Moderators and Mediators of the Relationship Between Social Support and Readiness to Change in OCD

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We investigated the relationship between social support and readiness to change (RTC) in individuals with OCD, specifically examining the potential moderating effects of age, depression severity, and symptom subtypes. A sample of 104 adults with OCD (61% female, mean age = 30.9 years) completed measures assessing RTC, social support, depression, OCD symptoms, and internalized stigma. In the main effects model, age ( β = .21), depression severity ( β = .21), and the unacceptable thoughts symptom factor ( β = .89) predicted RTC. The interaction model revealed a significant main effect of social support on RTC ( β = .58), with symptom subtype moderating this relationship. Notably, both unacceptable thoughts ( β = -.65) and harm obsessions ( β = -.67) showed a strong negative interaction with social support. We conclude that social support is positively associated with readiness to change in OCD, but this relationship varies in the presence of unacceptable thoughts and harm obsessions. Further, depression, age, and unacceptable thoughts have a positive relationship with RTC, independent of social support, in those with OCD. These findings suggest that encouraging non-professional social support may be a valuable treatment adjunct, though it should be used with caution for certain OCD subtypes. Future research should use more advanced modeling techniques and employ randomized clinical trials to examine the causal relationship between social support and readiness to change. obsessive-compulsive disorder readiness to change social support symptom subtypes depression Figures Figure 1 Introduction Obsessive compulsive disorder (OCD) is a frequently debilitating mental disorder affecting 1-3% of the population (Ruscio et al. 2010). OCD is characterized by the presence of unwanted or intrusive thoughts (obsessions) that provoke distress and by repetitive behaviors (compulsions) performed to reduce that distress (American Psychiatric Association, 2013). OCD is associated with significant impairment, often interfering with multiple domains of function (Huppert et al., 2009). A number of evidence-based pharmacological and behavioral interventions are available for individuals struggling with OCD, with the most efficacious being exposure and response prevention therapy (ERP; Hezel & Simpson, 2019; Law & Boisseau, 2019). While ERP is effective for many (Abramowitz et al., 2008; Öst et al., 2015), up to 50% of individuals with OCD either do not respond, relapse, or fail to complete treatment(Abramowitz & Arch, 2014; Law & Boisseau, 2019; Nathan & Gorman, 2007). Many barriers can undermine the effectiveness of treatment. A common challenge is motivating patients to engage in the therapy (O’Neill & Feusner, 2015; Ritchie, 1986; Wilson & Roman, 2007). Patients with OCD may struggle to challenge their obsessions and change their behaviors due to the overwhelming distress provoked by their unwanted thoughts. Since deliberately challenging feared thoughts and stimuli is the core of ERP, motivational barriers can lead to stagnation and attrition (Anderson, 2015). It follows that one mechanism for improving treatment outcomes may be to bolster readiness to change (RTC), or a patient’s willingness and motivation to address maladaptive cognitions and behaviors (McConnaughy et al., 1983; Prochaska et al., 1994) . There are several effective strategies for improving RTC, including consciousness raising, environmental re-evaluation, and building self-efficacy (Proshaka and Norcross, 2018). Non-professional social support can also serve as a motivator of change (Proshaka and Norcross, 2018) and has been shown to increase hopefulness, empowerment, and self-efficacy (Davidson et al., 2012; King & Simmons, 2018; Rees & Freeman, 2009; Shalaby & Agyapong, 2020). Despite evidence demonstrating the motivational benefits of non-professional social support, the effects of social support on motivation have not been studied in OCD. In a pilot study, we found that level of social support predicted RTC in 50 adults with OCD, controlling for the extent to which they adopted stigmatizing views of mental illness ( β = .40; King & Zaboski, 2024). Previous work in other conditions suggests that additional variables can mediate the relationship between social support and RTC. Both age and depression can lead to social isolation, lack of motivation, trouble initiating change, and reduced self-efficacy (Elmer & Stadtfeld, 2020; Gecas, 1989; National Research Council (US) Committee on Aging, Personality, and Adult Developmental Psychology, 2006). Further, subtypes of OCD are associated with different levels of internalized stigma, (Cathey & Wetterneck, 2013; Fung et al., 2007; Glazier et al., 2015), like disclosure of a sexually intrusive thought was associated with greater anticipated rejection than disclosure of a contamination-based intrusive thought (Cathey & Wetterneck, 2013). Given these associations, assessing the influence of depression, age, and OCD subtype is critical to understanding how non-professional social support can impact treatment for individuals with OCD. The present study assessed 104 adults with OCD to specifically assess how depression, age, and OCD subtype influence the relationship between social support and RTC, as well as relate to RTC themselves. We hypothesize that depression and age will have negative associations with RTC, and negatively interact with social support as a predictor of RTC. Similarly, we expect symptom subtype to negatively predict RTC and negatively interact with social support as a predictor of RTC. We believe the effect of symptom subtype will be strongest for the unacceptable thoughts OCD subtype. Methods Participants All procedures received Institutional Review Board approval. Participants were recruited nationally and locally through the Yale OCD Research Clinic using social media advertisements, local bus ads, community flyers, and outpatient referral sources. A primary diagnosis of OCD was established with an intake evaluation and validated with a structured diagnostic interview (Mini-International Neuropsychiatric Interview [MINI]; Sheehan, 1998). Diagnoses were validated by a licensed psychologist or a board-certified psychiatrist. After the diagnostic intake, participants completed self-reports scales on a web-based, HIPAA-compliant data capture system (REDCap; Harris et al., 2009 , 2019 ). Qualifying participants were paid $ 40 for completing an assessment battery. The final sample included N = 104 participants (61% female, 5% non-binary) between the ages of 18 and 69 (inclusive; M = 30.9, SD = 11.8). Measures University of Rhode Island Change Assessment The University of Rhode Island Change Assessment (URICA) is a widely used measure of RTC and continuity of motivation based on the transtheoretical model of change (Norcross et al., 2011 ). The transtheoretical model describes the process of change in five stages: precontemplation, contemplation, preparation, action, and maintenance (Norcross et al., 2011 ). RTC refers to the extent to which one desires change, feels they can change, and is motivated to enact change. Moreover, it conceptualizes behavior change as an ongoing process rather than a binary event (DiClemente et al., 2004 ; Opsal et al., 2019 ). The URICA has 32 questions and is broken into four subscales: precontemplation, contemplation, action, and maintenance (Field et al., 2009 ). All items are measured on a Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). The RTC score entails summing the mean response value for the contemplation, action, and maintenance subscales then subtracting the mean response value of the precontemplation subscale (Greene et al., 1999 ; Prochaska et al., 1994 ). The URICA has demonstrated good internal consistency (⍺ = .83) and reliability ( r = .79) in a number of behavioral health conditions, including anxiety disorders (Dozois et al., 2004 ; Field et al., 2009 ; Henderson et al., 2004 ; Willoughby & Edens, 1996 ). The URICA has also demonstrated predictive validity in that it relates to key clinical measures, including treatment adherence and outcome (Brogan et al., 1999 ; Dozois et al., 2004 ). Internalized Stigma of Mental Illness Scale The Internalized Stigma of Mental Illness (ISMI) scale measures feelings of internalized stigma related to having a mental illness. It comprises 29 questions and is divided into five subscales: alienation, stereotype endorsement, discrimination experience, social withdrawal, and stigma resistance. Responses are measured on a Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree) and summed to generate a total score (Ritshcer et al. 2003). The ISMI demonstrates good internal consistency (α = 0.94), reliability (ICC = 0.78), and construct validity (Boyd Ritsher et al., 2003 ; Chang et al., 2014 ). Higher scores are associated with greater feelings of depression, lower self-esteem, and greater symptom severity (Boyd et al., 2014 ). Beck Depression Inventory-II The Beck Depression Inventory II is a 21-question self-report measure designed to measure the physical and cognitive symptoms associated with depression (Hubley, 2014 ). Most items have 4 potential responses, each associated with a different value, and response values are summed to provide a total score ranging from 0–63. Total score interpretations are as follows: 0 to 13 (minimal depression), 14 to 19 (mild depression), 20 to 28 (moderate depression), and 29 to 63 (severe depression). The BDI-II has demonstrated good internal validity (α ≈ 0.90), test-retest reliability (α ≈ 0.73–0.96), and ability to differentiate between depressed and non-depressed psychiatric patients (Beck et al., 1996 ; Wang & Gorenstein, 2013 ). Dimensional Obsessive-Compulsive Scale The Dimensional Obsessive-Compulsive Scale (DOCS) is a 20-item self-report measure designed to measure OCD symptom severity within the four most reliably replicated symptom dimensions: germs/contamination, responsibility for harm/injury/bad luck, unacceptable thoughts, and symmetry/neatness/the need for things to be “just right” (Abramowitz et al., 2010 ). Initial testing of the DOCS demonstrated that it has good internal consistency (α ≈ 0.90) and high diagnostic sensitivity, as evidenced by a correlation of 0.69 with the total score on the Obsessive-Compulsive Inventory-Revised (Abramowitz & Deacon et al., 2006; Abramowitz et al., 2010 ). Sharing Survey This survey was developed within the Yale OCD Research Clinic to measure the experience of seeking and receiving social support specific to one’s OCD. The Sharing Survey is a 26-item self-report measured divided into four subscales: willingness to share (how readily the participant speaks about their diagnosis with friends and family), how others react (the extent to which friends or family react supportively), subjective experience (how the individual felt after sharing), and effect on relationship to diagnosis (how sharing affected one’s feelings about their disorder). Items are scored on a Likert scale from 1 (strongly disagree) to 7 (strongly agree), with an option of 0 (does not apply). Subscale scores are calculated by reverse coding when applicable and summing the relevant individual items. Analytic Plan We sought to verify the relationship between social support and RTC when controlling for internalized stigma, as well as to investigate the moderating influences of depression, age, and symptom subtype on this relationship. Hypothesized relationships between the measured variables were formalized a directed acyclic graph (DAG; Fig. 1 ). This DAG illustrates the connections we hypothesize exist between relevant variables as described in the introduction. As seen in the DAG, age, depression, and symptom factor act as potential confounding variables for the relationship between social support and RTC, and we expect to have some effect on RTC independent of a moderator effect. This structural approach to causal inference guided our statistical analysis. First, we extracted data from all scales and imputed missing values using the mice package in R (van Buuren & Groothuis-Oudshoorn K, 2011 ). Second, each participant in the data set was assigned a dominant subtype, defined as the subscale on the DOCS (Symmetry, Contamination, Unacceptable Thoughts, or Harm) in which the participant scored the highest. Next, the relationships from Fig. 1 were programmed into the R package Daggity (v 3.1; Textor et al., 2016 ). This package tells researchers which variables need to be controlled given a specified relationship of interest. For example, as we were interested in how all identified predictors affected RTC, we constructed a main effects model which predicted RTC with social support, age, depression severity, and symptom subtype. We then constructed an interaction model predicting RTC with social support with three interaction terms - age, depression, and symptom factor - to determine how these terms influenced the relationship between support and willingness to change. Finally, we conducted a mediation analysis (Hair et al., 2021 ) to determine if the moderating influence of subtype on RTC was mediated by internalized stigma, as suggested by our pilot work (King & Zaboski, 2024 ). This was done in three stages: A mediation model examined the effect of symptom factor on internalized stigma, then an outcome model assessed the effect of the symptom factor, internalized stigma, and covariates on RTC. Lastly, a mediation analysis in R with the ‘mediation’ package (Tingley et al., 2014 ), determined whether internalized stigma mediated the effect of symptom factor on RTC. Results Analyses included N = 104 participants. The mean BDI-II score was 19.95 ( SD = 11.62), indicating that the average respondent was experiencing moderate depression. The mean RTC score was 10.28 ( SD = 1.57), implying that most participants were in the contemplation phase of change, aware of the problematic nature of their OCD but still only considering change. Mean ISMI scores were 61.55 ( SD = 11), below average by comparison to those with any mental illness. The most common primary symptom factors in our study were harm and contamination (both with 29 respondents; both accounting for 28% of respondents), while the unacceptable thoughts and symmetry symptom dimensions accounted for 20 and 26 respondents, respectively. The average DOCS score was 29 ( SD = 12.7). Upon inspecting intakes for participants with lower DOCS scores, we found that lower scores were likely due to the DOCS not capturing relevant symptomatology (e.g., existential OCD) in all cases. On the Sharing Survey, the total mean of each subscale was greater than the score one would get by selecting “neither agree nor disagree” to each question. This suggests that adults with OCD are often willing to share their experiences, feel positive about them, and are met with support. These data are displayed in Table 1 . Table 1 Descriptive Statistics Variable M SD Min Max Age 31 12 18 69 Beck Depression Inventory - II 20 12 0 46 Willingness To Share 28 3.5 20 36 How Do Others React 32 6.8 14 48 Readiness To Change 10 1.6 6.4 13 Subjective Experience 34 7.7 13 49 Relationship To Diagnosis 31 6 18 42 Internalized Stigma of Mental Illness 62 11 37 96 Dimensions Obsessive Compulsive Scale 29 12.7 5 68 Main Effects Model The main effects model determined how selected predictors affected RTC (Table 2 ). Age ( β = .21; p = .029) and BDI-II ( β = .21; p = .029) scores both emerged as significant predictors of RTC with moderate effect sizes. Further, unacceptable thoughts—the factor most often associated with stigma—had a strong and statistically significant effect on RTC ( β = .89, p = .002). Table 2 Main Effects Model: Predictors of RTC Predictors Estimates CI p Social Support 0.15 -0.05–0.34 0.133 Age 0.21 0.02–0.39 0.029 BDI-II Score 0.21 0.02–0.41 0.029 Unacceptable Thoughts 0.89 0.35–1.43 0.002 Harm 0.11 -0.38–0.60 0.647 Symmetry 0.19 -0.32–0.70 0.452 Interaction Model With an interaction model (Table 3 ), we investigated whether age, depression, and symptom factor modified the effect of social support on RTC. There was a statistically significant, moderate main effect for social support ( p = .002, β = .58). Consistent with the main effects model, there were significant main effects for age ( β = .21), depression ( β = .20 ) , and the unacceptable thoughts symptom factor ( β = .84). The interactions between social support and age, BDI-II, and symmetry were not significant. That said, the unacceptable thoughts ( β = − .65, p = .016) and harm ( β = − .67, p = .01) symptom factors both had strong, negative interactions with social support. This interaction suggests that the relationship between social support and RTC depends in part on symptom subtype, with the negative coefficient highlighting that high levels of unacceptable thoughts or harm obsessions may weaken or potentially reverse any positive relationship between social support and RTC. Table 3 Interaction Model Predictors Estimates CI p Social Support 0.58 0.22–0.95 0.002 BDI-II Scores 0.21 0.02–0.40 0.031 Age 0.20 0.01–0.38 0.035 Unacceptable Thoughts 0.84 0.32–1.37 0.002 Harm 0.16 -0.32–0.63 0.522 Symmetry 0.21 -0.29–0.70 0.410 Social Support x BDI-II Score 0.10 -0.10–0.30 0.343 Social Support x Age -0.08 -0.27–0.11 0.403 Social Support x Unacceptable Thoughts -0.65 -1.17 – -0.12 0.016 Social Support x Harm -0.67 -1.18 – -0.16 0.010 Social Support x Symmetry -0.38 -0.90–0.14 0.149 Mediation Model To assess whether the effect of symptom subtype on RTC is mediated by internalized stigma, a mediation analysis was conducted (Table 4 ). The indirect effect was not significant ( p = .998), showing that internalized stigma (our predicted mediator) does not significantly explain the relationship between symptom subtype and RTC. That is, symptom subtype does not act on RTC through internalized stigma as we hypothesized. As follows from the above analyses, the direct effect of symptom subtype on RTC was significant in this model. Table 4 Mediation Model Results Predictor β p Mediation Model a Unacceptable Thoughts .07 .806 Harm -0.30 .256 Symmetry -0.44 .105 Outcome Model b Internalized Stigma .03 .805 Unacceptable Thoughts .87 .002 Harm .13 .613 Symmetry .17 .510 Standardized Age .19 .048 Standardized BDI Score .16 .189 Mediation Analysis c Indirect Effect 0.018 .998 Direct Effect 0.36 .004 Total Effect 0.33 .006 Prop. Mediated .0542 .993 *Statistically significant (𝛼 = .05). a Predicting internalized stigma with symptom subtype b Predicting RTC with internalized stigma, symptom subtype, age, and BDI-II score c Effect of internalized stigma on relationship between RTC and symptom subtype Discussion Through a hypothesis driven analysis of 104 participants, we modeled how social support influences RTC while considering the moderating effects of age, depression severity, and OCD symptom subtypes. We used a DAG to increase transparency and to guide analysis. Consistent with our hypothesis, our main effects model revealed that age, depression severity, and symptom subtype were significant predictors of RTC. Further, our interaction model uncovered a robust main effect of social support on RTC, and this relationship was significantly and strongly moderated by symptom subtype, particularly for individuals with unacceptable and harm-related thoughts. In our initial model, we found that both age and depression have a positive relationship with RTC, a finding that runs counter to prior results linking age and depression to lower motivation to change (Hudson & Fraley 2016 ; Smith 2013 ) and decreased RTC (De La Cruz et al. 2021 ). The positive relationship we found may be undergirded by the influence of OCD symptom severity on RTC. That is, there is reason to believe that OCD symptom severity is connected to both duration of illness (a proxy for age) and level of depression (Zaboski et al., 2019 ; Zaboski et al., 2024 ). Because worsening symptoms likely increase one’s affinity to seek help and desire to change, this could explain the positive associations between age, depression and RTC found here. Regarding unacceptable and harm-related thoughts, results were more nuanced. Initially, we found a strong, positive association between unacceptable thoughts, harm-related thoughts, and RTC, suggesting that these symptom subtypes increase one’s desire to change. These findings are consistent with the substance abuse literature indicating that increased feelings of alienation and discrimination can motivate positive change (Ayhan et al. 2024 , Akdag et al. 2017). However, when investigating the interactions between social support and symptom subtype as predictors of RTC, a more complex picture emerged. That is, unacceptable and harm-related thoughts had a negative influence on the relationship between social support and RTC suggesting that these subtypes may be demotivating when considered in the context of social support. We believe this complexity is best explained by the addition of the social context. To elaborate, it is plausible that the alienation engendered by such stigmatizing symptom subtypes may be motivating when it is internal (not verbalized), but confronting this alienation in social settings may reverse this effect. This would explain why such symptom subtypes are motivating in the abstract but demotivating when interacting with social groups. This relates to research on shame, which can have different effects on motivation depending on whether the motivational source is internal or external (Callow et al. 2021 ; Lickel et al. 2014 ). These results highlight the importance of symptom subtype in understanding the relationship between social support and RTC, as well as the context in which symptom subtypes are shared. We found no evidence that the moderating effect of symptom subtype was mediated by internalized stigma. On the contrary, our findings suggest that subtype influences the relationship between social support and RTC through some other variable yet to be identified or does so outside of mediation. For instance, the subtypes of OCD may be distinct enough that they influence RTC within a person without needing to impact a deeper cognitive structure. Clinical Implications Given that patients frequently struggle to foster a willingness to change when starting therapy (O’Neill & Feusner, 2015 ; Ritchie, 1986 ; Wilson & Roman, 2007 ), it is imperative that clinical researchers find the tools to motivate them at this critical juncture. Our initial hypothesis was that social support could be such a tool and that the impact of social support would be influenced by depression, age, and OCD symptom subtype. The present study confirms that level of social support has a strong positive association with RTC when controlling for these variables and the interactions between them. For clinicians, encouraging patients to deliberately share their experiences with non-professionals could aid in treatment. However, one caveat pertains to the unacceptable thoughts and harm symptom subtypes; that is, our analysis suggests that social support may not be a useful tool for those struggling with obsessions related to unacceptable thoughts or thoughts of harm. This interactions between unacceptable/harm-related thoughts and social support in predicting RTC suggest that not all symptom subtypes respond to social support. This perhaps necessitates more personalized treatment based on subtype than previously thought. For instance, in addition to individuating hierarchies and considering the ethics of those exposures (Abramowitz, 2019 ), our findings suggest that, when attempting to motivate patients, different subtypes may also require different motivational techniques. When treating patients experiencing unacceptable and harm-related thoughts, encouraging sharing with non-professionals may not be as effective a treatment tool as for other subtypes, and clinicians may wish to consider other forms of support instead (e.g., family). Finally, the positive associations we found between age and RTC suggest that older participants may generally find themselves in more advanced stages of change. Moreover, symptoms of depression should be carefully monitored and considered when designing treatment for individuals with OCD, as they have the potential to improve RTC when they are framed as motivators for change (Storch, E. A. et al., 2021 ). Limitations and Future Directions One limitation worth noting is that the measure of social support deployed – The Sharing Survey (supplement 1) – has not been validated. We chose to use a novel measure constructed in the clinic for this research question because of the specificity of the interactions we sought to include. That is, we were not in general social support but rather the subjective support felt specifically when individuals with OCD share experiences with non-professional peers. We did not feel any standardized measure of social support precisely captured this interaction; thus a novel measure was most appropriate for our research question. The causal relationships that we tested may be oversimplified. The DAG that we constructed assumes unidirectional relationships between variables, yet the relationship between social support and readiness to change may be bidirectional, with increased motivation potentially leading individuals to seek more social support. Additionally, our approach does not account for potential unmeasured confounders or temporal dynamics between variables that could influence the relationship between social support and RTC. Future research could employ more sophisticated causal modeling techniques, such as time-varying DAGs or structural equation modeling, to capture the dynamic nature of these relationships more comprehensively. Alternatively, methods like randomized clinical trials could simplify the causal relationships between variables and answer additional questions about the efficacy of non-professional social support networks in clinical practice. Another limitation is inherent to the sample. All participants contacted us, suggesting a minimal desire for change. This may have limited the range of RTC scores collected. Nevertheless, even with a restricted range of RTC, we detected moderate and strong effects. Future work that includes more diverse samples may reveal stronger and more nuanced relationships. Declarations Author Contribution K.K. - conceptualized study, interviewed patients, wrote main manuscript text, analyzed dataB.Z. - conceptualized study, reviewed patient interviews, reviewed manuscriptS.K. - established framework to collect dataC.P. - conceptualized study, reviewed manuscript Declaration of Interest Statement Kyle King – no conflicts to report Steven Kichuk – no conflicts to report Dr. Brian Zaboski - For the past three years, BZ has consulted with Biohaven Pharmaceuticals and received royalties from Oxford University Press; these relationships are not related to the work described here. Dr. Christopher Pittenger - In the past three years, CP has consulted for Biohaven Pharmaceuticals, Ceruvia Neurosciences, UCB BioPharma, Freedom Biosciences, Transcend Therapeutics, Alco Therapeutics, Lucid/Care, Nobilis Therapeutics, Mind Therapeutics, F-Prime Capital, and Madison Avenue Partners. He holds equity in Alco Therapeutics, Mind Therapeutics, and Lucid/Care. He receives or has received research support from Biohaven Pharmaceuticals, Freedom Biosciences, and Transcend Therapeutics. He receives royalties from Oxford University Press and UpToDate. He has filed patents on pharmacological treatments for OCD and related disorders, psychedelic therapeutics, and autoantibodies in OCD. None of these relationships are of relevance to the work described here. References Abramowitz, J. S., & Arch, J. J. (2014). Strategies for Improving Long-Term Outcomes in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder: Insights From Learning Theory. Cognitive and Behavioral Practice , 21 (1), 20–31. https://doi.org/10.1016/j.cbpra.2013.06.004 Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., Timpano, K. R., McGrath, P. B., Riemann, B. C., Adams, T., Björgvinsson, T., Storch, E. A., & Hale, L. R. (2010). 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OCD is characterized by the presence of unwanted or intrusive thoughts (obsessions) that provoke distress and by repetitive behaviors (compulsions) performed to reduce that distress (American Psychiatric Association, 2013). OCD is associated with significant impairment, often interfering with multiple domains of function (Huppert et al., 2009). A number of evidence-based pharmacological and behavioral interventions are available for individuals struggling with OCD, with the most efficacious being exposure and response prevention therapy (ERP; Hezel \u0026amp; Simpson, 2019; Law \u0026amp; Boisseau, 2019). While ERP is effective for many (Abramowitz et al., 2008; Öst et al., 2015), up to 50% of individuals with OCD either do not respond, relapse, or fail to complete treatment(Abramowitz \u0026amp; Arch, 2014; Law \u0026amp; Boisseau, 2019; Nathan \u0026amp; Gorman, 2007). \u003c/p\u003e\n\u003cp\u003eMany barriers can undermine the effectiveness of treatment. A common challenge is motivating patients to engage in the therapy (O’Neill \u0026amp; Feusner, 2015; Ritchie, 1986; Wilson \u0026amp; Roman, 2007). Patients with OCD may struggle to challenge their obsessions and change their behaviors due to the overwhelming distress provoked by their unwanted thoughts. Since deliberately challenging feared thoughts and stimuli is the core of ERP, motivational barriers can lead to stagnation and attrition (Anderson, 2015). It follows that one mechanism for improving treatment outcomes may be to bolster readiness to change (RTC), or a patient’s willingness and motivation to address maladaptive cognitions and behaviors (McConnaughy et al., 1983; Prochaska et al., 1994)\u003cem\u003e. \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere are several effective strategies for improving RTC, including consciousness raising, environmental re-evaluation, and building self-efficacy (Proshaka and Norcross, 2018). Non-professional social support can also serve as a motivator of change (Proshaka and Norcross, 2018) and has been shown to increase hopefulness, empowerment, and self-efficacy (Davidson et al., 2012; King \u0026amp; Simmons, 2018; Rees \u0026amp; Freeman, 2009; Shalaby \u0026amp; Agyapong, 2020). Despite evidence demonstrating the motivational benefits of non-professional social support, the effects of social support on motivation have not been studied in OCD. \u003c/p\u003e\n\u003cp\u003eIn a pilot study, we found that level of social support predicted RTC in 50 adults with OCD, controlling for the extent to which they adopted stigmatizing views of mental illness (\u003cem\u003eβ\u003c/em\u003e = .40; King \u0026amp; Zaboski, 2024). Previous work in other conditions suggests that additional variables can mediate the relationship between social support and RTC. Both age and depression can lead to social isolation, lack of motivation, trouble initiating change, and reduced self-efficacy (Elmer \u0026amp; Stadtfeld, 2020; Gecas, 1989; National Research Council (US) Committee on Aging, Personality, and Adult Developmental Psychology, 2006). Further, subtypes of OCD are associated with different levels of internalized stigma, (Cathey \u0026amp; Wetterneck, 2013; Fung et al., 2007; Glazier et al., 2015), like disclosure of a sexually intrusive thought was associated with greater anticipated rejection than disclosure of a contamination-based intrusive thought (Cathey \u0026amp; Wetterneck, 2013). \u003c/p\u003e\n\u003cp\u003eGiven these associations, assessing the influence of depression, age, and OCD subtype is critical to understanding how non-professional social support can impact treatment for individuals with OCD. The present study assessed 104 adults with OCD to specifically assess how depression, age, and OCD subtype influence the relationship between social support and RTC, as well as relate to RTC themselves. We hypothesize that depression and age will have negative associations with RTC, and negatively interact with social support as a predictor of RTC. Similarly, we expect symptom subtype to negatively predict RTC and negatively interact with social support as a predictor of RTC. We believe the effect of symptom subtype will be strongest for the unacceptable thoughts OCD subtype. \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants\u003c/h2\u003e\n \u003cp\u003eAll procedures received Institutional Review Board approval. Participants were recruited nationally and locally through the Yale OCD Research Clinic using social media advertisements, local bus ads, community flyers, and outpatient referral sources. A primary diagnosis of OCD was established with an intake evaluation and validated with a structured diagnostic interview (Mini-International Neuropsychiatric Interview [MINI]; Sheehan, 1998). Diagnoses were validated by a licensed psychologist or a board-certified psychiatrist. After the diagnostic intake, participants completed self-reports scales on a web-based, HIPAA-compliant data capture system (REDCap; Harris et al., \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Qualifying participants were paid \u003cspan\u003e$\u003c/span\u003e40 for completing an assessment battery. The final sample included \u003cem\u003eN\u0026thinsp;=\u003c/em\u003e\u0026thinsp;104 participants (61% female, 5% non-binary) between the ages of 18 and 69 (inclusive; \u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30.9, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11.8).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eUniversity of Rhode Island Change Assessment\u003c/h2\u003e\n \u003cp\u003eThe University of Rhode Island Change Assessment (URICA) is a widely used measure of RTC and continuity of motivation based on the transtheoretical model of change (Norcross et al., \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e). The transtheoretical model describes the process of change in five stages: precontemplation, contemplation, preparation, action, and maintenance (Norcross et al., \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e). RTC refers to the extent to which one desires change, feels they can change, and is motivated to enact change. Moreover, it conceptualizes behavior change as an ongoing process rather than a binary event (DiClemente et al., \u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e; Opsal et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe URICA has 32 questions and is broken into four subscales: precontemplation, contemplation, action, and maintenance (Field et al., \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e). All items are measured on a Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). The RTC score entails summing the mean response value for the contemplation, action, and maintenance subscales then subtracting the mean response value of the precontemplation subscale (Greene et al., \u003cspan class=\"CitationRef\"\u003e1999\u003c/span\u003e; Prochaska et al., \u003cspan class=\"CitationRef\"\u003e1994\u003c/span\u003e). The URICA has demonstrated good internal consistency (⍺ = .83) and reliability (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.79) in a number of behavioral health conditions, including anxiety disorders (Dozois et al., \u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e; Field et al., \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e; Henderson et al., \u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e; Willoughby \u0026amp; Edens, \u003cspan class=\"CitationRef\"\u003e1996\u003c/span\u003e). The URICA has also demonstrated predictive validity in that it relates to key clinical measures, including treatment adherence and outcome (Brogan et al., \u003cspan class=\"CitationRef\"\u003e1999\u003c/span\u003e; Dozois et al., \u003cspan class=\"CitationRef\"\u003e2004\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eInternalized Stigma of Mental Illness Scale\u003c/h2\u003e\n \u003cp\u003eThe Internalized Stigma of Mental Illness (ISMI) scale measures feelings of internalized stigma related to having a mental illness. It comprises 29 questions and is divided into five subscales: alienation, stereotype endorsement, discrimination experience, social withdrawal, and stigma resistance. Responses are measured on a Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree) and summed to generate a total score (Ritshcer et al. 2003). The ISMI demonstrates good internal consistency (\u0026alpha; = 0.94), reliability (ICC = 0.78), and construct validity (Boyd Ritsher et al., \u003cspan class=\"CitationRef\"\u003e2003\u003c/span\u003e; Chang et al., \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e). Higher scores are associated with greater feelings of depression, lower self-esteem, and greater symptom severity (Boyd et al., \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eBeck Depression Inventory-II\u003c/h3\u003e\n\u003cp\u003eThe Beck Depression Inventory II is a 21-question self-report measure designed to measure the physical and cognitive symptoms associated with depression (Hubley, \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e). Most items have 4 potential responses, each associated with a different value, and response values are summed to provide a total score ranging from 0\u0026ndash;63. Total score interpretations are as follows: 0 to 13 (minimal depression), 14 to 19 (mild depression), 20 to 28 (moderate depression), and 29 to 63 (severe depression). The BDI-II has demonstrated good internal validity (\u0026alpha;\u0026thinsp;\u0026asymp;\u0026thinsp;0.90), test-retest reliability (\u0026alpha;\u0026thinsp;\u0026asymp;\u0026thinsp;0.73\u0026ndash;0.96), and ability to differentiate between depressed and non-depressed psychiatric patients (Beck et al., \u003cspan class=\"CitationRef\"\u003e1996\u003c/span\u003e; Wang \u0026amp; Gorenstein, \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eDimensional Obsessive-Compulsive Scale\u003c/h3\u003e\n\u003cp\u003eThe Dimensional Obsessive-Compulsive Scale (DOCS) is a 20-item self-report measure designed to measure OCD symptom severity within the four most reliably replicated symptom dimensions: germs/contamination, responsibility for harm/injury/bad luck, unacceptable thoughts, and symmetry/neatness/the need for things to be \u0026ldquo;just right\u0026rdquo; (Abramowitz et al., \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e). Initial testing of the DOCS demonstrated that it has good internal consistency (\u0026alpha;\u0026thinsp;\u0026asymp;\u0026thinsp;0.90) and high diagnostic sensitivity, as evidenced by a correlation of 0.69 with the total score on the Obsessive-Compulsive Inventory-Revised (Abramowitz \u0026amp; Deacon et al., 2006; Abramowitz et al., \u003cspan class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eSharing Survey\u003c/h2\u003e\n \u003cp\u003eThis survey was developed within the Yale OCD Research Clinic to measure the experience of seeking and receiving social support specific to one\u0026rsquo;s OCD. The Sharing Survey is a 26-item self-report measured divided into four subscales: willingness to share (how readily the participant speaks about their diagnosis with friends and family), how others react (the extent to which friends or family react supportively), subjective experience (how the individual felt after sharing), and effect on relationship to diagnosis (how sharing affected one\u0026rsquo;s feelings about their disorder). Items are scored on a Likert scale from 1 (strongly disagree) to 7 (strongly agree), with an option of 0 (does not apply). Subscale scores are calculated by reverse coding when applicable and summing the relevant individual items.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eAnalytic Plan\u003c/h2\u003e\n \u003cp\u003eWe sought to verify the relationship between social support and RTC when controlling for internalized stigma, as well as to investigate the moderating influences of depression, age, and symptom subtype on this relationship. Hypothesized relationships between the measured variables were formalized a directed acyclic graph (DAG; \u003cstrong\u003eFig.\u0026nbsp;1\u003c/strong\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003cp\u003eThis DAG illustrates the connections we hypothesize exist between relevant variables as described in the introduction. As seen in the DAG, age, depression, and symptom factor act as potential confounding variables for the relationship between social support and RTC, and we expect to have some effect on RTC independent of a moderator effect.\u003c/p\u003e\n \u003cp\u003eThis structural approach to causal inference guided our statistical analysis. First, we extracted data from all scales and imputed missing values using the mice package in R (van Buuren \u0026amp; Groothuis-Oudshoorn K, \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e). Second, each participant in the data set was assigned a dominant subtype, defined as the subscale on the DOCS (Symmetry, Contamination, Unacceptable Thoughts, or Harm) in which the participant scored the highest. Next, the relationships from Fig. 1 were programmed into the R package Daggity (v 3.1; Textor et al., \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e). This package tells researchers which variables need to be controlled given a specified relationship of interest. For example, as we were interested in how all identified predictors affected RTC, we constructed a main effects model which predicted RTC with social support, age, depression severity, and symptom subtype. We then constructed an interaction model predicting RTC with social support with three interaction terms - age, depression, and symptom factor - to determine how these terms influenced the relationship between support and willingness to change.\u003c/p\u003e\n \u003cp\u003eFinally, we conducted a mediation analysis (Hair et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e) to determine if the moderating influence of subtype on RTC was mediated by internalized stigma, as suggested by our pilot work (King \u0026amp; Zaboski, \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e). This was done in three stages: A mediation model examined the effect of symptom factor on internalized stigma, then an outcome model assessed the effect of the symptom factor, internalized stigma, and covariates on RTC. Lastly, a mediation analysis in R with the \u0026lsquo;mediation\u0026rsquo; package (Tingley et al., \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e), determined whether internalized stigma mediated the effect of symptom factor on RTC.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAnalyses included \u003cem\u003eN\u0026thinsp;=\u003c/em\u003e\u0026thinsp;104 participants. The mean BDI-II score was 19.95 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11.62), indicating that the average respondent was experiencing moderate depression. The mean RTC score was 10.28 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.57), implying that most participants were in the contemplation phase of change, aware of the problematic nature of their OCD but still only considering change. Mean ISMI scores were 61.55 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11), below average by comparison to those with any mental illness. The most common primary symptom factors in our study were harm and contamination (both with 29 respondents; both accounting for 28% of respondents), while the unacceptable thoughts and symmetry symptom dimensions accounted for 20 and 26 respondents, respectively. The average DOCS score was 29 (\u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12.7). Upon inspecting intakes for participants with lower DOCS scores, we found that lower scores were likely due to the DOCS not capturing relevant symptomatology (e.g., existential OCD) in all cases. On the Sharing Survey, the total mean of each subscale was greater than the score one would get by selecting \u0026ldquo;neither agree nor disagree\u0026rdquo; to each question. This suggests that adults with OCD are often willing to share their experiences, feel positive about them, and are met with support. These data are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescriptive Statistics\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMax\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeck Depression Inventory - II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWillingness To Share\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow Do Others React\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReadiness To Change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubjective Experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelationship To Diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternalized Stigma of Mental Illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimensions Obsessive Compulsive Scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eMain Effects Model\u003c/h2\u003e \u003cp\u003eThe main effects model determined how selected predictors affected RTC (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Age (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.21; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.029) and BDI-II (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.21; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.029) scores both emerged as significant predictors of RTC with moderate effect sizes. Further, unacceptable thoughts\u0026mdash;the factor most often associated with stigma\u0026mdash;had a strong and statistically significant effect on RTC (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.89, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.002).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eMain Effects Model: Predictors of RTC\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePredictors\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eEstimates\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eCI\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.05\u0026ndash;0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.133\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02\u0026ndash;0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDI-II Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02\u0026ndash;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnacceptable Thoughts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.35\u0026ndash;1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.38\u0026ndash;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.647\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymmetry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.32\u0026ndash;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eInteraction Model\u003c/h2\u003e \u003cp\u003eWith an interaction model (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), we investigated whether age, depression, and symptom factor modified the effect of social support on RTC. There was a statistically significant, moderate main effect for social support (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.002, \u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.58). Consistent with the main effects model, there were significant main effects for age (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.21), depression (\u003cem\u003eβ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.20\u003cem\u003e)\u003c/em\u003e, and the unacceptable thoughts symptom factor (\u003cem\u003eβ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.84). The interactions between social support and age, BDI-II, and symmetry were not significant. That said, the unacceptable thoughts (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;.65, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.016) and harm (\u003cem\u003eβ\u003c/em\u003e = \u0026minus;\u0026thinsp;.67, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.01) symptom factors both had strong, negative interactions with social support. This interaction suggests that the relationship between social support and RTC depends in part on symptom subtype, with the negative coefficient highlighting that high levels of unacceptable thoughts or harm obsessions may weaken or potentially reverse any positive relationship between social support and RTC.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eInteraction Model\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePredictors\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eEstimates\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eCI\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.22\u0026ndash;0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBDI-II Scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02\u0026ndash;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.01\u0026ndash;0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnacceptable Thoughts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.32\u0026ndash;1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.32\u0026ndash;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymmetry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.29\u0026ndash;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.410\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support x BDI-II Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.10\u0026ndash;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.343\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support x Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.27\u0026ndash;0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support x Unacceptable Thoughts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.17\u0026nbsp;\u0026ndash;\u0026nbsp;-0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support x Harm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-1.18\u0026nbsp;\u0026ndash;\u0026nbsp;-0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Support x Symmetry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.90\u0026ndash;0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eMediation Model\u003c/h2\u003e \u003cp\u003eTo assess whether the effect of symptom subtype on RTC is mediated by internalized stigma, a mediation analysis was conducted (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The indirect effect was not significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.998), showing that internalized stigma (our predicted mediator) does not significantly explain the relationship between symptom subtype and RTC. That is, symptom subtype does not act on RTC through internalized stigma as we hypothesized. As follows from the above analyses, the direct effect of symptom subtype on RTC was significant in this model.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eMediation Model Results\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePredictor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMediation Model\u003c/em\u003e\u003csup\u003e\u003cem\u003ea\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnacceptable Thoughts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.806\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.256\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymmetry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.105\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOutcome Model\u003c/em\u003e\u003csup\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternalized Stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.805\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnacceptable Thoughts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHarm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.613\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymmetry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.510\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStandardized Age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.048\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStandardized BDI Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.189\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMediation Analysis\u003c/em\u003e\u003csup\u003e\u003cem\u003ec\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndirect Effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDirect Effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Effect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProp. Mediated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e.0542\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.993\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Statistically significant (\u0026#120572; = .05).\u003c/p\u003e \u003cp\u003e \u003csup\u003ea\u003c/sup\u003ePredicting internalized stigma with symptom subtype \u003csup\u003eb\u003c/sup\u003ePredicting RTC with internalized stigma, symptom subtype, age, and BDI-II score \u003csup\u003ec\u003c/sup\u003eEffect of internalized stigma on relationship between RTC and symptom subtype\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e Through a hypothesis driven analysis of 104 participants, we modeled how social support influences RTC while considering the moderating effects of age, depression severity, and OCD symptom subtypes. We used a DAG to increase transparency and to guide analysis. Consistent with our hypothesis, our main effects model revealed that age, depression severity, and symptom subtype were significant predictors of RTC. Further, our interaction model uncovered a robust main effect of social support on RTC, and this relationship was significantly and strongly moderated by symptom subtype, particularly for individuals with unacceptable and harm-related thoughts.\u003c/p\u003e \u003cp\u003eIn our initial model, we found that both age and depression have a positive relationship with RTC, a finding that runs counter to prior results linking age and depression to lower motivation to change (Hudson \u0026amp; Fraley \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Smith \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) and decreased RTC (De La Cruz et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The positive relationship we found may be undergirded by the influence of OCD symptom severity on RTC. That is, there is reason to believe that OCD symptom severity is connected to both duration of illness (a proxy for age) and level of depression (Zaboski et al., \u003cspan citationid=\"CR86\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Zaboski et al., \u003cspan citationid=\"CR87\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Because worsening symptoms likely increase one\u0026rsquo;s affinity to seek help and desire to change, this could explain the positive associations between age, depression and RTC found here.\u003c/p\u003e \u003cp\u003eRegarding unacceptable and harm-related thoughts, results were more nuanced. Initially, we found a strong, positive association between unacceptable thoughts, harm-related thoughts, and RTC, suggesting that these symptom subtypes increase one\u0026rsquo;s desire to change. These findings are consistent with the substance abuse literature indicating that increased feelings of alienation and discrimination can motivate positive change (Ayhan et al. \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e, Akdag et al. 2017). However, when investigating the interactions between social support and symptom subtype as predictors of RTC, a more complex picture emerged. That is, unacceptable and harm-related thoughts had a negative influence on the relationship between social support and RTC suggesting that these subtypes may be demotivating when considered in the context of social support. We believe this complexity is best explained by the addition of the social context. To elaborate, it is plausible that the alienation engendered by such stigmatizing symptom subtypes may be motivating when it is internal (not verbalized), but confronting this alienation in social settings may reverse this effect. This would explain why such symptom subtypes are motivating in the abstract but demotivating when interacting with social groups. This relates to research on shame, which can have different effects on motivation depending on whether the motivational source is internal or external (Callow et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lickel et al. \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). These results highlight the importance of symptom subtype in understanding the relationship between social support and RTC, as well as the context in which symptom subtypes are shared.\u003c/p\u003e \u003cp\u003eWe found no evidence that the moderating effect of symptom subtype was mediated by internalized stigma. On the contrary, our findings suggest that subtype influences the relationship between social support and RTC through some other variable yet to be identified or does so outside of mediation. For instance, the subtypes of OCD may be distinct enough that they influence RTC within a person without needing to impact a deeper cognitive structure.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eGiven that patients frequently struggle to foster a willingness to change when starting therapy (O\u0026rsquo;Neill \u0026amp; Feusner, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Ritchie, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e1986\u003c/span\u003e; Wilson \u0026amp; Roman, \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), it is imperative that clinical researchers find the tools to motivate them at this critical juncture. Our initial hypothesis was that social support could be such a tool and that the impact of social support would be influenced by depression, age, and OCD symptom subtype. The present study confirms that level of social support has a strong positive association with RTC when controlling for these variables and the interactions between them. For clinicians, encouraging patients to deliberately share their experiences with non-professionals could aid in treatment. However, one caveat pertains to the unacceptable thoughts and harm symptom subtypes; that is, our analysis suggests that social support may not be a useful tool for those struggling with obsessions related to unacceptable thoughts or thoughts of harm.\u003c/p\u003e \u003cp\u003eThis interactions between unacceptable/harm-related thoughts and social support in predicting RTC suggest that not all symptom subtypes respond to social support. This perhaps necessitates more personalized treatment based on subtype than previously thought. For instance, in addition to individuating hierarchies and considering the ethics of those exposures (Abramowitz, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), our findings suggest that, when attempting to motivate patients, different subtypes may also require different motivational techniques. When treating patients experiencing unacceptable and harm-related thoughts, encouraging sharing with non-professionals may not be as effective a treatment tool as for other subtypes, and clinicians may wish to consider other forms of support instead (e.g., family).\u003c/p\u003e \u003cp\u003eFinally, the positive associations we found between age and RTC suggest that older participants may generally find themselves in more advanced stages of change. Moreover, symptoms of depression should be carefully monitored and considered when designing treatment for individuals with OCD, as they have the potential to improve RTC when they are framed as motivators for change (Storch, E. A. et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eOne limitation worth noting is that the measure of social support deployed \u0026ndash; The Sharing Survey (supplement 1) \u0026ndash; has not been validated. We chose to use a novel measure constructed in the clinic for this research question because of the specificity of the interactions we sought to include. That is, we were not in general social support but rather the subjective support felt specifically when individuals with OCD share experiences with non-professional peers. We did not feel any standardized measure of social support precisely captured this interaction; thus a novel measure was most appropriate for our research question.\u003c/p\u003e \u003cp\u003eThe causal relationships that we tested may be oversimplified. The DAG that we constructed assumes unidirectional relationships between variables, yet the relationship between social support and readiness to change may be bidirectional, with increased motivation potentially leading individuals to seek more social support. Additionally, our approach does not account for potential unmeasured confounders or temporal dynamics between variables that could influence the relationship between social support and RTC. Future research could employ more sophisticated causal modeling techniques, such as time-varying DAGs or structural equation modeling, to capture the dynamic nature of these relationships more comprehensively. Alternatively, methods like randomized clinical trials could simplify the causal relationships between variables and answer additional questions about the efficacy of non-professional social support networks in clinical practice.\u003c/p\u003e \u003cp\u003eAnother limitation is inherent to the sample. All participants contacted us, suggesting a minimal desire for change. This may have limited the range of RTC scores collected. Nevertheless, even with a restricted range of RTC, we detected moderate and strong effects. Future work that includes more diverse samples may reveal stronger and more nuanced relationships.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eK.K. - conceptualized study, interviewed patients, wrote main manuscript text, analyzed dataB.Z. - conceptualized study, reviewed patient interviews, reviewed manuscriptS.K. - established framework to collect dataC.P. - conceptualized study, reviewed manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKyle King – no conflicts to report\u003c/p\u003e\n\u003cp\u003eSteven Kichuk – no conflicts to report\u003c/p\u003e\n\u003cp\u003eDr. Brian Zaboski -\u0026nbsp;For the past three years, BZ has consulted with Biohaven Pharmaceuticals and received royalties from Oxford University Press; these relationships are not related to the work described here.\u003c/p\u003e\n\u003cp\u003eDr. Christopher Pittenger -\u0026nbsp;In the past three years, CP has consulted for Biohaven Pharmaceuticals, Ceruvia Neurosciences, UCB BioPharma, Freedom Biosciences, Transcend Therapeutics, Alco Therapeutics, Lucid/Care, Nobilis Therapeutics, Mind Therapeutics, F-Prime Capital, and Madison Avenue Partners. \u0026nbsp;He holds equity in Alco Therapeutics, Mind Therapeutics, and Lucid/Care. \u0026nbsp;He receives or has received research support from Biohaven Pharmaceuticals, Freedom Biosciences, and Transcend Therapeutics. \u0026nbsp;He receives royalties from Oxford University Press and UpToDate. \u0026nbsp;He has filed patents on pharmacological treatments for OCD and related disorders, psychedelic therapeutics, and autoantibodies in OCD. \u0026nbsp;None of these relationships are of relevance to the work described here. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbramowitz, J. 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Predicting OCD severity from religiosity and personality: A machine learning and neural network approach. \u003cem\u003eJournal of Mood \u0026amp; Anxiety Disorders, 8\u003c/em\u003e, Article 100089. https://doi.org/10.1016/j.xjmad.2024.100089\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-contemporary-psychotherapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocp","sideBox":"Learn more about [Journal of Contemporary Psychotherapy](http://link.springer.com/journal/10879)","snPcode":"10879","submissionUrl":"https://submission.springernature.com/new-submission/10879/3?","title":"Journal of Contemporary Psychotherapy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"obsessive-compulsive disorder, readiness to change, social support, symptom subtypes, depression","lastPublishedDoi":"10.21203/rs.3.rs-6625012/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6625012/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIndividuals with obsessive-compulsive disorder (OCD) often struggle to find willingness to engage in treatment; social support presents as a means of increasing willingness. We investigated the relationship between social support and readiness to change (RTC) in individuals with OCD, specifically examining the potential moderating effects of age, depression severity, and symptom subtypes. A sample of 104 adults with OCD (61% female, mean age = 30.9 years) completed measures assessing RTC, social support, depression, OCD symptoms, and internalized stigma. In the main effects model, age (\u003cem\u003eβ\u003c/em\u003e = .21), depression severity (\u003cem\u003eβ\u003c/em\u003e = .21), and the unacceptable thoughts symptom factor (\u003cem\u003eβ\u003c/em\u003e = .89) predicted RTC. The interaction model revealed a significant main effect of social support on RTC (\u003cem\u003eβ\u003c/em\u003e = .58), with symptom subtype moderating this relationship. Notably, both unacceptable thoughts (\u003cem\u003eβ\u003c/em\u003e = -.65) and harm obsessions (\u003cem\u003eβ\u003c/em\u003e = -.67) showed a strong negative interaction with social support. We conclude that social support is positively associated with readiness to change in OCD, but this relationship varies in the presence of unacceptable thoughts and harm obsessions. Further, depression, age, and unacceptable thoughts have a positive relationship with RTC, independent of social support, in those with OCD. These findings suggest that encouraging non-professional social support may be a valuable treatment adjunct, though it should be used with caution for certain OCD subtypes. Future research should use more advanced modeling techniques and employ randomized clinical trials to examine the causal relationship between social support and readiness to change.\u003c/p\u003e","manuscriptTitle":"Moderators and Mediators of the Relationship Between Social Support and Readiness to Change in OCD","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-21 09:05:46","doi":"10.21203/rs.3.rs-6625012/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-03T13:31:08+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-27T18:56:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323030624158151155082541993689688397267","date":"2025-06-06T15:53:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-19T12:09:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-09T05:28:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-09T05:24:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Contemporary Psychotherapy","date":"2025-05-09T04:39:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-contemporary-psychotherapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocp","sideBox":"Learn more about [Journal of Contemporary Psychotherapy](http://link.springer.com/journal/10879)","snPcode":"10879","submissionUrl":"https://submission.springernature.com/new-submission/10879/3?","title":"Journal of Contemporary Psychotherapy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"58933a5c-21c6-4e1f-8365-2f484433058d","owner":[],"postedDate":"May 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T16:00:19+00:00","versionOfRecord":{"articleIdentity":"rs-6625012","link":"https://doi.org/10.1007/s10879-025-09692-8","journal":{"identity":"journal-of-contemporary-psychotherapy","isVorOnly":false,"title":"Journal of Contemporary Psychotherapy"},"publishedOn":"2025-10-30 15:57:17","publishedOnDateReadable":"October 30th, 2025"},"versionCreatedAt":"2025-05-21 09:05:46","video":"","vorDoi":"10.1007/s10879-025-09692-8","vorDoiUrl":"https://doi.org/10.1007/s10879-025-09692-8","workflowStages":[]},"version":"v1","identity":"rs-6625012","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6625012","identity":"rs-6625012","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}