Treatment for OCD Scrupulosity Must Respect Faith

Cognitive therapy

When addressing the cognitive aspect of treating compulsivity, clinicians should be cautious and sensitive. Some distorted beliefs are easy to identify and dismantle, such as the idea that one must have absolute certainty in one’s thoughts, or that making a mistake makes one a bad person. These assumptions contradict most religious teachings and are easily challenged. Thoughts that involve the belief that certain thoughts can cause certain events to occur can be more complex.

Non-religious observers may criticise such magical thinking because it suggests that internal thoughts can influence external reality. However, it is important to note that OCD therapists do not try to change a person’s religious beliefs. Instead, they aim to change the way people think about their religion if it interferes with their ability to practice it in a healthy way. In this way, therapists work with faith, even if it seems mythological to them.

Behavioural therapy

Exposure with response prevention (ERP) is the core intervention in behavioural therapy for OCD. It involves gradually confronting fears, whether literal, mental or emotional, while resisting the urge to engage in compulsive behaviours. When used effectively, ERP reduces anxiety and the urge to act compulsively, ultimately promoting greater acceptance of uncertainty. It is important to emphasise that ERP never involves encouraging conscientious people to commit sin or violate their religious beliefs. However, it may require them to move within the boundaries of sin.

In other words, engaging in actions that are consistent with the individual’s religious code but increase the potential for their fears to materialise. Clear and open communication between therapist and client is essential in this process. For some people, making negative statements about God may be seen as a necessary step in addressing their mental health problems and drawing closer to God. However, others may find this approach unacceptable. In such cases, alternative strategies would be used to address the fear of blasphemy. Imaginal exposure, such as writing a story in which their fears come true, can be a helpful tool in the treatment of scrupulosity.

However, it is important that clients are willing to participate in such exposures and understand their purpose. If clients feel coerced by therapists into violating religious principles, the result may be a loss of trust in the therapist and feelings of shame for the individual suffering from scrupulosity.

Mindfulness

Mindfulness involves observing thoughts, feelings and sensations in the present moment without judgement. In the context of OCD, it also involves recognising when one is preoccupied with symptoms and consciously returning from that preoccupation without engaging in rituals. An effective way of understanding this concept within a religious framework is through prayer. People who pray choose to focus their attention on the words of a sacred text or religious concept. If they become aware of other thoughts, they simply acknowledge them and then bring their attention back to prayer.

This mirrors the practice of meditation, which often involves anchoring to the breath and the same behaviour of noticing distractions and returning to the present moment without trying to solve any problems. Treating OCD involves learning how to take a more detached and objective stance towards unwanted thoughts and feelings. Mindfulness is a valuable tool because it does not require any additional beliefs or assertions about the universe that might conflict with one’s religious beliefs. It simply requires that we adopt the role of an observer of internal processes rather than a victim of them.

The chosen people

Judaism, a monotheistic religion, draws its laws and inspiration from the Torah (the first five books of the Old Testament in the Christian tradition) and the Talmud (a vast collection of writings by ancient scholars interpreting the Torah). At its core is a belief in a God who created the universe and established a set of laws to guide followers in matters of morality, health, family and securing a positive future for themselves and future generations.

The stereotype of the “neurotic Jew”, while often offensive, brings to mind figures such as Woody Allen and Jewish individuals primarily from Reform (rather than Orthodox) traditions, living in Western societies, and of Ashkenazi (Eastern European) descent. However, Judaism is practised all over the world and encompasses different denominations and cultural traditions. Part of this stereotype includes references to obsessive-compulsive disorder (OCD), with some misconceptions suggesting that Jewish people are more prone to OCD than other cultures.

However, research has not shown a clear link between the prevalence of OCD and specific cultures. Nevertheless, Judaism encourages curiosity and a tendency to question its sacred texts, which may have fostered a tradition and culture of seeking answers from mental health professionals more readily than in other cultures.

Judaism requires its adherents to navigate two main aspects: Jewish law and introspection regarding its interpretation. Striking a balance between the two can be particularly challenging for people with OCD, as OCD is largely characterised by an inability to tolerate uncertainty. Here are some examples of compulsions that are unique to Judaism:

• Jewish dietary laws (kosher) identify certain foods as forbidden (e.g. pork and shellfish) due to their classification as impure. Care is taken to ensure that no trace of these foods comes into contact with permitted foods. If someone offers me a slice of apple, which is permissible, how can I be sure that the knife used to slice it has not previously come into contact with non-kosher food? If it has, how do I know that it has been properly cleaned?
• Orthodox Jewish law requires spouses to abstain from physical contact during menstruation. If my wife and I have accidentally brushed against each other, I am not sure if it happened or if I intended it to happen. How much time should I spend investigating this incident?
• Jewish law forbids working on Saturdays. While relaxing on the couch and watching sports is enjoyable, turning on the television and selecting the right channel requires effort. Is this considered work? Although I am not Orthodox, my faith is important to me. My rabbi says it is not a problem, but I wonder if his leniency is appropriate. Some people do not even turn on the light on Saturdays. How can I be sure that I am doing the right thing?
• My religion teaches me to pray with intention (kavanah). Reciting words is not enough; I must pray from my heart. However, when I check whether I am praying with true intention, it feels insincere. I try to really feel and connect, but the more I try, the more it seems like I am faking it. What if I have never really prayed all this time?

Assets and liabilities

A notable challenge in treating OCD in the context of Judaism is the religion’s emphasis on observance. The more observant an individual is, the more laws they are expected to follow, creating additional areas in which OCD can interfere. Specific laws relate to cleanliness, and the prescribed methods of achieving and maintaining cleanliness can be complex, even for knowledgeable and observant Jews.

In addition, the strong tribal identity and historical experiences of Jewish individuals, characterised by a combination of in-group solidarity and out-group oppression, can contribute to emotional contamination. Exposure to experiences outside of Judaism may be perceived as a threat to one’s Jewish identity, which some see as crucial to maintaining free of contamination. This can manifest itself in various ways that interfere with social functioning, such as fear of churches or crosses.

However, Judaism also offers certain assets that can help in the treatment of OCD. The mandate to put one’s health above all else is an important aspect of Jewish culture. For example, people who are ill are excused from participating in fasting rituals during holidays. This concept provides an avenue for the use of cognitive behavioural therapy (CBT), particularly exposure with response prevention (ERP), in the treatment of OCD.

While exposure-based treatments never require individuals to violate their religious beliefs, they do encourage them to confront uncertainty and embrace flexibility in their beliefs. This does not mean that the mandate to prioritise health permits exposure, or that breaking religious laws is forgiven. Rather, the belief that challenging actions may be necessary or religiously mandated can serve as a motivation to take risks and face uncertainty.

Another way in which Judaism can be an ally in combating OCD is in its emphasis on behaviour rather than thoughts. In other words, people are judged more on their actions than on their thoughts or momentary desires. However, this may not be the case in more orthodox traditions, where certain thoughts are considered sinful to even acknowledge. When treating scrupulosity in individuals from such cultures, clinicians need to work within this framework rather than argue against it.

Furthermore, because of the emphasis on education in Jewish culture, therapists are often held in high esteem and their professional input is generally well received. Even if the therapist is not Jewish, his or her academic achievements often give him or her inherent credibility. This increases the likelihood of collaboration with CBT and facilitates collaboration with rabbis seeking support for their students.

The Saved

Rooted in the New Testament of the Bible, Christianity is a faith that revolves around the life, death and resurrection of Jesus Christ, who is revered as the divine figure who leads believers to righteousness and salvation from inherent sinfulness. However, different interpretations of the New Testament have given rise to various Christian sects around the world, each with its own cultural and religious practices.

Despite these differences, they are united by a common belief in Christ as the divine cleanser from sin. Central to many Christian denominations is a focus on the afterlife, where absolution from sin leads to a favourable outcome (heaven), while remaining in sin condemns one to an unfavourable fate (hell). Sin involves the conscious transgression of God’s laws and the deliberate rejection of Christ’s salvation.

Within this framework, people struggling with obsessive-compulsive disorder (OCD) face an additional emotional burden, especially those who suffer from scrupulosity, a subtype of OCD specific to religious obsessions. In Christianity, where a personal connection to God and Christ is central, any perceived contamination, real or imagined, can cause profound distress, akin to being separated from one’s parents.

Moreover, suffering is often seen as a deserved consequence. The idea is that pain is inherently purposeful, leading to an investigation into its cause and subsequent efforts to seek absolution and alleviate the torment. Consequently, Christian OCD sufferers often attribute their inner turmoil to an inherent aspect of their faith, rather than recognising it as an effect of OCD or neurochemistry.

Here are some examples of the obsessions with scrupulosity that are uniquely manifest in the Christian context:

• Homosexuality and sin: Although I do not identify as homosexual, I am troubled by intrusive thoughts about persons of the same sex. While I strive to dismiss such thoughts, I sometimes fear that spending time with them indicates a sinful act on my part.
• Separation from Christ: Believing that Christ dwells within me, I occasionally experience a void when I pray. What if this absence means that I have become separated from Christ, abandoned because of sins I cannot remember committing?
• A pact with Satan: It seems that every decision I make carries the risk of unwittingly making a pact and surrendering my soul to Satan. How can I tell if my decisions are being influenced by Satan? What if I have consciously offered myself to him? How can I be sure that I haven’t?
• Unforgivable blasphemy: In my faith, blasphemy against the Holy Spirit is an unforgivable offence. Sometimes my mind conjures up disturbing and blasphemous thoughts about the Holy Spirit, prompting me to recite a certain number of prayers immediately afterwards, regardless of the situation. Delaying this ritual means deliberate blasphemy, leading to eternal condemnation with no hope of redemption.
• Scrupulosity obsessions specific to Christianity present unique challenges for those who struggle with OCD in the context of their faith. The internal struggle faced by these individuals often intertwines their religious beliefs with the intricate manifestations of the disorder, creating a complex tapestry that demands understanding, empathy and support from both religious communities and mental health professionals.

Navigating the dichotomy

Christianity presents inherent challenges in dealing with the phenomenon known as thought-action fusion. Cognitive behavioural therapists identify this cognitive error as the confusion between thinking a ‘bad’ thought and actually engaging in a ‘bad’ behaviour. In Christian belief systems, however, thinking certain thoughts is often considered just as problematic as doing the actions associated with those thoughts. For example, lusting after someone other than one’s spouse is considered an act of adultery, even if it is confined to the realm of thought. The emphasis on free will in Christianity adds another layer of complexity.

Many Christians see their morality as closely linked to how they respond to their thoughts and emotions. However, this belief sometimes leads to confusion about one’s ability to control or generate certain thoughts and emotions. When combined with OCD, it often leads to compulsive checking, rumination on the content of thoughts, and over-analysis of why certain thoughts occur instead of others. Furthermore, accepting uncertainty, a crucial element in combating OCD, can be challenging when there is a strong belief in a literal hell after death. Coping with the concept of insurmountable and eternal torment may require a shift from accepting uncertainty to a commitment to one’s values.

Within Christian culture, forgiveness and compassion, as taught by Christ, are powerful tools in the fight against OCD. Although Christian OCD sufferers may struggle with self-compassion to avoid the perceived sin of pride, there is still a religious basis for self-forgiveness, whether for perceived or actual transgressions.

Furthermore, in terms of accepting uncertainty, many Christians, armed with appropriate cognitive behavioural therapy (CBT) tools, can approach uncertainty with openness, guided by the belief that God and Christ will determine what is best for them as long as they remain faithful. These concepts can be used effectively as motivators to engage in exposure and response prevention (ERP) therapy, as long as they are not used as a means of seeking reassurance.

A notable difference between Jewish and Christian scrupulosity is the fear of breaking the law versus the fear of sinning. In Judaism, the primary fear often revolves around breaking the law and incurring negative consequences from God, usually in the earthly realm, as Jewish teachings provide limited insight into the afterlife. In Christianity, the primary fear is the concept of sin, experienced as a transgression of divine law within the soul, with the unwanted consequence being the stain of sin itself – separation from heaven.

Balancing cultural sensitivity in the treatment of OCD

While studying for my licensing exams, I learned about the importance of understanding cultural issues in clinical practice and promoting cultural sensitivity among clinicians. However, I found that some of the material seemed to over-generalise about different cultures, such as stating that ‘blacks are like this’ or ‘Asians are like that’. As a result, I was concerned that I might inadvertently disrespect Native Americans by making eye contact based on what I had read.

Similarly, the study materials suggested that Jews favoured talk therapy and insight-oriented approaches, presumably linked to the value of education in Jewish culture. However, my experience has shown that this is not always the case. In reality, my Jewish clients have primarily shown an interest in practical behavioural tools to effectively manage their OCD in relation to their faith.

It is important to recognise that ‘Jewish culture’ does not mean the same thing to everyone of Jewish heritage. Someone who grew up in a predominantly secular or “Reform” Jewish household may have little in common culturally with an Orthodox yeshiva student (pursuing religious studies), even though both may experience OCD manifestations that are deeply connected to their Jewish faith.

Similarly, I have treated people with Christian OCD from evangelical, Mormon and even atheist backgrounds who may not share many beliefs other than an appreciation of Christmas as a festive time. Therefore, while understanding the philosophical underpinnings of a religion can inform the development of effective CBT/ERP treatment plans, it is important to remember that we are treating unique individuals, not stereotypes.

For religious people, maintaining confidence in their faith is essential to their well-being. OCD undermines this confidence by amplifying religious practices into overly time-consuming compulsions and introducing intrusive thoughts that conflict with their religious beliefs or may be offensive or sacrilegious. CBT therapists working with religious scrupulosity need to familiarise themselves with the cultural practices of each individual client in order to implement exposure techniques that fit within their religious framework without violating their beliefs.

This may involve studying the religious texts that contribute to their obsessions and consulting with religious advisors whom the client trusts. In some cases, the client themselves may be the religious expert, although their judgement may be clouded by OCD, hindering their ability to practice their faith authentically. The ultimate goal of OCD therapy is to reconnect with one’s core values. If a connection with God is at the heart of these values, then OCD treatment should not conflict with them, but rather strengthen and enhance that connection.

Sources

• Ciarrocchi, J. W. 1995. The Doubting Disease: Help for Scrupulosity and Religious Compulsions. Mahwah, NJ: Paulist Press.
• Abramowitz, J. S., Deacon, B. J., Woods, C. M., & Tolin, D. F. (2004). Association between Protestant religiosity and obsessive–compulsive symptoms and cognitions. Depression & Anxiety (1091-4269), 20(2), 70-76.
• Siev, J., Baer, L., & Minichiello, W. E. (2011). Obsessive-compulsive disorder with predominantly scrupulous symptoms: clinical and religious characteristics. Journal Of Clinical Psychology, 67(12), 1188-1196.
• Huppert, J. D., Siev, J., & Kushner, E. S. (2007). When religion and obsessive–compulsive disorder collide: Treating scrupulosity in ultra-orthodox Jews. Journal Of Clinical Psychology, 63(10), 925-941.