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. Author manuscript; available in PMC: 2024 Apr 1.
Published in final edited form as: J Interpers Violence. 2022 Oct 1;38(7-8):5699–5720. doi: 10.1177/08862605221127205

Daily Associations Between Trauma-Related Mental Contamination and Use of Specific Coping Strategies: Results of a Daily Monitoring Study

Jordyn M Tipsword 1, Matthew W Southward 1, Anita M Adams 1, C Alex Brake 2, Christal L Badour 1
PMCID: PMC10145604  NIHMSID: NIHMS1888854  PMID: 36184917

Abstract

Mental contamination (MC) – a sense of dirtiness experienced without contacting an identifiable pollutant – is a distressing and enduring experience among many survivors of sexual trauma. MC has been linked to more frequent use of avoidant coping behaviors (e.g., washing behavior, substance use, binge eating) and approach coping. However, it is unclear if specific approach and avoidant coping strategies are more consistently related to perseverative experiences of trauma-related MC, if the use of certain strategies predicts changes in MC, and if fluctuations in MC predict the use of certain strategies. The present study evaluated contemporaneous and prospective relationships between sexual trauma-related MC and use of 11 specific coping strategies among 41 women with a history of sexual trauma using an experience sampling design. Women completed twice-daily assessments of coping strategy use and MC for 14 days. Between-persons, women reporting more intense MC on average reported more frequent use of distraction, denial, giving up, self-blame, thought suppression, washing behavior, emotional processing, and emotional expression than those experiencing less intense MC. Within-person increases in MC were associated with more frequent concurrent use of all coping strategies except seeking support. Lastly, within-person increases in MC predicted more frequent use of giving up, substance use, and seeking support at the next assessment and within-person increases in substance use predicted less severe MC at the next assessment. Future work should aim to identify factors influencing the selection and/or quality of use of these specific coping strategies among individuals experiencing MC.

Keywords: mental contamination, avoidance coping, approach coping, sexual trauma, PTSD symptoms

Trauma-related mental contamination (MC), an experience of contamination occurring without a physical contaminant (Rachman, 1994), is a common, distressing, and potentially enduring experience following sexual trauma (Badour et al., 2013; Brake et al., 2021; Olatunji et al., 2008). Approximately one quarter of women who experience an urge to wash immediately after a sexual assault have reported experiencing trauma-related MC for months to years post-trauma (Fairbrother & Rachman, 2004). Trauma-related MC is related to a range of cognitive (e.g., “I can never be clean because of what happened”; Brake et al., 2019), behavioral (e.g., urges to wash or washing/cleansing; Fairbrother & Rachman, 2004), and affective (e.g., disgust, shame; Brake et al., 2021) forms of distress. Trauma-related MC is also linked to an array of deleterious outcomes, including symptoms of posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) and risky behaviors (Badour et al., 2013; Brake et al., 2018; Coughtrey et al., 2012a; Coughtrey et al., 2018; Ojserkis et al., 2018; Olatunji et al., 2008). In particular, existing work has increasingly demonstrated that trauma-related MC is positively associated with – but distinct from – symptoms of OCD and PTSD (Coughtrey et al., 2012a; Coughtrey et al., 2018; Ojserkis et al., 2018; Olatunji et al., 2008).

Examination of coping strategies in relation to trauma-related MC may aid in better understanding the persistence of MC following sexual trauma. Coping strategies are defined as cognitive, behavioral, and/or emotional strategies used to manage distress elicited by stressful experiences (Folkman & Lazarus, 1988) and can be categorized into broad domains (e.g., approach/avoidance coping; Roth & Cohen, 1986). Avoidance coping refers to efforts aimed at distracting or distancing oneself from stressful situations or things (Folkman & Lazarus, 1988; Ullman et al., 2007), while approach coping aims to actively address or resolve the causes of distress (Folkman & Lazarus, 1988). In the only work to date to directly evaluate associations between coping and trauma-related MC, individuals who reported higher MC reported more frequent use of both avoidance and approach coping to manage trauma-related distress (Tipsword et al., 2022). Additionally, higher than usual MC on a given day positively predicted self-reported use of avoidance – but not approach – coping several hours later. Individuals experiencing MC may use more avoidance-oriented strategies because these strategies provide short-term relief from trauma-related distress; however, these same strategies may maintain distress in the long term by preventing trauma-related processing necessary for recovery.

Despite preliminary work focused on broad domains of avoidance versus approach coping, there is a dearth of literature examining associations between specific coping strategies and trauma-related MC. Examination of individual coping strategies is needed as different individuals may manage distress associated with MC in differing ways. For example, one individual may engage in excessive washing behavior to manage distress while another may use alcohol to “numb” their distress. In both cases, these coping strategies serve an avoidant function; however, these strategies may differ in how effectively they lead to reductions in distress and in their associated negative consequences (McLean & Foa, 2017; Seligowski et al., 2014). Elucidating the role of specific coping strategies linked to the maintenance or exacerbation of MC may directly inform intervention targets for trauma-informed care.

Extant research has primarily focused on washing/cleansing urges and associated behaviors (e.g., washing hands, showering) in the context of MC-related coping (Badour et al., 2013; Fairbrother & Rachman, 2004). This is not surprising given that MC was first identified as a clinical phenomenon among patients with contamination-based OCD. This early literature noted that, in contrast to contamination concerns involving physical contact, contamination concerns arising in the absence of physical contaminants often involved perceived moral violations or interpersonal betrayal (Rachman, 2004). Urges to wash are common in the hours or days following sexual assault and some individuals continue to report prolonged and compulsive washing-related urges and behaviors that may persist for months or years (Fairbrother & Rachman, 2004). Urges to wash have also been documented among other groups experiencing MC, including samples with other trauma histories, nonclinical samples, and samples with OCD (Badour et al., 2013; Coughtrey et al., 2012b; Waller & Boschen, 2015). However, washing often fails to reduce MC above and beyond the passage of time, suggesting that washing may be ineffective at alleviating short- and long-term MC-related distress (Coughtrey et al., 2012b; Waller & Boschen, 2015). Further, washing behavior may become compulsive and functionally impairing among some individuals with MC (Coughtrey et al., 2012b). Beyond washing behavior, Brake and colleagues (2018) documented a positive correlation between trauma-related MC and frequency of risky behaviors (e.g., binge eating, substance use). Although other specific avoidance coping strategies are likely used among individuals experiencing trauma-related MC (e.g., distraction, thought suppression), this has yet to be examined.

Expectations regarding relationships between specific approach-oriented coping strategies and MC are less clear. Though one study failed to document an association between the broad domain of approach coping and subsequent MC (Tipsword et al., 2022), specific approach-oriented strategies may lead to reductions in MC. In particular, engagement in emotional processing (i.e., attempting to identify or understand emotions; Stanton et al., 2009) may facilitate an awareness of experiences underlying MC (e.g., by elucidating which emotions an individual is experiencing and/or triggers for those emotions), which might produce reductions in MC-related distress. Likewise, use of acceptance might facilitate reductions in MC by assisting individuals in tolerating MC and other forms of trauma-related distress rather than suppressing – and subsequently exacerbating – that distress. Further, though extant work suggests that higher levels and use of social support may aid in managing trauma-related distress (Littleton, 2010), it remains unclear whether the use of coping strategies involving others may similarly be linked to lower MC. The experience of MC frequently involves feelings of shame, which has been theorized to contribute to ongoing MC (Steil et al., 2011) and limit the likelihood of seeking social support when experiencing MC (Brake et al., 2021; Rachman et al., 2015).

In sum, there is a dearth of research on relationships between specific coping strategies and trauma-related MC. We sought to address this gap by evaluating prospective associations between trauma-related MC and specific avoidance and approach strategies among women experiencing persistent sexual trauma-related MC using an experience sampling design. Associations were evaluated both between-persons (i.e., to what extent is MC associated with the tendency to use specific coping strategies?) and within-persons (i.e., to what extent does variation in one’s daily experience of trauma-related MC predict subsequent use of specific coping strategies and vice versa?). Between-persons, we hypothesized that individuals experiencing higher trauma-related MC would report more frequent use of the avoidance-oriented strategies of washing, self-blame, thought suppression, denial, distraction, giving up, and substance use. Within-persons, we hypothesized that experiencing higher MC than usual would predict more frequent use of those same strategies at the next assessment. Finally, we explored the relations between MC and several previously unexamined strategies: emotional processing, emotional expression, seeking support, and acceptance. Given limited theoretical or empirical work on links between these strategies and MC, we did not make predictions about these relations. Further, given the absence of work evaluating short-term links between specific coping strategies and subsequent MC, we did not make any predictions about these relationships.

Method

Participants

Participants were recruited from the community as part of a larger study examining PTSD symptoms and MC among individuals with a history of sexual trauma (Brake et al., 2021). A total of 41 women ranging from 18 to 57 years old (Mage = 32.95, SD = 12.59) were included in analyses. Participants self-identified as Caucasian (73.2%), African American (19.5%), multiracial (4.9%), and belonging to another racial group (2.4%). Hispanic ethnicity was endorsed by 9.8% of participants. All participants reported experiencing current sexual trauma-related MC upon enrolling in the study (see Baseline Mental Contamination). Women reported having experienced the following types of sexual trauma: sexual contact that occurred under force or the threat of force (90.2%), sexual contact that occurred while the participant was under the influence of substances and was thus unable to provide consent (58.5%), and/or sexual contact with an adult that occurred during childhood (56.1%). The majority of participants in the sample (68.3%; n = 28) met diagnostic criteria for current PTSD.

Measures

Sexual trauma history.

Experiences of sexual trauma were evaluated via four items from the National Stressful Events Survey (NSES; Kilpatrick et al., 2011). The NSES was a national epidemiological survey developed by the DSM-5 Trauma & Stressor-Related Disorders workgroup to evaluate the prevalence of exposure to DSM-5 Criterion A traumatic events and PTSD symptoms linked to those events. Responses from the NSES have been used in previous work estimating the prevalence of traumatic events, including sexual trauma (e.g., Kilpatrick et al., 2013). Selected items from the NSES in the current study evaluated sexual contact by an adult during childhood; sexual contact occurring under force or threat of force; sexual contact occurring while under the influence of substances; and unwanted sexual experiences involving oral, anal, and/or vaginal penetration. Participants were eligible if they provided an affirmative response (0 = “No”, 1 = “Yes”) indicating that they had experienced any of the first three items during their lifetime.

Baseline PTSD symptoms.

Severity of PTSD symptoms at baseline was evaluated via the past-month version of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers et al., 2013). All CAPS-5 interviews were conducted by a trained graduate student. A PTSD symptom severity score was computed by summing the frequency and intensity scores (0 = “Absent” to 4 = “Extreme / incapacitating”) for all 20 PTSD symptom items and PTSD diagnostic status was determined by evaluating whether responses satisfied DSM-5 criteria within each PTSD symptom cluster (Weathers et al., 2018). The CAPS-5 has demonstrated excellent psychometric properties (Weathers et al., 2018) and exhibited satisfactory internal consistency in the current study (α = .84; McDonald’s ω = .84). Additionally, an independent graduate student trained in the CAPS-5 rated 20% of randomly selected interviews. There was excellent interrater reliability for diagnostic status (κ = 1.0) and level of agreement on total symptom severity (average r = .98).

Baseline mental contamination.

Current experiences of trauma-related MC were evaluated using the Posttraumatic Experience of Mental Contamination scale (PEMC; Brake et al., 2019). The PEMC is a 20-item self-report questionnaire derived from the Vancouver Obsessional Compulsive Inventory – Mental Contamination scale (VOCI-MC; Radomsky et al., 2014). Items on the PEMC asked participants about experiences of MC related to the worst or most distressing instance of sexual trauma they had experienced (e.g., “Since the event, I often feel dirty inside my body”). Participants indicated the extent to which they agreed with each item using a five-point Likert-type scale (0 = “Not at all” to 4 = “Very much”). Item responses were summed to create a total severity score, with higher scores indicating more severe MC. A cutoff score of 10 was selected based on scores indicating moderate MC severity on the VOCI-MC (Coughtrey et al., 2014). The PEMC has demonstrated strong reliability (α = .92 and McDonald’s ω = .91 in the current study) and convergent validity with the VOCI-MC and has exhibited a single-factor structure (Brake et al., 2019). As the PEMC evaluated experiences of MC occurring since participants’ most distressing experience involving sexual trauma, current trauma-related MC was also confirmed during the in-person laboratory visit using a two-item excerpt from Fairbrother and Rachman’s (2004) sexual assault-related MC interview (“What, if anything brings back that feeling of dirtiness now?” and “What about memories of the unwanted sexual experience, do they bring back that feeling of dirtiness?”). Participants who gave clear affirmative responses to both items were considered to be experiencing current trauma-related MC.

Past-year substance use.

Frequency of past-year substance use was assessed using three items from the Frequency subscale of the Risky Behavior Questionnaire (RBQ; Weiss et al., 2018). Selected items assessed the number of times participants 1) consumed alcohol to the point of intoxication, 2) misused prescription drugs, and 3) used street drugs (e.g., marijuana or cocaine) during the past year. Participants entered a total count score that constituted their total score for each item. Preliminary evaluations of the psychometric properties of the RBQ Frequency subscale yielded moderate convergent validity with measures of specific types of risky behaviors, including substance use severity, and a single-factor structure (Weiss et al., 2018). The use of select items from the RBQ to characterize engagement in specific risky behaviors is supported by previous work adapting it for this purpose (e.g., Flores et al., 2021).

Daily mental contamination.

Trauma-related MC was evaluated twice daily via the State Mental Contamination Scale (SMCS; Lorona et al., 2018). The SMCS is a 15-item self-report questionnaire evaluating state experiences of MC (e.g., “I feel dirty or contaminated even though I haven’t touched anything dirty”). Participants rated the extent to which they agreed with each item since the previous daily assessment using a Likert-type scale (0 = “Strongly disagree” to 4 = “Strongly agree”). Participants were also instructed to respond based on experiences of MC related to their most distressing sexual trauma. Individual item scores were summed to create a total score for each assessment timepoint. The SMCS has exhibited strong convergent validity with the VOCI-MC and a single-factor structure in existing work (Lorona et al., 2018). Total scores exhibited strong reliability in evaluating between-person differences (Rkf = .99) and within-person change (RC = .95) across the assessment period in the current study.

Daily coping strategies.

A total of 13 coping strategies were evaluated twice per day for 14 days using single-item ratings. Assessed coping strategies included: distraction (i.e., directing one’s attention away from distressing thoughts or experiences), denial (i.e., rejecting the reality of distressing thoughts or experiences), giving up (i.e., surrendering to distressing thoughts or experiences), substance use (i.e., use of alcohol or other substances to manage distressing thoughts/experiences), self-blame (i.e., asserting one’s perceived responsibility for traumatic experiences), washing behavior, thought suppression (i.e., attempting to push away distressing thoughts), emotional processing (i.e., attempting to understand or identify one’s emotions), emotional expression (i.e., sharing one’s emotions openly), acceptance, learning to live with it, seeking emotional support, and seeking comfort. Given significant statistical and content overlap between the items for acceptance and learning to live with it and the items for seeking emotional support and seeking comfort (see Data Analytic Approach), those items were aggregated to create overall acceptance (i.e., allowing one’s distressing thoughts/experiences to exist without trying to change them) and seeking support (i.e., seeking comfort or encouragement from others) scores, respectively. Thus, we evaluated a total of 11 coping strategies. Participants rated the frequency with which they had used each strategy in relation to their index trauma since the previous assessment using a four-point Likert-type scale (1 = “I haven’t been doing this at all” to 4 = “I’ve been doing this a lot”).

Coping items related to distraction, denial, giving up, substance use, self-blame, seeking support, and acceptance were obtained from the Brief COPE (Carver, 1997). The Brief COPE is a widely used 28-item inventory evaluating frequency of engaging in specific coping strategies to manage distress. Eight items from the Brief COPE were selected based on pilot data suggesting a significant cross-sectional association with MC (distraction, denial, giving up, substance use, self-blame) and/or previous use in daily assessments evaluating coping (seeking emotional support, seeking comfort, acceptance; Park et al., 2004). Items related to washing behavior and thought suppression were adapted from the Vancouver Obsessive Compulsive Inventory (VOCI; Thordarson et al., 2004) and the Thought Suppression Inventory (TSI; Rassin, 2003), respectively. Both items were selected based on previous work establishing the relevance of washing behavior and thought suppression to MC (Coughtrey et al., 2012b). Finally, items related to emotional processing and emotional expression were adapted from the Emotional Approach Coping measure (EAC; Stanton et al., 2000). Both items have previously been utilized in daily diary assessments (Park et al., 2004), supporting their use in the present study.

Procedure

All procedures were approved by the university’s Institutional Review Board and informed consent was obtained prior to enrolling in the study. Participants were recruited from the community using online advertisements and flyers. Interested individuals first completed a phone screen to determine eligibility. Participants were considered eligible if they reported a history of sexual trauma and current experiences of trauma-related MC. Eligible individuals completed an online battery of questionnaires not relevant to the present study. Next, they attended a laboratory visit, during which they completed the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) interview with a trained graduate clinician to determine PTSD symptom severity and diagnostic status in relation to their most distressing sexual trauma. Current experiences of MC were also confirmed. Participants then completed additional questionnaires and were instructed on how to complete the daily diary assessments.

Next, participants completed 14 days of twice-daily assessments using a smartphone app. Participants were prompted to complete daily assessments at 9:00 AM EST and 5:00 PM EST each day and received reminders every 30 minutes until the survey was completed or the assessment window closed. Assessment windows closed (and a given assessment was “skipped”) if the participant did not respond to questionnaires within four hours of the assessment window opening (i.e., by 1:00 PM EST or 9:00 PM EST, respectively). Participants completed a total of 974 out of 1148 (84.8%) possible daily assessments. The mean number of responses per participant was 23.76 (SD = 5.24, range 7–28) and over 90% of participants completed 15 or more of the 28 possible daily assessments. Participants received $1 for each daily assessment they completed and could therefore receive a total of $28 if they completed all daily assessments. To promote study adherence, participants received a $5 bonus each time they completed four consecutive daily assessments. Given the sensitive nature of questions regarding participants’ trauma history and trauma-related concerns, all participants in the current study were provided with mental health resources and referral sheets as part of their participation.

Data Analytic Approach

Descriptive analyses and data management were conducted using SPSS and primary analyses were conducted using SAS Version 9.4. First, person-mean scores were computed for all daily variables and zero-order correlations were computed among all primary variables of interest. Next, we disaggregated between- from within-person variability in all daily variables according to Wang and Maxwell’s (2015) recommendations. We calculated grand-mean centered scores for each daily variable by subtracting the sample grand mean from each person-mean score to represent between-person variability in each daily variable. Finally, we calculated person-mean centered scores for each daily variable by subtracting the person-mean score from each raw daily score to represent within-person variability in each daily variable.

Upon review of zero-order correlations among person-mean coping variables, very high positive correlations were observed between two sets of variables: (1) “I’ve been accepting the reality of the fact that it has happened” [acceptance] and “I’ve been learning to live with it” [learning to live with it] (r = .96) and (2) “I’ve been getting emotional support from others” [seeking emotional support] and “I’ve been getting comfort and understanding from someone” [seeking comfort] (r = .99). As items in each pair also shared overlapping content and are found within the Brief COPE Acceptance and Seeking Support subscales, respectively, variable scores were averaged to create aggregated Acceptance and Seeking Support scores at each timepoint.

Primary analyses tested two sets of hierarchical linear regression models (HLMs). HLM was utilized as it can account for the nested nature of daily assessments within individuals and statistical non-independence of observations in designs utilizing repeated assessments. The first set of analyses evaluated whether MC (at time t-1) predicted use of coping strategies at the subsequent assessment (time t), testing separate models for each coping strategy (i.e., daily distraction, denial, giving up, substance use, self-blame, washing behavior, thought suppression, emotional processing, emotional expression, seeking support, and acceptance). We included both between-person grand-mean-centered MC scores and within-person person-mean-centered MC scores as main effects in each model. To examine whether MC predicted assessment-to-assessment changes in the use of each strategy, we included the lagged (t-1) score of each strategy in its respective model. Consistent with Wang and Maxwell’s (2015) recommendations, we also included timing of assessment (in hours) as a covariate in each model. Daily assessments were centered to reflect the mid-point of the assessment period (coded from −160 to 160 for assessment 1 to 28). Finally, we included baseline grand-mean-centered PTSD symptoms as a covariate in all models to adjust for individual differences in these outcomes. Restricted maximum likelihood estimation (REML) was used to fit all models and the Kenward-Roger method was used to calculate degrees of freedom. An autoregressive lagged covariance structure was used to account for associations from one timepoint to the next and participant intercepts were allowed to vary as a random effect. The Benjamini-Hochberg procedure was used to control the false discovery rate for this series of statistical tests (Benjamini & Hochberg, 1995) and only p-values less than the adjusted critical value were considered statistically significant.

The second set of models examined whether use of specific coping strategies (t-1) predicted MC at the subsequent assessment (t). Separate models were again tested for each coping strategy. We included the between-person tendency to engage in the given coping strategy (person mean scores aggregated over the two-week assessment period) and within-person prior assessment scores for the given coping strategy (t-1) as main effects in each model. Covariates in each model included baseline PTSD symptoms, timing of assessment (hours), and lagged MC scores. Again, the Benjamini-Hochberg procedure was used to control the false discovery rate (Benjamini & Hochberg, 1995).

We also conducted a sensitivity analysis, excluding evening-to-morning changes as day-to-day carryover effects may differ qualitatively from within-day effects. Both sets of models above were re-evaluated when excluding evening-to-next-morning effects (i.e., excluding prediction of morning outcomes by lagged prior evening predictor values).

Results

Descriptive Statistics and Correlations

Descriptive statistics, correlations among covariates and daily variables, and within-person correlations among daily variables are presented in Table 1 and Appendix A. The mean score for baseline MC well exceeded the cutoff score for moderate MC severity (PEMC ≥10; Coughtrey et al., 2014). On average, frequencies for daily coping strategy use were numerically highest for distraction, acceptance, thought suppression, and emotional processing, followed by emotional expression, seeking support, self-blame, washing behavior, giving up, substance use, and denial.

Table 1.

Descriptive Statistics and Correlations Among Model Variables

Variable 2 3 4 5 6 7 8 9 10 11 12 13 14 M (SD) Range
1. Baseline mental contamination
 (PEMC)		 .45** .51** .53** .37* .40** .34* .29 .46** .57** .36* .33* .41** .33* 50.32 (14.67) 0 – 80
2. Baseline PTSD symptoms
 (CAPS-5)		 – .59** .59** .46** .49** .19 .36* .60** .56** .24 .17 .22 .28 32.17 (10.57) 0 – 80
3. Daily mental contamination
 (SMCS)		 – – .55** .47** .45** .17 .61** .82** .79** .51** .39** .22 .39** 14.38 (15.56) 0 – 60
4. Daily distraction
 (Brief COPE)		 – .23** – .42** .38* .33* .46** .70** .79** .58** .56** .43** .61** 2.72 (0.97) 1 – 4
5. Daily denial
 (Brief COPE)		 – .34** .20** – .75** .38* .35* .51** .52** .05 −.02 .04 .15 1.47 (0.70) 1 – 4
6. Daily giving up
 (Brief COPE)		 – .22** .13** .27** – .37* .53** .44** .55** .03 −.08 .03 .13 1.64 (0.63) 1 – 4
7. Daily substance use
 (Brief COPE)		 – .15** .12** .30** .26** – .38* .15 .22 .20 .21 .30 .12 1.58 (0.78) 1 – 4
8. Daily self-blame
 (Brief COPE)		 – .34** .15** .23** .32** .22** – .52** .57** .46** .23 .15 .22 1.93 (0.82) 1 – 4
9. Daily washing behavior
 (VOCI-MC)		 – .32** .17** .15** .16** .11** .23** – .74** .52** .51** .34* .41** 1.88 (0.88) 1 – 4
10. Daily thought suppression
 (TSI)		 – .37** .31** .17** .19** .14** .33** .31** – .52** .37* .27 .55** 2.35 (0.84) 1 – 4
11. Daily emotional processing
 (EAC)		 – .20** .11** .13** .03 .07* .15** .17** .23** – .85** .61** .66** 2.08 (0.78) 1 – 4
12. Daily emotional expression
 (EAC)		 – .12** .07 .07* .04 .12** .09** .13** .18** .45** – .80** .55** 2.02 (0.84) 1 – 4
13. Daily seeking support
 (Brief COPE)		 – .06 .04 .05 .06 .17** .16** .09** .06 .28** .47** – .37* 2.02 (0.93) 1 – 4
14. Daily acceptance
 (Brief COPE)		 – .13** .13** .08* .22** .08* .15** .18** .15** .30** .30** .33** – 2.58 (0.93) 1 – 4
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Note.

*

p < .05

**

p ≤ .01. Between-person correlations are presented above the diagonal and within-person correlations are presented below the diagonal. Means, standard deviations, and between-person correlations were all computed using person-mean daily scores. CAPS-5 Clinician Administered PTSD Scale for DSM-5, EAC Emotional Approach Coping measure, PEMC Posttraumatic Experience of Mental Contamination scale, SMCS State Mental Contamination Scale, TSI Thought Suppression Inventory, VOCI-MC Vancouver Obsessional Compulsive Inventory-Mental Contamination Scale.

Average daily MC was positively associated with average daily use of distraction, denial, giving up, self-blame, washing behavior, thought suppression, acceptance, emotional processing, and emotional expression. Average daily MC was not significantly associated with average daily substance use or seeking support. Average daily MC demonstrated the numerically strongest correlations with washing behavior, thought suppression, and self-blame. Similarly, baseline MC demonstrated the numerically strongest correlations with washing behavior, thought suppression, and distraction. Average values for coping strategies generally demonstrated positive intercorrelations, with all but two (substance use and seeking support) exhibiting significant positive associations with the average values of the majority of other strategies. Average daily MC was also positively associated with both baseline MC and baseline PTSD symptom severity.

Within-person variation in daily MC was significantly and positively associated with the use of all coping strategies except seeking support. Within-person variation in daily MC demonstrated the numerically strongest correlations with thought suppression, denial, self-blame, and washing behavior. Similar to the between-person correlations, most coping strategies exhibited positive within-person associations with the use of all other coping strategies, with the exception of seeking support, emotional expression, and emotional processing.

Primary Analyses

Lagged daily mental contamination predicting next assessment coping.

Higher between-person daily MC was significantly associated with more frequent use of distraction, B = .02, SE = .01, p = .01, 95% CI [.01, .04]; self-blame, B = .03, SE = .01, p < .01, 95% CI [.01, .04]; washing behavior, B = .03, SE = .01, p < .01, 95% CI [.02, .05]; thought suppression, B = .02, SE = .004, p < .01, 95% CI [.01, .03]; and emotional processing, B = .02, SE = .01, p = .01, 95% CI [.01, .03] (Appendix B). Effect sizes were similar across these strategies. Between-person differences in typical severity of daily MC were not significantly associated with use of the remaining coping strategies. Within-persons, higher than typical MC at a given assessment predicted increased use of giving up, B = .01, SE = .002, p = .01, 95% CI [.001, .01]; substance use, B = .01, SE = .002, p < .01, 95% CI [.003, .01]; and seeking support, B = .01, SE = .003, p = .02, 95% CI [.001, .01] from one assessment to the next (Appendix B). Effect sizes were similar across these three strategies. Daily MC did not significantly predict assessment-to-assessment changes in the remaining coping strategies.

Lagged daily coping predicting next assessment mental contamination.

Higher between-person daily use of distraction, B = 7.14, SE = 2.76, p = .01, 95% CI [1.54, 12.74]; self-blame, B = 11.13, SE = 2.85, p < .01, 95% CI [5.34, 16.91]; washing behavior, B = 15.37, SE = 2.67, p < .01, 95% CI [9.95, 20.78]; thought suppression, B = 15.60, SE = 2.73, p < .01, 95% CI [10.07, 21.13]; emotional processing, B = 9.64, SE = 2.98, p < .01, 95% CI [3.59, 15.68]; and emotional expression, B = 6.69, SE = 2.89, p = .03, 95% CI [0.82, 12.56] were related to more intense MC (Appendix C). Effect sizes were numerically larger for self-blame, washing behavior, and thought suppression than for other strategies. Within-persons, higher than typical substance use at a given assessment predicted decreased MC from one assessment to the next, B = −.97, SE = .42, p = .02, 95% CI [−1.80, −0.14] (Appendix C). None of the remaining strategies significantly predicted within-person assessment-to-assessment changes in MC.

Sensitivity Analysis of Within-Day Relations Only

When we repeated our lagged analyses but excluded evening-to-next-morning effects, we found generally consistent effects with the exception of two results (see notation in Appendix B). When excluding evening-to-next-morning effects, higher than typical MC at a given assessment predicted increased use of self-blame, B = .01, SE = .004, p = .01, 95% CI [.003, .02] and no longer significantly predicted use of seeking support, B = .003, SE = .004, p = .51, 95% CI [−0.01, 0.01], from one assessment to the next.

Discussion

This study investigated relations between trauma-related MC and specific approach- and avoidance-oriented coping strategies in a sample of women experiencing persistent sexual trauma-related MC across 14 days. Our primary hypothesis was generally supported: individuals who reported more intense MC also tended to report more frequent use of several avoidance-oriented strategies (i.e., distraction, denial, giving up, self-blame, thought suppression, and washing behavior) across the diary period, with the strongest associations observed for washing behavior and thought suppression. However, those experiencing higher MC also tended to use the approach-oriented strategies of emotional processing (i.e., attempting to identify or understand emotions; Stanton et al., 2009) and emotional expression (i.e., sharing one’s emotions openly) more frequently. These results converge with an increasing body of work linking washing behavior to persistent MC among women with a history of sexual trauma (Badour et al., 2013; Fairbrother & Rachman, 2004). Findings regarding MC and thought suppression also align with work asserting that thoughts associated with MC (e.g., “I’m inherently dirty”) produce significant distress (Rachman, 2004) and may thus prompt suppression efforts. However, our study also builds upon prior work by demonstrating that MC is associated with the tendency to use a range of avoidant coping strategies. Together, our findings underscore that focusing solely on links between MC and washing behavior may fail to adequately capture the range of coping efforts individuals use to manage MC. Future research may seek to evaluate contextual factors impacting the use of various avoidant coping strategies (e.g., washing, thought suppression).

Daily MC was not linked to the tendency to seek social support or engage in substance-related coping across the diary period. That MC was not significantly associated with the tendency to seek social support is notable given previous empirical and theoretical work asserting that MC may elicit feelings of shame and self-disgust – both of which may promote social withdrawal, thereby limiting opportunities to seek and obtain social support (Brake et al., 2021; Rachman et al., 2015; Steil et al., 2011). Regarding substance use, most participants in our sample reported no drug use (illicit or misuse of prescription medications) in the past year and only slightly more than half reported drinking to intoxication one or more times during that same period. As such, more weight should be placed on findings regarding within-person associations between MC and substance use coping (both concurrent and prospective) in the present study as within-person associations allow for a consideration of day-to-day variation in substance use coping among those who use substances. Given notable rates of substance use among survivors of sexual trauma (e.g., Ullman et al., 2013), future studies should test associations between MC and substance-related coping among samples reporting more frequent substance use.

Use of avoidant strategies may provide short-term relief from MC and other forms of trauma-related distress (Folkman & Moskowitz, 2004). Over time, individuals experiencing distress related to MC may seek to process that distress, either individually or with the assistance of others. Our novel finding regarding positive between-person associations between MC and the tendency to use both emotional processing and emotional expression may support this interpretation. Individuals who experience more intense MC may turn to many different coping strategies in an effort to mitigate distress, as has been observed for PTSD and other posttraumatic outcomes (e.g., Short et al., 2018; Stanisławski, 2019). Further, the finding that more intense MC was only linked to a higher tendency to use approach coping strategies related to emotional experiences may indicate that emotion-focused approach strategies are more accessible than other types of approach strategies in attempting to address MC. Taken together, findings regarding between-person correlations among MC and specific coping strategies highlight the overall tendency to use a variety of coping strategies among individuals with more severe MC.

Importantly, this study was the first to examine within-person relations between daily variability in MC and use of specific coping strategies. Within-persons, increases in MC were related to concurrent increases in use of all coping strategies except seeking support. However, higher than typical MC at a given assessment only predicted higher use of giving up, substance use, and seeking support at the next assessment (8–16 hours later). We also note that MC no longer significantly predicted seeking support and higher MC predicted higher use of self-blame at the next assessment when evaluating only within-day effects in sensitivity analyses. These differences suggest that coping processes involving seeking support and self-blame may occur on different timeframes, wherein individuals are more likely to use self-blame as an immediate response to acute increases in MC but may require a longer period of time to seek out and secure support from others. Such an explanation may also provide a framework for contextualizing the finding that experiencing more severe MC was not associated with the tendency to seek support either a) across the daily diary period or b) at the same timepoint but was associated with subsequent support seeking when examined within persons. Future research should investigate the time elapsed between the onset of MC-related distress and use of specific strategies, as well as the time elapsed between use of specific strategies and improvement in MC-related distress.

The only coping strategy that predicted lower MC at the next assessment was substance use. Though a minority of participants in the sample reported engaging in substance use overall and MC severity was not related to typical use of substances across the diary period, we found a reciprocal relationship between MC and substance-related coping within-persons. Together, these findings suggest that although substance use was not a consistent response among our sample, those who did engage in substance-related coping were more likely to do so after experiencing higher than typical MC and reported subsequent short-term decreases in MC. This pattern is consistent with the concept of a mutual maintenance model, wherein individuals use substances to manage MC-related distress, substance use is negatively reinforced through immediate distress reduction, and substance use is thus more likely to be used in future coping efforts. Over time, however, substance-related coping may interfere with the likelihood of using more adaptive coping strategies that could lead to longer-term improvements in MC. As the current study did not assess daily use of specific substances and our sample endorsed numerically low past-year use of substances, we encourage future researchers to examine whether the degree of relief from MC-related distress may differ across substances.

The fact that substance use was the only coping strategy that predicted subsequent reductions in MC may indicate that most of the strategies assessed here are relatively ineffective at changing MC. Alternatively, it may be the case that the coping strategies we assessed are effective at reducing MC for intervals shorter than those measured here (i.e., less than 8–16 hours) and/or that dimensions other than strategy frequency (e.g., strategy effectiveness, strategy quality, or the function or goal of strategy use; Aldao, 2013; Eldesouky & Goodman, 2021; Southward et al., 2021; Southward & Sauer-Zavala, 2022) may predict decreases in MC. We encourage future researchers to assess MC and coping more frequently to improve the temporal resolution of findings and to assess these multiple dimensions of coping.

Further, though acute increases in MC were associated with simultaneous increases in use of various coping strategies, higher use of the majority of these strategies – with the exception of giving up, seeking of support, and substance use – was not sustained at the subsequent assessment (8–16 hours later). These findings may indicate that increases in MC are time-limited and that sustained coping efforts across a period of several hours are not necessary to manage such increases. Alternatively, such findings may suggest that participants perceived giving up, seeking support, and substance use to be more effective or accessible than the remaining strategies following an acute increase in MC. It is notable that all of these strategies involve a degree of passivity in relation to distress (e.g., by resigning to distress [giving up], incorporating others into efforts to mitigate distress [seeking support], and numbing one’s experience of distress [substance use]) and may thus be easier to sustain for periods of several hours or longer than more active coping approaches. However, unidirectional effects for giving up and seeking support suggest that if these strategies are indeed deemed more accessible or employable following acute elevations in MC, they may not be effective in reducing subsequent MC. Future work would benefit from exploring the duration of acute elevations in MC and the perceived short- and long-term effectiveness and adaptiveness of strategies.

The results of this study should be considered in light of its limitations. Although we assessed participants’ experiences for 14 days, only conducting twice-daily assessments limits the temporal resolution of our findings. Participants also reported on their use of coping strategies in relation to their index traumatic event. Though broader trauma-related distress is likely to encompass MC-related distress, we are unable to determine to what extent participants used strategies to cope with MC in particular. We are similarly unable to determine which aspects of trauma-related distress participants used substances to cope with or which substances participants used. Additionally, we only measured coping strategy frequency and did not assess other dimensions of coping strategy use (e.g., quality of strategy use). Our sample was relatively small and, as our analyses included only female participants, our between-person results may not generalize to individuals of other gender identities. Participants reported numerically low daily levels of MC relative to the maximum total score on the SMCS, limiting the generalizability of these findings and, potentially, attenuating effect sizes. Finally, as participants completed study procedures in their natural environment, they may have experienced different levels of exposure to trauma reminders that might trigger MC. Although we adjusted for PTSD symptoms in all analyses, future studies may consider using an event-triggered design to measure more proximal effects of acute increases in MC on coping strategy use following exposure to trauma reminders.

Despite these limitations, we replicated previous findings on the between-person associations between MC and avoidance-oriented coping and extended these findings to within-person relations between MC and specific coping strategies. Using a 14-day experiencing sampling design, we found that people experiencing more severe MC tended to use all coping strategies except substance use and seeking support more often and that experiencing higher than typical MC was similarly associated with more frequent use of all coping strategies except seeking support at the same timepoint. Further, though experiencing higher than typical MC predicted more frequent subsequent use of several coping strategies, more frequent use of all of these strategies except for substance use did not predict subsequent decreases in MC. This pattern of results suggests that other strategies – or other coping-related factors, such as the perceived effectiveness of strategies – may be relevant in better understanding fluctuations in MC and/or efforts to cope with MC. Taken together, our findings help specify relationships between MC and use of specific coping strategies and provide greater nuance to our understanding of experiences of trauma-related MC occurring in naturalistic settings.

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