Thought-action fusion (TAF) and OCD
What is thought-action fusion?
Thought-action fusion (TAF) is an important part of most OCD presentations. It’s very helpful to understand what TAF is and how it relates to OCD treatment because important misunderstandings found within TAF play a central role in maintaining OCD.
TAF is a multifaceted concept and it includes “moral TAF” and “likelihood TAF”. Moral TAF occurs when an individual interprets having a thought as an indication of moral badness. Likelihood TAF occurs when an individual interprets having a thought as an indication that an event in reality will occur. To illustrate these forms of TAF in action, let’s explore Ashley’s example.
Ashley's TAF:
Ashley first noticed intrusive sexual thoughts about a year ago when she was having a conversation with her sister, Candace, and Candance’s partner Roland. Ashley, Candance, and Roland had gone out to dinner and, near the end of dinner, Roland got up to use the restroom. Out of nowhere, Ashley had the thought, “What if I followed Roland to the bathroom and we had sex?” After noticing this thought, Ashley had another thought: “What does this mean about me that I have this thought? Does this mean I’m attracted to Roland? Does this mean I would actually attempt to have sex with my sister’s partner? If I were to do something like that, my sister would hate me…and I would hate myself.”
Reeling from these thoughts, Ashley found it hard to stay focused on her conversation with her sister. With some difficulty, Ashley was able to maintain some semblance of attention. However, when Roland came back, Candace then got up to go to the restroom. As Candace walked to the restroom, Ashley had another thought, “What if I were to reach across the table and start kissing Roland right now?” This thought was followed by a collection of other thoughts, such as:
Why am I having this thought?
Does this thought mean I want to be with Roland?
What kind of sister am I to have this thought about my sister’s partner?
Having this thought means I’m a bad person.
Am I about to start kissing Roland?
Ashley grabbed the chair she was seated in and held on very tight, believing this would keep her from inexplicably grabbing Roland and starting to kiss him. Once again, it was very hard to have a conversation with Roland, as Ashley’s mind was filled with images of kissing him and thoughts related to these images.
Candace got back from the bathroom. Both Candace and Roland noticed Ashley seemed distracted and anxious. They asked Ashley if she was OK.
Ashley felt ashamed to tell them what she was experiencing. After all, how could she tell Candace and Roland something like: “Oh, yes. Thanks for noticing I’m distracted and anxious. I’m actually distracted because I’m noticing having thoughts about kissing and having sex with Roland and I’m worried I might actually do these things.”
So, Ashley made up a story: “I think that something I ate didn’t sit so well with me.”
After a few more minutes of conversation, they left the restaurant and Ashley went home. Ashley couldn’t stop thinking about what happened, including trying to figure out why she had the thoughts she had, what it meant about her that she had these thoughts, and if these thoughts meant she would act on them.
Fast forward six months and Ashley’s life had drastically changed. Ashley noticed intrusive sexual thoughts most of the day, every day. She not only had sexual thoughts about Roland, but about her sister, and her parents, her friends, her supervisor and co-workers, and even her two pet dogs. Although she did her best to try and suppress the thoughts, no matter what she tried to do, she couldn’t keep the thoughts from coming back. And they came back more and more frequently.
Furthermore, Ashley developed an entire repertoire of behavior that was designed to keep her from acting on the thoughts. For example, during Ashley’s weekly meeting with her supervisor, she would wrap her feet and ankles around the chair in her supervisor's office, thinking that this wrapping would keep her from spontaneously and inexplicably jumping across her supervisor’s desk and beginning to kiss and grope her supervisor. Ashley began avoiding spending time with her family because every time she was around her family she had intrusive sexual thoughts and related feelings of anxiety and guilt. She even started to struggle being at home because the sexual thoughts were activated when she was around her pet dogs.
Throughout these six months, Ashley began to despair more and more. “I must be a terrible person to have these thoughts and, if I’m not very careful, I’ll probably act on these terrible thoughts.”
How identifying TAF is involved in OCD treatment:
In Ashley’s example, she was experiencing both moral TAF and likelihood TAF. Ashley’s moral TAF can be seen when she has thoughts such as “That I’m having this thought means I’m a bad person” which is related to an underlying thought “It is morally wrong to have romantic and / or sexual thoughts about X, Y, Z”. Ashley’s likelihood TAF can be seen when she has thoughts such as “That I’m having this thought means I’m likely about to act on this thought”.
Ashley’s moral TAF and likelihood TAF contribute to feelings of guilt (“I’m bad because I’m having these thoughts”) and feelings of anxiety (“I might be in danger of behaving in a way that causes damage to myself or others”). As a result, Ashley participates in a variety of cognitive and behavioral strategies designed to control and minimize the thoughts while simultaneously reducing the chances she acts on the thoughts (e.g., inexplicably groping her sister). Unfortunately, the more Ashley attempts to control her thoughts and feelings, the more and more she notices those thoughts. As a result, Ashley’s life becomes more and more dominated by the thoughts she wants to eliminate and the painful guilty and anxious feelings caused by those thoughts.
If Ashley were to participate in OCD treatment, one of the first things Ashley would review with her therapist is that everyone has unwanted, uncontrollable, abhorrent and/or taboo thoughts. Ashley would also be shown that no one has direct control over these unwanted, uncontrollable, abhorrent and/or taboo thoughts and, the more Ashley tries to control these thoughts, the more frequently they will show up.
Ashley and her therapist will review that having these thoughts is an entirely normal part of the human experience, that having these thoughts is not likely an indication of moral badness or likelihood of threat. If Ashley demands to know for sure that these thoughts are not likely an indication of moral badness or likelihood of threat, she and her therapist will review the inevitability of uncertainty and the importance of taking calculated risks.
Finally, Ashley will be shown that an effective way of reducing the frequency of her intrusive, unwanted thoughts (and the painful emotions related to the thoughts) is to participate in exposure and response prevention treatment, which includes allowing the unwanted, distressful thoughts to be there while simultaneously not participating in safety behaviors (you can read more about how ERP works here).