Treatment for OCD Scrupulosity Needs To Respect the Faith

While religion is not the cause of OCD, it can be a source of material for OCD that can be all-consuming to the believer.

Learn more about faith and mental health.

Faith is that which we use to connect what we can prove to what we believe to be true. Many things easily fall in both categories. I can prove (at least by some reasonable standard) that I am writing this on a computer, and not a hippopotamus. I also believe I am writing this on a computer, so it requires little effort. I may also believe that you are reading this and enjoying it so far. And of course, proving this assertion at this point in time would be quite difficult. So I fill the space between my knowledge that I am writing this and my belief that you are reading it with faith. Faith is the willingness to remain in the presence of uncertainty while maintaining confidence in what you believe to be true.

Obsessive-compulsive disorder OCD) is a mental health condition characterized by unwanted intrusive thoughts (obsessions) and ritualistic, repeated responses aimed at neutralizing those thoughts (compulsions). When people obsess about their religion, we call it scrupulosity. Joseph Ciarrocci explains in his book "The Doubting Disease" that the word scrupulosity stems from the word scrupulum, which means a small, sharp stone¹. In other words, scruples are small but distracting irritants. For centuries, long before we had a term called OCD, it was noted that some people seem to get really stuck on the small details of their religious faith. This can be catastrophic for a number of reasons. What follows is a discussion of how this form of OCD can manifest specifically in Judaism and Christianity.

"Faith is believing when common sense tells you not to." Fred Gailey to Doris Walker in the 1947 movie Miracle on 34^th Street.

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Here are some of the things people obsess about when OCD targets any religious faith:

• I may not really believe in my religion
• I may have offended God, committed blasphemy or sin
• I may be punished for my failure to obey my religion
• I may have lost my connection to God
• I may be practicing my faith in the wrong way
• I may lose my faith or may come to believe in another faith
• I may not fully understand an important tenet of my faith
• I may have had a thought, feeling, or sensation that is in and of itself a sin to have experienced
• I may have failed to adequately shield myself from breaking the laws of my faith
• I may have inadequately taken responsibility for having broken the laws of my faith

Note that the presence of these thoughts alone is not necessarily a sign of OCD. A person coming to his own philosophical conclusions can very openly embrace that he may not believe in his religion of birth. The thoughts above are considered OCD symptoms when they are unwanted, intrusive, repetitive, and cause distress.

Common compulsions in religious scrupulosity include:

• Excessive displays of devotion to a tenet (e.g. excessive washing of hands in connection to a religious text about cleanliness)
• Excessive or overly mechanized prayer
• Excessive avoidance of triggers of unwanted thoughts that may run contrary to religious beliefs
• Avoidance of religious practice or reminders of religion for fear of being triggered
• Reassurance seeking with religious texts, spiritual advisers, family members, etc.
• Mental rituals, including analysis and mental checking for evidence of sin or blasphemy
• Self-punishment rituals aimed at cleansing a contaminated soul
• Checking for specific feelings to ensure a genuine connection to faith

Treating Scrupulosity

It is important to remember that different manifestations of OCD do not require different treatments. The most effective treatment for OCD to date is a combination of cognitive behavioral therapy (CBT) and mindfulness interventions. Some OCD sufferers also benefit from certain anti-obsessional medications that better allow them to do the therapeutic work. OCD is a problem of uncertainty tolerance and whether a person is uncertain about the cleanliness of her hands, body, or soul, is largely irrelevant. In short, OCD treatment looks at three aspects of experience: the cognitive (distorted thinking), the behavioral (modifying responses) and the mindful (the perspective to one's experience).

It might be an easy presumption that religion itself, the presence of a series of rules and ideas for how to live and die, correlates to obsessive-compulsive symptom severity. This does not appear to be true, though religiosity (the level of strictness) may be correlated. For example, a study of Christian Protestants with OCD demonstrated more severe symptoms in the highly religious than the moderately religious². Most people with scrupulosity find that the symptoms actually interfere in the practice of their religion not improve it³. So something to consider in treatment is the cost/benefit ratio of doing compulsions vs. getting treatment for OCD.

Cognitive Therapy

Clinicians treating scrupulosity should approach the cognitive aspect of treatment with some caution and sensitivity. Some distorted beliefs are easy to point out and break down, such as "I must be certain that I am having the right thoughts" or "If I make a mistake, I am a bad person." These are easy to identify because they are assumptions and run contrary to most religious beliefs. However, thoughts like, "If I think this, it will cause xyz to happen" can be trickier. To the non-religious observer, calling out magical thinking (the belief that what goes on inside the head affects what happens outside the head) can be at odds with religious doctrine. The OCD therapist is never trying to change a person's religious beliefs, only suggesting modifications in the specific sense that the way they might be thinking about their religion is impairing the healthy practice of that religion. So the key is to work with the faith, however mythological it may appear to the therapist.

Behavioral therapy

The core intervention used in treating OCD on the behavioral front is called exposure with response prevention (ERP). This entails gradually confronting the fear (whether literal, mental, or emotional) while resisting engaging in compulsions. Done appropriately, the outcome is reduced fear, reduced urges to do compulsions, or both. Ultimately, the goal is enhanced ability to accept uncertainty. ERP never involves asking a scrupulosity sufferer to commit a sin or violate a religious belief, but it may involve dancing around the border of sin. In other words, taking risks that are within the sufferer's religious code, but that increase the potential for fears to be realized. Effective communication between therapist and client is essential here. For some, making a negative statement about God falls under the category of doing what one must do to treat their mental health issue and ultimately bring them close to God. For others, this might not be acceptable. Other strategies would therefore be employed to confront the fear of blaspheming. Imaginal exposure (e.g. writing out a narrative that describes fears coming true) can be a useful tool in treating scrupulosity, but it is important that the client engage in this exposure willingly and understand the purpose of the exposure. If the client feels bullied by the therapist to break a religious tenet, the end result is distrust of the therapist and shame for the sufferer.

Mindfulness

Mindfulness means observing thoughts, feelings, and sensations in the present moment without judgment. In the case of OCD, it also means recognizing when you've become distracted by your symptoms and returning from that distraction without rituals. A good way to understand this in a religious context is through prayer. For those who pray, they choose to focus their attention on the words of a holy book or on a religious concept. When they become aware of other thoughts, they simply note them and then return to the anchor of the prayer. This is no different than meditation, which might involve anchoring oneself to the breath and essentially engage in the same behavior of noticing when distracted and returning without problem-solving. Treating OCD involves learning how to be a more impartial or stoic spectator of unwanted thoughts and feelings. Mindfulness is useful because it requires no additional beliefs and no claims about the universe that could run contrary to a religion. It requires only that one position themselves as an observer of their internal process instead of a victim of it.

The Chosen People

Judaism is a monotheistic religion that derives its laws and inspiration from the Torah (the first five books of what Christians would call the Old Testament of the bible) and the Talmud (an expansive collection of writings from ancient teachers interpreting the Torah). In short, they believe in a god, who is the creator of the universe and who set out a series of laws that function to instruct followers on morality, health, family matters, and the securing of a good future for themselves and future generations.

The (often offensive) stereotype of the "neurotic Jew" brings to mind images of Woody Allen and Jewish people who are typically from a Reform tradition (not Orthodox), living in western culture and of Ashkenazi (eastern European) descent. However, Judaism is practiced around the world in various denominations and cultural traditions. Part of this specific stereotype includes references to being obsessive-compulsive and many believe that Jewish people are more likely to have OCD than other cultures. This is in fact untrue. Research has shown no clear connection between the percentage of OCD sufferers and their culture. However, Judaism is a religion grounded in curiosity about their holy books from which may have sprung a tradition and culture of asking questions. Though it is unclear if this makes people obsessive, it may make them more likely to seek answers from mental health professionals than other cultures.

Judaism demands of its followers the reconciling of two main issues: Jewish law and introspection on its interpretation. This balancing act can be particularly challenging for a person suffering from obsessive-compulsive disorder, which is largely characterized by a difficulty in accepting uncertainty. Here are some examples of scrupulosity obsessions somewhat unique to Judaism:

• Jewish dietary law (kosher) identifies certain foods as disallowed for eating (e.g. pork and shellfish). These foods are considered unclean and efforts are made to wash objects in a specific way to ensure that no amount of uncleanliness come in contact with anything to be eaten. If I am offered a slice of apple, which is a permitted food, how do I know that the knife used to slice that apple has not previously come in contact with food that is not kosher or if it has, how do I know that it has been properly washed?
• Orthodox Jewish law requires that my wife and I have no physical contact during her menses. When I passed by her, we may have brushed into each other. I really don't think so, but the more I review it, the more I can't tell for sure. If it did happen, I am also unsure if I intended for it to happen or if it was an accident, if it even did happen at all. How much time should I spend reviewing this?
• Jewish law requires that I not work on Saturday. I am at my most relaxed watching sports on the couch and there is a big game this Saturday. Watching it entails turning on the television and turning it to the right channel. This requires some kind of effort. Is it work? I'm not Orthodox, but I do care deeply about my faith. My rabbi says it is not a problem, but maybe he's not strict enough. I know some people don't even turn on the lights on Saturday. How do I know for certain that I am doing the right thing?
• My religion teaches me to pray with Kavanah - intention. I can't just recite the words and say that I prayed. I must pray from the heart. But when I check to see if I am praying with intention, it doesn't feel like real intention. I try to really feel it, really connect with it, but the more I try the more I feel like I'm faking. What if all this time I'm not really praying?

Assets and Liabilities

One significant challenge in treating OCD within Judaism is the religion's emphasis on law itself. The more religious, the more laws that get attended to, the more areas in which OCD can meddle. Several laws pertain specifically to cleanliness, for example, and the manner in which one is expected to get clean and stay clean may vary for reasons even the most learned and pious Jew could find confusing. Furthermore, the tribal identification of Jews and a history of in-group solidarity vs. out-group oppression may lead to various forms of emotional contamination. For example, contact with cultural experiences outside of Judaism may be viewed as threatening to one's Jewish identity, which may be viewed as important to keep free of contamination. This can manifest in a number of ways that can impede social functioning, such as anxiety over being in the presence of a church or a cross.

One asset in Jewish culture is the mandate to take care of one's health above all. People who are sick, for example, are not expected to participate in holiday rituals that involve fasting. This concept provides an avenue through which cognitive behavioral therapy (CBT) and in particular, exposure with response prevention (ERP), can be utilized to treat the OCD. Though exposure-based treatments never require a person to violate their religious beliefs, they do invite them to confront uncertainty and flexibility in their beliefs. This doesn't mean that the mandate to take care of one's health makes it "ok" to do exposures or that law breaking will be forgiven. Rather, belief that it may be necessary or religiously mandated to do challenging things can be used as a motivation for taking risk and confronting uncertainty.

Another way in which Judaism itself can be an ally in fighting OCD is that overall the religion emphasizes behavior over thoughts. In other words, people are judged moral or immoral somewhat more on what they do than on what they may think or desire in any given moment. This is not always true in more Orthodox traditions where some thoughts are considered sinful to pay attention to in the first place. Clinicians treating scrupulosity with someone from this culture need to work within this system, rather than argue with it⁴. Furthermore, given Jewish culture's emphasis on education, therapists are often looked at in high regard and their input is generally well received. Even if the therapist is not Jewish, some inherent credibility is given to their academic achievements. This makes cooperation with CBT more likely, as well as collaboration with rabbis seeking help for their students.

The Saved

Christianity is a faith inspired by what is called the New Testament of the Bible, which is comprised primarily of a series of accounts of the life, death, and resurrection of their messiah, Jesus Christ. Christ is both a part of God and an independent entity sent to Earth for the purpose of guiding people toward righteousness and releasing them of their inherent sinfulness. Interpretations of the New Testament over time have led to many different sects of Christianity around the world (including additional testaments as in Mormonism), with a variety of different cultural and religious practices. Though two forms of Christianity may look starkly different, they are all bound together by a belief in Christ as the divine remover of sin. Many forms of Christianity focus a great deal of attention on the afterlife and the idea that being cleansed of sin results in a positive afterlife (Heaven) while those remaining in sin are doomed to a negative afterlife (Hell). Sin comes in many different forms, but basically involves the willful violation of God's laws and the willful rejection of Christ's salvation. OCD comes into play when sufferers struggle with uncertainty over what is voluntary or incapable of being avoided in the mind.

Christians with scrupulosity suffer a profound emotional wound at the hands of OCD. Central to Christian philosophy is the personal relationship to God and Christ and any contaminating presence, real or imagined, can be experienced as painfully as being cut off from one's mother or father. Furthermore, suffering is often viewed as deserved. The idea works backwards from the experience of pain being automatically for cause, then an investigation into that cause, then an attempt to repent and get absolution from that cause to relieve the pain. Thus, the internal torment of the Christian OCD sufferer is often first presumed part of being Christian and not a trick of the OCD or neurochemistry.

Here are some examples of scrupulosity obsessions somewhat unique to Christianity:

• My church teaches that homosexuality is a sin and though I know I am not homosexual, I get intrusive thoughts about people of the same sex. When I have these thoughts, I try to ignore them, but sometimes I fear that I have allowed myself to spend more time than I should have in their presence and this may mean that I have sinned.
• I believe that Christ is a part of me and resides in my heart at all times. But when I pray, I sometimes feel nothing. What if I am disconnected from Christ and have been left behind for sins I don't remember committing?
• Everything I do it seems like I might be making a deal and selling my soul to Satan. When I choose one thing over another, how do I know Satan is not making me select that choice? What if I have given myself over to Satan without knowing it? What if I did it knowingly? How do I know I have not done it?
• In my faith you cannot be forgiven for blasphemy against the Holy Spirit. Sometimes my mind says disgusting sexual and violent things about the Holy Spirit, so I have to pray a specific number of times immediately after this happens, no matter what I'm doing. If I wait too long to try to undo it, it means I meant to blaspheme and I will be condemned forever with no chance of salvation.

Assets and Liabilities

One of the challenges inherent in Christianity is grappling with thought-action fusion. Cognitive behavioral therapists use this term to identify a psychological error in which one is confusing thinking a "bad" thought with engaging in a "bad" behavior. But many Christians believe that thinking certain thoughts is as problematic as engaging in the behaviors reflected by those thoughts. For example, lusting after someone other than your spouse may be understood as committing an act of adultery even if only in your mind. Another challenge is the emphasis on free will in Christianity. Many Christians believe that their morality is connected to the way in which they respond to their thoughts and feelings. However, embedded in this belief is often confusion over one's ability to create or not create certain kinds of thoughts and feelings. When mixed with OCD, this can often lead to compulsive checking and review of the content of thoughts and endless theorizing over what it means that a particular thought presented itself instead of a different one. Furthermore, part of accepting uncertainty, a necessary ingredient in fighting OCD, can involve accepting that fears could come true and might have to be coped with somehow. However, a firm belief in a literal hell after life is by definition impossible to be coped with (if it could be coped with, it wouldn't be Hell). This can require some shifting of the emphasis from uncertainty acceptance to values commitment in some cases.

One of the OCD-fighting assets in Christian culture is the notion of forgiveness and compassion as taught by Christ. Though the tendency in Christian OCD sufferers is to avoid self-compassion in an attempt to avoid the "sin of pride," there is still a religious basis for forgiving oneself for transgressions, perceived or actual. In terms of the OCD struggle to accept uncertainty, many Christians, given the right CBT tools, can approach uncertainty with open arms under the umbrella belief that God and Christ will assess what is best for them and provide it so long as they continue to remain faithful. These concepts can be incorporated well as motivators to engage in ERP, so long as they are not being used as an "out" or self-reassurance mechanism.

One of the most notable differences between Jewish and Christian scrupulosity is in the fear of law breaking vs. sinning. In Judaism, the primary fear often rests in the idea that a follower will break the law and bring about negative consequences from God (usually on Earth as Judaism has very little to say about the afterlife overall). In Christianity, the fear is often more focused on the notion of sin, which is experienced as a law broken in the soul and the unwanted consequence is this sin itself, a stain on the soul that separates them from Heaven.

Generalize, but don't generally generalize

I remember studying for my licensing exams and being required to learn about the different considerations relevant to different cultures. This was to instill a cultural sensitivity in clinicians, which is important. But so much of it boiled down to "black people are like this" and "Asians are like that." I have been terrified of accidentally looking a Native American in the eye since reading that one is apparently not supposed to do this. The study materials suggested that Jews prefer talk therapy and insight-oriented work, presumably connected to the role of respect for education in Jewish culture. I have not seen this to be the case at all. Rather, my Jewish clients have mostly been interested in concrete behavioral tools to effectively separate their OCD from their faith.

"Jewish culture" doesn't mean the same thing to every Jew. Someone raised in a largely secular or "reformed" Jewish household often has very little in common culturally with an Orthodox Yeshiva student (training to be a religious scholar) and yet both may have OCD manifestations that very much have to do with their beliefs about what it is to be Jewish. Similarly I have treated Christian scrupulosity with Evangelicals, Mormons, and even atheists from Christian households, none of whom would have much to agree on except that Christmas is a lovely time of year. So while it may be helpful to understand the philosophical underpinnings of a religion in order to develop the most effective CBT/ERP treatment plan, it's important to remember that we are treating people, not those people.

For the religious person, confidence in their faith is essential to wellbeing. OCD chips away at the confidence by exaggerating religious practices into excessively time-consuming compulsions and presenting intrusive conflicting, offensive, or sacrilegious thoughts in a religious context. Treatment providers using CBT to treat this form of OCD need to educate themselves on the different cultural practices of each scrupulous client to effectively implement the best exposure techniques without violating the religion itself. This may include reading the religious texts that drive some of the obsessions and consulting with religious advisers that the client trusts. Often the religious expert is the client himself, but his OCD may be clouding his own judgment of how to honestly practice his faith without OCD getting in the way. The goal of any OCD therapy is to get back to one's values. If a connection with God is at the core of those values, then treatment for OCD shouldn't conflict with that. It should enhance it.

Date of original publication: August 22, 2016

Updated: January 07, 2020