
made to limit or prevent this contagion. Some stimuli (e.g., dirty band-
ages, decaying food) can provoke both disgust and a fear of contamina-
tion. Others can provoke one or the other but not both.
There is far more disgust than contamination fear. There are innu-
merable stimuli or situations capable of provoking disgust that convey
16 Contamination Fears

no threat and produce no fear. In the large majority of fears there is

no element of disgust. The cues for disgust generally are olfactory and
visual and include putrefaction and the stench from decaying vegetable
matter and bodily waste. Smell plays little part in fear. In instances of
disgust the distress is readily removed by cleaning, and once it is com-
pleted, no threat or discomfort persists. The successful removal of the
contaminant can be confirmed visually and by the disappearance of
the smell. Disgust contamination and fear contamination run different
time courses.
In those instances of contamination which threaten one’s health the
problem and the fear are relieved but not removed even after full clean-
ing. The possibility that one might have been infected by contact with a
harmful contaminant cannot be adequately resolved by cleaning, as in
fears of AIDS. Unlike disgust contamination, the triggers for the fear
of being infected by a contaminant are not always identifiable. The sus-
pect viruses or germs are invisible and difficult to remove with certainty.
The threat of becoming ill or suffering from a disease is not imminent
but is persistent and generates fear and doubt. Disease contamination is
accompanied and followed by considerable doubting in a manner that
seldom occurs in disgust reactions.
The facial expressions associated with disgust and fear differ, as do the
physiological reactions that accompany the two emotions. The physical
reactions to stimuli that evoke disgust include an array of gastric sensa-
tions such as nausea, gagging, and vomiting. Fear reactions include a
pounding heart, sweating, trembling, and shortness of breath.
Fear and disgust interact in some cases of mental contamination.
People are the primary source of the contamination, and they can be a
source of disgust. Feelings of contamination after a sexual assault almost
certainly have an element of disgust, mixed in with feelings of aversion
and anger. It is suggested that there are elements of disgust and aversion
in most, or all, instances of mental contamination caused by physical or
psychological violations. In several of the case excerpts described here,
these elements were explicit or implicit (e.g., in the cases of betrayal,
humiliation, and assault). Understandably, in such cases it is often a feel-
ing of angry disgust.
 Clinical Fears of Contamination 17

The relationship between disgust propensity and mental contamina-

tion was investigated in a study of 63 OCD patients by Melli et al. (2014).
They found significant correlations between mental contamination, dis-
gust propensity, and OCD symptoms, and provisionally concluded that
mental contamination plays a mediating role in the relation between
disgust and OCD.

1.9 Sensitivity to contamination

Most people function as if they are at a lower risk of health problems than
are other people. For example, if they rate the risk of a person like them-
selves having a 10% risk of a significant stomach ailment over the next
10 years, they give themselves a rating of say 2%. They assume that they
are less vulnerable than other people to health risks. These assumptions
were described by Shelley Taylor (1989) as “adaptive fiction illusions.” At
the other extreme, abnormal beliefs and feelings about contamination
can reach delusional levels. They often have a bizarre quality, are imper-
vious to contradictory evidence, and tend towards permanence. Some
clinical examples include: a belief that one is vulnerable to contami-
nation from mind germs, or from the sight of physically handicapped
people, or that one can develop gangrene from touching any patients in
hospital. In these cases, as in others, the bizarre quality of the belief is all
the more remarkable because many of the people holding such beliefs
are well informed and acknowledge that their beliefs are strange and
restricted to themselves. The beliefs predispose the person to the acqui-
sition of fears of contamination.
A comprehensive account of how these beliefs are formed and con-
solidated is not yet available, but numbers of patients describe extraor-
dinary parental beliefs and practices that must have sensitized them to
the pervasiveness of danger. “The world is full of dangers,” “Pollution
and disease inhabit the world,” “All public facilities are cesspits,” “I must
wash all of your toys in Lysol® repeatedly.”
The common co-occurrence of contact and mental contamination
raises the possibility of a broad sensitivity to contamination, and there
is some supporting statistical evidence (Rachman, 2006). The report
by Ware et al. (1994) of a significant correlation (0.34) between disgust
18 Contamination Fears

sensitivity and the washing subscale of the Maudsley Obsessional Com-

pulsive Inventory (MOCI) was a first step, especially as disgust did not
correlate with the other subscales of the MOCI (e.g., checking). On
similar lines, Sawchuk et al. (2000) found a correlation of 0.49 between
disgust sensitivity and the contamination subscale of the revised
MOCI, the Vancouver Obsessive Compulsive Inventory (VOCI). A
recent study which validated a measure of contamination sensitivity—
the Contamination Sensitivity Scale (CSS)—found that the CSS is a
valid and reliable measure of a sensitivity to contamination, and that
CSS scores were significantly correlated with scales assessing contact
contamination, mental contamination, disgust sensitivity and anxiety
sensitivity in OCD, and anxious and student samples (Radomsky et al.,
2014). In addition, CSS scores were significantly higher among indi-
viduals diagnosed with OCD who reported contamination fears than
those diagnosed with OCD who did not report contamination-related
concerns. Interestingly, scores were also elevated (although less so)
among individuals diagnosed with anxiety disorders other than OCD,
indicating that a sensitivity to contamination might be a transdiagnos-
tic quality.
The next step is the investigation of the associations between the two
divisions of contamination, contact and mental, and anxiety/disgust
sensitivity (AS, DS). The correlation between contact contamination
and anxiety sensitivity was expected to be larger than the correlation
with disgust sensitivity. In a mixed sample of clinical and non-­clinical
participants, the VOCI contamination scores correlated with the anx-
iety sensitivity index (ASI) at 0.53, p < 0.001, and with DS at 0.38,
p < 0.001 (Radomsky et al., 2014). The hypothesis is that the two divi-
sions of contamination share a common element—­hypersensitivity.
It is deduced that the sensitivity to contamination is related to other
types of sensitivity, beginning with AS and DS, and this prediction
was recently been supported by Radomsky et al. (2014) using the
research scale for assessing sensitivity to contamination (CSS), that is
reproduced in the Toolkit (Part 3).
The possible occurrence of elevated states of sensitivity to contamina-
tion is raised by cases in which strong feelings of contamination erupt
 Clinical Fears of Contamination 19

suddenly. Not infrequently they erupt full-blown, and many neutral cues
are immediately converted into contaminants. Oversensitivity might
help to explain those occasions in which disproportionately strong feel-
ings of contamination are evoked by relatively mild contaminants, by
cues that ordinarily produce minimal contamination. There is no short-
age of clinical examples of sudden, rapid onsets and disproportionately
strong reactions.
Given the connections between OCD problems and depression,
patients who have a general sensitivity to contamination might be at an
elevated risk of becoming contaminated during states of low mood or
frank depression.

Case illustration of fear of contamination in OCD

Ian is a man in his 40s who suffered from disabling OCD for over 20 years. His fears
of contamination were so severe and widespread that he became housebound and was
unable to continue working. He felt contaminated “all the time” and prior to the course
of cognitive behavior therapy (CBT) was washing his hands up to 80 times per day. His
hands were excoriated and twice a month his dermatologist treated them with a special
cream. On retiring to bed he coated his hands with medicated cream and put on gloves
to contain the cream and to prevent further contamination.
During the 20 years, Ian received a great deal of psychological and pharmacological
treatment, including several courses of exposure and response prevention (ERP) and
two full courses of CBT. He had also received treatment in a specialized, national OCD
in-patient therapy unit on two occasions. Although he had some benefit from the treat-
ments, the improvements soon faded and he remained in a distressed and disabled con-
dition, frightened and housebound.
Ian was then referred to a specialist OCD out-patient clinic, and after an extensive
clinical interview and the results of several psychometric tests, he was diagnosed as suf-
fering from mental contamination. On the VOCI-Mental Contamination Scale, a ques-
tionnaire for assessing the presence of mental contamination, his score of 47 placed him
in the severe category.
His OCD had developed after his wife unexpectedly sued him for divorce and he had
been obliged to leave his home and was given only limited access to his very young son.
Months later Ian was shocked when he learned that his wife had engaged in clandestine
affairs during the marriage, and he felt deeply betrayed.
On his own initiative he arranged child-care payments, but a child support agency
nevertheless started sending him increasingly intimidating demands, and his several
attempts to explain the situation to a variety of government officials at the agency were
dismissed “contemptuously.” Ian dreaded the arrival of the brown government envelopes
20 Contamination Fears

containing the demands, and started to wash his hands vigorously after opening the
letters. The envelopes felt polluted and therefore he needed to cleanse himself. As the
fear intensified he resorted to wearing thick gloves before touching the letters, wash-
ing himself and then changing into “sterile” clothing. The contagion spread to other
government letters and ultimately to anything, or anyone, associated with government.
Post-offices and the entire area surrounding them were particularly contagious, and he
was housebound.
The first of the nine sessions of CBT, consisting of the provision of information about
mental contamination and the planned treatment, was followed by in-depth cognitive
analyses of the betrayal, its effects, and his current appraisal of the events and people
involved. A clear connection was established between the betrayal and its humiliating
and degrading consequences, and the emergence of his fear of contamination/pollution.
It was established that his feelings of contamination were easily and powerfully pro-
voked by mental events, such as images and memories, not only by actually touching
the “government” cues. In session four he was asked to imagine a few scenes that were
neutral and then two scenes that were related to the betrayal and humiliations. Ian was
adept at forming vivid images, but the first betrayal scenes produced only a tiny change
in the feelings of contamination in his hands (from 0% to 2%). However, the second
image produced a remarkable increase, from 0% to 90%. He was surprised that the feel-
ings of contamination were “All over my body, not just my hands!” and he felt polluted
internally. The image was a contaminant.
The effects of this and similar images meant that he was vulnerable to the feelings
of contamination anywhere at any time; the feelings were evoked by images, memo-
ries, remarks, and telephone calls, and could arise even while resting quietly at home.
Moreover, contrary to his belief, the contamination was not confined to his hands. “For
that reason washing your hands, however vigorously, is not effective because it is misdi-
rected. The problem, the contamination, is not your hands. It is all over your body, even
inside you.” Ian then recalled that recently he had cleaned out a garbage bin without any
difficulty but was certain that if it had been government property it would have provoked
uncontrollable contamination.
Repeated exposures to government cues were unlikely to affect the power of the dis-
turbing images. The intensive repeated exposures that were used in most of his previous
treatments had not been successful, so a cognitive approach was adopted. A detailed
analysis of his contamination-related cognitions was undertaken and a few behavioral
experiments were completed. The most frequent and disturbing images were rescripted
into neutral or pleasant images, and Ian was taught how to rescript for himself if neces-
sary. This proved to be a valuable coping technique for him.
During the cognitive analyses it emerged that his reactions to contact with, or the
sight of the contaminating cues, made him feel miserable and helpless. Ian’s appraisal
of his fear of contamination changed. It emerged that the contaminants did not evoke a
threat of being physically harmed but rather that he would get emotionally upset, feeling
sad and helpless. Hence the direction of therapy was modified. He learned to recognize
the miserable feelings and how to cope with them.
 Clinical Fears of Contamination 21

In order to help him escape from being trapped in his home, behavioral experiments
were carried out to ascertain whether the new cognitive interpretations and tactics
would work outside his home. On a few excursions from his home to test the alternative
explanations he discovered that when he interpreted his discomfort as a sign of danger
the contamination swelled up, but when he interpreted the discomfort as a sign of feeling
miserable, he could cope and reassure himself that it was transient. When he made the
latter interpretation, he experienced minimal contamination. The results of the behav-
ioral experiments helped him to overcome his fear of leaving the house and by session
six of the CBT he was no longer housebound.
Proceeding along these lines he made satisfactory progress and by the end of the
ninth session Ian was no longer engaging in compulsive washing and able to move about
freely. He dispensed with the protective gloves that he had worn at night. The results of
the post-therapy psychometric tests placed him in the non-clinical range. His score on
a standard measure, the Yale–Brown Obsessive Compulsive Scale (YBOCS), declined
from 34 to 8, and the Mental Contamination Scale was 29, below the clinical cut-off
of 39. The improvements were stable at the 6-month follow-up, and at the 12-month
follow-­up his YBOCS score was 5 and his Mental Contamination Scale score was 27. Ian
attributed his progress to learning about mental contamination and how the betrayal
and its consequences had made him feel degraded and contaminated.
 Chapter 2

Feelings and Features of Contact

and Mental Contamination

2.1 Feelings of contamination

Contamination is an intense, unpleasant, and persisting feeling of having
been polluted, dirtied, infected, or endangered as a result of ­contact, dir-
ect or indirect, with an item/place/person perceived to be impure, dirty,
infectious, or dangerous. The feeling of contamination is ­accompanied
by negative emotions, among which fear, disgust, ­dirtiness, moral impu-
rity, and shame are prominent.
Typical pollutants are decaying vegetable matter, putrefying meat,
urine, and excrement. Dirty/infectious contaminants include public
washrooms, door-handles, blood, contact with bodily products such as
blood/saliva/semen, and contact with people or places believed to be
infected (e.g., hospitals, and places/people thought to be associated with
sudden acute respiratory syndrome). The fear of contracting AIDS is
a common problem. Potentially harmful substances such as chemicals,
pesticides, and certain foods can become sources of fear contamination.
The construal of contamination is based on cultural and religious beliefs
and by the knowledge prevailing in the particular society. The word
“dirt” is derived from drit, borrowed from Old Norse, meaning excre-
ment (Ayto, 1990), and beliefs about pollution by excrement are espe-
cially disturbing and widespread, probably universal.
Strong feelings of contamination are extremely uncomfortable and
can be threatening. They generate a powerful urge to clean away the
contaminant, and this takes precedence over other behavior. The feel-
ings dominate the person’s thinking and actions and instigate vigorous
attempts to remove the contaminant, most frequently by cleaning. “My
hands feel aflame with contamination.” The feeling of contamination
triggers avoidance behavior and attempts at prevention by removing
24 CONTAMINATION FEARS

potential sources of contamination. The idea can be summed up in this

way: “Avoid if you can, but escape if you can’t.” In cases of contamination
it is a matter of “Avoid if you can, but wash if you can’t.”
Affected people attempt to prevent the spread of the contamination
by “isolating” their hands, for example by using their feet or elbows
to open doors. If this is not practical they might resort to protecting
themselves by wearing gloves or holding tissues. A simple demonstra-
tion of this feeling and its consequences can be carried out by asking
people to insert their fingers into a jar containing sticky jam. It makes
them feel dirty, and so they isolate their hands, avoid touching their
clothing or face and hair, and have a strong urge to wash away the
offending jam.
Activity 2.1 gives an exercise that therapists can use to gain a fuller
understanding of the experiences of their patients. “What does it feel
like to be contaminated?”

Activity 2.1: The feeling of contact contamination

Place your fingers in a jam jar and then spread some of the jam on both
hands, so that they are both sticky. Does it make you feel uncomfortable?
Do you have a strong urge to clean your hands? Do you avoid touching your
hair, clothing, or other possessions? Do you avoid spreading the sticky jam?
Now wash your hands thoroughly. Is it a relief? Are you now able to touch
your hair, clothing, and possessions without hesitation?
Those sticky feelings and their consequences are a tame example of signifi-
cant, pervasive, and persistent feelings of contamination.
If you have a friend, colleague, or family member willing to do it as well,
compare the results. Different people have different reactions, but for some
people, and many patients, the feelings of contamination are disturbingly
strong. Consider the frustration and distress that patients suffering from
intense, pervasive, and uncontrollable daily feelings of contamination have
to endure.
Also, try this exercise, but wait a while before washing. For most (but not all)
people, feelings of contamination and urges to wash reliably decline over
time; but the amount of time it takes varies significantly from one person to
the next. Behavior therapists often tell their contamination-­fearful patients
to simply wait until it feels better, but some patients find this unpredictabil-
ity troubling.
 FEELINGS AND FEATURES OF CONTACT AND MENTAL CONTAMINATION 25

2.2 Types of contamination

Patients who suffer from OCD in which contamination is a major com-
ponent have a daily struggle trying to overcome intense, frightening,
dominating, and pervasive feelings of this character. They go to bed
each night knowing that when they wake up they will feel ­compelled
to carry out the same compulsive washing routines all over again.
They are locked in by the fear and despair of ever feeling free of the
contamination.
In clinically significant fears patients believe that the infectious/­
polluted/dangerous substances will cause serious harm to their well-
being and physical or mental health, and also present a social threat.
They know that the contamination will persist until adequate cleaning
has been completed, but find it difficult to achieve certainty about the
sufficiency of their cleaning. They fear that unconstrained contamin-
ation might spread to other parts of their body, clothing, and possessions.
Among those many patients with OCD who are burdened by an exag-
gerated sense of responsibility, the fear of contaminating others is a sec-
ond layer of the fear and brings additional distress and leaden guilt. It
comes as no surprise that people despair over their inability to control
the waves of contamination. Compulsive cleaning which overrides the
person’s rational appraisals is behavior that is largely out of control; it is
abnormal and recognized to be abnormal. Understandably the affect-
ed people worry that they might be weird or mentally unstable because
their thoughts and behavior are so irrational, uncontrollable, disturb-
ing, and perplexing. At times they feel overwhelmed by the feelings of
contamination.
Fears of contamination are classified into two groups: contact contam-
ination and mental contamination. The familiar form, contact contamin-
ation, arises from physical contact with a tangible, harmful, unpleasant
substance. The less obvious form, mental contamination, arises without
physical contact. It is provoked by a person or persons, not by inanimate
tangible substances. Mental contamination develops in people who have
experienced a psychological or physical violation and is unique to the
affected person.
26 CONTAMINATION FEARS

There are sub-types within each group. Contact contamination is

caused by physical contact with dirt such as decaying material, animal/
human waste, bodily fluids, germs, or dangerous substances such as pes-
ticides. These three types of contact contamination are distinguishable
but sometimes are entangled (e.g., there are mixtures of dirt and disease;
see Figure 2.1).
The second group, mental contamination, has perplexing features and
is difficult to observe. The source of mental contamination is human
and the feelings of pollution and mental contamination are provoked
by memories, images, and thoughts. It arises from physical or psycho-
logical violation and is manifested in four ways: visual contamination,
morphing, mental pollution, or self-contamination (see Figure 2.2). The
affected people are usually perplexed when they begin to learn that their
feelings of contamination can arise even when they have not touched
a tangible contaminant. The learning process tends to be gradual, but
once they grasp the nature of their mental contamination, they make
sense of many puzzling experiences, past and present.
The two groups are distinguishable, but overlaps are common, espe-
cially after a physical violation such as rape, which often is followed by
feelings of both contact and mental contamination (see Figure 2.3).

Contact contamination

Disease Dirt

Harmful
substances

Fig. 2.1 Contact contamination.

 FEELINGS AND FEATURES OF CONTACT AND MENTAL CONTAMINATION 27

Mental contamination

Physical Self-
violation contamination
Visual
contamination

Psychological
violation
Morphing

Fig. 2.2 Mental contamination.

Contact Mental
contamination 33% contamination
11% 15%

Fig. 2.3 The overlap between contact contamination and mental contamination
based on a sample of 54 people with OCD. Of these, 41% did not report a fear of
contamination but suffered from obsessions, compulsive checking, etc.
(Data from Journal of Obsessive-Compulsive and Related Disorders, 1 (4), Anna E. Coughtrey, Roz
Shafran, Debbie Knibbs, and S. Rachman, Mental contamination in obsessive-compulsive disorder,
pp. 244–50, 2012.)
28 CONTAMINATION FEARS

Given this overlap, it is necessary to decide how best to treat those

many patients, roughly 50%, who suffer from mental contamination
or mental contamination plus contact contamination. A discussion
of this important overlap, and treatment guidelines are provided in
Chapter 6.

2.2.1 Contact contamination

Unpleasant feelings provoked by contact with nasty contaminants
are universally experienced, and many items and places are widely
recognized to be contaminated. These feelings of contamination are
normal, in the sense that they are universal. Feelings of contamina-
tion that are extraordinarily intense, widespread, persisting, disturb-
ing, and dysfunctional are a psychological problem. See Boxes 2.1
and 2.2.

2.2.2 Mental contamination

“This disease is beyond my practise.”

Many patients suffering from OCD continue to feel dirty despite strenu-
ous attempts to clean themselves. Taking four, five, or six hot showers
in succession fails to produce the desired state of cleanliness. Why does
repeated washing fail?
The concept of mental contamination was introduced as part of an
attempt to explain why numerous patients with OCD express great frus-
tration about their inability to achieve a feeling of thorough cleanliness.
“It looks clean but feels dirty” (Rachman, 1994). Initially mental contam-
ination was thought to be an unusual variant of contamination, but as
the evidence accumulated it became evident that mental contamination
is far more common than originally estimated. It is not a minor matter
(Rachman, 2013b).
It is a feeling of internal dirtiness/pollution that is caused by a psy-
chological or physical violation. The source of the pollution is human,
and the affected person develops strong feelings of contamination that
are evoked by direct or indirect contact with the violator. Indirect con-
tacts include memories, images, or thoughts about the violator or the
violation. For example, after a life-altering betrayal, the thoughts and
 FEELINGS AND FEATURES OF CONTACT AND MENTAL CONTAMINATION 29

Box 2.1 Features of contact contamination

◆ Feelings of pollution, infection, or threat provoked by perceived

contact with a source of harmful, infectious, or soiled substances
(mainly concerned with dirt or disease)
◆ Feelings evoked instantly by contact
◆ Mainly focused on the skin, especially hands
◆ The contaminant is tangible
◆ The source of the danger/discomfort is known
◆ The discomfort of contamination dominates other behavior
◆ The site of the contaminant is identifiable
◆ Contamination spreads widely
◆ Does not easily degrade
◆ Transmissible to others
◆ Other people are considered to be vulnerable to the contaminant
◆ Associated with compulsive checking if person is prone to inflated
sense of responsibility
◆ Anxiety is evocable by relevant memory/image of contamination
◆ Lacks a moral element
◆ Accompanied by revulsion, fear, or nausea
◆ Transiently responsive to cleaning
◆ Treatment is moderately effective

memories of the betrayal and of the betrayer can evoke intense feelings
of contamination. In most instances there is a moral element involved
in the violation. Commonly, the patient is unwilling or unable to say out
loud the name of the violator.
Negative emotions such as disgust, fear, anger, helplessness, shame,
guilt, and revulsion are associated with the contamination. These unpleas-
ant feelings instigate attempts to clean away the contamination, but as it
is mainly a sense of internal dirtiness, the site is difficult to localize and
30 CONTAMINATION FEARS

Box 2.2 Beliefs and appraisals about contact

contamination

◆ To avoid illness I must always handle garbage and garbage bins

very carefully
◆ I wash my hands after handling money because it is so dirty
◆ I am sure to pick up a sickness whenever I travel
◆ I avoid public telephones because they are sources of contam­
ination
◆ I worry that I might pick up contamination that will affect my
health years from now
◆ Once contaminated, always contaminated—it doesn’t go away
◆ If I get sick, I must make absolutely sure to avoid passing it on to
other people
◆ Some types of contamination can cause mental instability
◆ I pick up infections very easily
◆ It is important for me to keep up to date with the latest informa-
tion about germs and diseases
◆ I never ever feel properly clean, all over
◆ To be safe it is essential for me to wash my hands very thoroughly
and frequently
◆ I am allergic to almost all chemicals
◆ I worry that if I get sick, I won’t be able to cope
◆ I am responsible for keeping my home completely free of germs
◆ I need to be very careful to keep away from people with an obvious
cold
◆ If I eat food that is past the due date, my stomach will get seriously
upset
◆ To keep safe from germs it is essential to use powerful disinfectants
◆ When I get an illness it takes me a very long time to recover
 FEELINGS AND FEATURES OF CONTACT AND MENTAL CONTAMINATION 31

Box 2.2 Beliefs and appraisals about contact contamination (continued)

◆ One can pick up sicknesses on buses because they are very dirty
◆ Contamination never fades away
◆ When I get sick, I get really sick
◆ For reasons of safety it is essential for me to keep everything very
clean
◆ It is safest to avoid touching animals because they are sources of
contamination
◆ If I thought that I had passed my sickness on to others, it would
make me extremely upset
◆ I am much more sensitive to pollutants than most other people
◆ Any contact with bodily fluids (blood, saliva, sweat) can lead to
infections
◆ To be safe I try to avoid using public toilets because they are highly
contaminated
◆ If there is any sickness around I am sure to pick it up
◆ Unless I am careful to wash thoroughly I might get ill

hence compulsive handwashing is not effective. The source and the site of
internal pollution are unclear to the affected person. See Box 2.3.
Mental contamination is specific and unique to the affected person, and
is not transmissible. It can be induced or exacerbated by “mental events”
such as accusations, insults, threats, humiliations, assaults, and memor-
ies and by unwanted and unacceptable thoughts and images (e.g., inces-
tuous images, impulses to molest children). A person, object, or place
that is associated with the primary (human) source of the contamination,
the violator, can become a secondary source of contamination. The con-
taminated person avoids contact with clothing or other possessions of
the violator, and tends to avoid places associated with the violator.
After a physical violation, such as rape, there is a threat to one’s health
and intense persisting feelings of pollution and mental distress. The feel-
ings of pollution are intolerable and some victims of rape are convinced
32 CONTAMINATION FEARS

Box 2.3 Pollution of the mind

The term pollution of the mind was used in 1666 by John Bunyan to
describe his life-long affliction. An intensely religious man, he was
flooded with blasphemous urges and malicious thoughts which pol-
luted him. Lady Macbeth is a royal example of mental pollution.
Although she was not present during the murder of King Duncan,
she experienced intense guilt about her crucial role in his death. The
intangible quality of mental contamination frustrated her attempts to
remove the feelings of guilt and distress by washing her hands com-
pulsively. It failed to give her peace or relief (Rachman, 2013a). Her
nurse observed Lady Macbeth persistently rubbing her hands: “It is
an accustom’d action with her, to seem thus washing her hands: I have
known her continue in this a quarter of an hour,” (Macbeth, Act 5,
scene 1). Her repeated attempts to clean herself were futile. “What,
will these hands ne’er be clean?” and later, “Here’s the smell of blood
still: all the perfumes of Arabia will not sweeten this little hand. Oh,
oh, oh.” Her doctor was moved: “What a sigh is there!” and he con-
ceded that “This disease is beyond my practise.”

that the traces of the violator’s bodily fluids remain in or on their body
for many years after the assault (Steil et al., 2011). In common with vic-
tims of other traumas they may feel irreparably damaged; for example,
“I am irrevocably polluted and permanently damaged.”
After a psychological violation the person might be left with a mixture
of pollution and fear, depending on the nature of the violation. Betrayals
tend to be followed by feelings of pollution, distress, self-doubt, and anger
rather than fear (Rachman, 2010). Exposure to prolonged degradation is
usually followed by feelings of pollution, low self-esteem, helplessness,
anger, and fear. Pollution that arises after being seriously manipulated is
accompanied by self-criticism and anger towards the violator, and not
infrequently it prompts thoughts of retaliation or revenge.
The fear of becoming contaminated by touching or even coming into
proximity of a weird, disreputable person is at bottom a fear that one’s
 FEELINGS AND FEATURES OF CONTACT AND MENTAL CONTAMINATION 33

character, personality, or mental stability might be compromised by the

insinuation of undesirable qualities of the “weird” person. In extreme
cases the threat goes deeper and the affected person fears being trans-
formed into someone akin to the undesirable person, a fear of mor-
phing. In caste communities, people take great care to avoid physical
contact or even remote contact with members of a lower caste, such as
the “untouchables,” for fear of pollution and a fall into the lower caste, a
literal degradation (Human Rights Watch Report, 1999).
There is evidence that some perpetrators of unacceptable acts develop
feelings of pollution (Rachman et al., 2012), but they rarely seek therapy.
See Box 2.4.

Box 2.4 Beliefs and appraisals about mental

contamination

◆ Many things look clean but feel dirty

◆ People should be pure in mind and in body
◆ Some people think I am weird because I am a clean freak
◆ I must always avoid people with low morals
◆ Before leaving home I need to make sure that I am absolutely clean
◆ If I think about contamination it will increase my risk of actually
becoming contaminated
◆ Seeing disgusting pornographic material would make me feel sick
and dirty
◆ If I touched the possessions or clothing of someone who had treat-
ed me very badly I would need to have a good wash
◆ People who do something immoral will be punished
◆ Sometimes I have a need to wash even though I know that I haven’t
touched anything dirty/dangerous
◆ If I was touched by someone who had treated me very badly it
would make me feel unclean
◆ People who read pornography must be avoided
34 CONTAMINATION FEARS

Box 2.4 Beliefs and appraisals about mental contamination (continued)

◆ Mixing with immoral people would definitely make me feel unclean

◆ I will never be forgiven for my horrible thoughts
◆ If I am touched by a nasty or immoral person it makes me feel very
unclean
◆ It is quite possible to feel contaminated even without touching
any contaminated material
◆ It is immoral for me to use bad language at any time
◆ Simply thinking about contamination can make me feel actually
contaminated
◆ No matter how hard I try with my washing I never feel completely
clean
◆ If I cannot control my nasty thoughts I will go crazy
◆ Simply remembering a contaminating experience can make me
feel actually contaminated
◆ It is completely wrong for me to tell dirty jokes
◆ I am responsible for other people’s bad behavior towards me
◆ When I am in a low mood I am far more sensitive to feelings of
being contaminated
◆ I will never get rid of the feeling that I am unclean and dirty
◆ I definitely avoid movies that contain foul language and explicit
sex scenes
◆ I have a hard time getting rid of the feeling that I am unclean
◆ People think I am weird because of my worries about dirt and
diseases
◆ If I did something immoral it would make me feel unclean
◆ When I feel bad about myself, having a shower makes me feel
better
◆ Having to listen to someone making disgusting, nasty remarks
makes me feel tainted and dirty
◆ People will reject me if they find out about my nasty thoughts
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