Summary and Response to Treating Scrupulosity in Religious Individuals Using Cognitive-Behavioral Therapy

Introduction

This is a summary, select quotations, and responses from myself to Jonathan D. Huppert and Jedidiah Siev’s article “Treating Scrupulosity in Religious Individuals Using Cognitive-Behavioral Therapy” as published in Cognitive and Behavioral Practice 17 (2010) pp. 382-392.

It is perhaps the best article I have read for practitioners or patients on the treatment of scrupulosity.

The Meat

  • “Treating religious patients with scrupulosity raises a number of unique clinical challenges for many clinicians. For example, how does one distinguish normal beliefs from pathological scrupulosity? How does one adapt exposures to a religious patient whose fears are related to sinning? How far should one go in exposures in such cases? How and when does one include clergy in treatment?” – pg. 382.
    • As someone who suffers from scrupulosity this issue of discerning what is normal belief and what is pathological is very difficult, and is (from my perspective) what sets scrupulosity apart from other forms of OCD – in which the individual is generally aware of the unreasonableness of their actions.
  • “…the presence of religious symptoms in OCD predicts poorer treatment outcomes according to some studies (Alonso et al., 2001; Ferrao et al., 2006; Mataix-Cols, Marks, Greist, Kobak, & Baer, 2002; Rufer, Grothusen, Mab, Peter, & Hand, 2005) but not others (Abramowitz, Franklin, Schwartz, & Furr, 2003).” – pg. 382.
    • I’d like to read more on this, as my personal experience is that my more generic OCD symptoms respond well to medication but scrupulous symptoms are much more resilient. I have not experienced ERP, other than self-instituted.
  • “…healthy members of the religious community, including clergy, may inadvertently reinforce rituals by offering reassurance or expressing admiration for the rituals, a process somewhat analogous to the positive reinforcement received by individuals with eating disorders for losing weight.” – pg. 382.
    • This is very true and one of the challenges for all ministers. Interestingly, Dr. Ian Osborn in his book Can Christianity Cure Obsessive-Compulsive Disorder?  suggests the prevalence of OCD in contemporary society may be the result of changes in society, meaning that this problem may not have been as rampant before 1500 or perhaps 1000 AD. I’m unsure that I agree with this hypothesis.
    • It should be noted that clergy have not always been unequipped to deal with scrupulosity. While the techniques may have at times been primitive, soul care in church history has provided for the care of the scrupulous, it is more recently when Christianity cut itself off from much of its history that these methods where lost.1I am not suggesting that we should follow all the traditions of the ages, but I do think that it is a mistake to write off what has been learned in prior generations.
  • “Hence, although the choice of exposure and response prevention (EX/RP), a first-line treatment for OCD, is indicated in the literature for treating OCD…, its implementation for religious patients with scrupulosity necessitates nuanced modifications…” – pg. 382.
  • “The core fear across religions within scrupulosity is related to a fear of sinning. At the same time, the typical manifestation of scrupulosity differs by religion. Whereas displeasing God, going to hell, and devil worship are common obsessional themes among scrupulous devout Christians…, especially born-again, Protestant, or Pentecostal, obsessional themes among scrupulous ultra-Orthodox Jews more closely follow the forms of general OCD themes, such as contamination/washing and doubting/checking… For example, a patient may fear contamination and wash excessively, but in the case of scrupulosity, the feared contamination is religious (e.g., dietary or menstrual impurity, cleanliness before prayer).” – pg. 383.
  • “…how does one distinguish OCD from strict, devout observance?…The most straightforward, obvious answer is by asking the patient whether others in their religious community have the same beliefs and behaviors.” – pg. 384.
    • This is very useful. In general the individual will be practicing beliefs in a way not practiced by others – even if they are in a strict / legalistic religious community2Though if the leader(s) of the community are scrupulous, it is possible that they will only be matching the intensity of the religious community.. One difficulty though is that some practices are not well-known as to frequency. For example, who prays and how often do they pray and what do their prayers consist of?
  • “Our stance (once OCD is clearly identified as the main presenting problem) is that OCD attaches itself to each individual’s most important or core values, but is not caused by those values (cf. Rachman, 1998). Thus, the fact that they have scrupulosity and not a fear of contamination or of being responsible for something horrible happening like a house burning down is because they view serving God and adhering faithfully to religion as high priorities.” – pg. 385.
    • This is comforting. For the scrupulous our fears oftentimes circle around whether we are doing what is appropriate/necessary/good in our relationship with God (which I usually counter by emphasizing God and His grace/power). Yet, still, it is comforting to think that the reason I struggle with these doubts is b/c OCD centers on what is core to my life.
  • “They include the idea that OCD fears are not latent desires to be an apostate; to the contrary, they are OCD’s method of turning the patient’s own core values against himself or herself (the response to which—as in judo—is to harness the power of the attack against the aggressor; in the case of OCD to accept the thought. That is, to say to oneself, “I accept the risk of this sin,” thus not engaging in a mental battle with the OCD).” – pg. 385.
    • In my case I suppose this might look something like, “I accept the risk that by not entering into single-focused prayer3By this I mean prayer in which my sole attention and energies are focused on prayer, not the “always” praying that many others think of, which to my scrupulous mind oftentimes seems too close to “not praying.” I am disappointing God.” The good news for me is that while I may disappoint God, God is bigger than me and saved me in spite of, not because of who I am.
  • “This distinction between true awe of God accompanied by a desire to serve Him versus obsessional fear of God resonates well with many patients. According to most religious systems, the service of God is not supposed to lead to suffering, but to a sense of peace, connection, and fulfillment. The extent to which a patient’s experience is inconsistent with this can indicate that religious awe—and even fear—has been appropriated by OCD.” – pg. 385.
    • I disagree with the statement that “the service of God is not supposed to lead to suffering” but agree that it should lead to a “sense of peace, connection, and fulfillment” – I do not think these are mutually exclusive. Suffering is a significant part of the Christian’s experience as we resist temptation and experience God’s refining fire at work within us, healing us and making us whole.
    • On the other hand, I do agree that I can see my OCD is self-centered…That is, it focuses on my self and what I need to do to make things better rather than upon who God is and what He is doing in my life. I unthrone God and throne myself in a very subtle way. I also lack the ability to truly demonstrate love and care for those around me…so while I may avoid most sins of commission, I am greatly offending in sins of omission.
  • “…it is best to avoid antagonizing religious individuals with concepts that they may find counter to their belief system, such as the evolutionary function of anxiety. Instead, one can discuss what function anxiety serves, or why God created people to experience anxiety.” – pg. 385.
    • YES! The theory of why we have anxiety from an evolutionary perspective is not necessary to treating anxiety and is a significant stumbling block for many Christians.
  • “…explaining the effects of thought suppression is extremely important, with particular implications for many religious individuals. The patient may resist exposure to thoughts deemed unacceptable on religious grounds; however, by accepting them and allowing them to exist in his or her mind, the patient will actually reduce the long-term frequency and intensity of such thoughts (e.g., blasphemy).” – pg. 385.
    • This is akin to the old joke, “Don’t think about purple elephants….What are you thinking about?” (Purple Elephants). When we focus our attention on not thinking about something, we automatically draw it to mind. I oftentimes occur thought replacement – focusing on something else instead of the negative thought (e.g. moving from contemplation of my sinfulness to God’s glory and grace). I hypothesize that this is not always possible however and sometimes accepting the thought may be the only way forward.
  • “At first, the prospect of accepting sinful thoughts seems at odds with the notion found in many religions that they should be stopped or annulled, and generally we find it unhelpful to attempt to dissuade patients who believe otherwise that thoughts are morally inconsequential. Indeed, there is some evidence that religiously normative beliefs about the moral importance of thoughts are unrelated to OCD (Siev, Chambless, & Huppert, 2010). Rather, we encourage patients to consider the differences between intentional and unintentional thoughts, and between intentional thoughts for the purpose of enjoyment and those for the purpose of treatment (i.e., exposures).” – pg. 385.
    • The problem here, from my perspective, is that we (the scrupulous) underestimate rather than overestimate the sinful nature of our thoughts. Our thoughts are much worse and our minds more depraved than we imagine…while this thrusts us initially into despair, it also free us – b/c we recognize that God is the only means by which we can be freed of them and our own petty attempts to free ourselves are not working and will not work.
  • “Overcorrection is an important EX/RP technique. By tolerating more extreme exposures than are necessary in typical daily living, patients provide themselves with room for backsliding without impact on functioning, and more importantly, conservative tests of the likelihood of their feared consequences coming to fruition.” – pg. 386.
  • “Knowing that a patient washes or checks is insufficient to design effective exposures, for which one must understand the core fears and the function of the rituals at the most basic level possible.” – pg. 386.
    • This is something I have thought of in other words, but which appeared fresh to me as written here.
  • “How does one encourage a religious patient to accept the risk of sin?…we make a clear distinction between risking the possibility of sin with normative behavior and purposefully sinning. The former is a natural part of life—one cannot live life without some level of risk—and in EX/RP we increase the level of risk without going to the point that the level of risk is forbidden by religious law…we do not believe it is of value for a therapist to encourage a religious patient truly to sin or even to say “I am sinning” while taking a risk.” – pg. 386.
  • “Even this approach is not readily accepted by all devout patients. Some argue that living a religious life requires avoiding not only sin, but any behavior that approaches sin. There is Talmudic precedent, for example, to set up boundaries and fence-laws to distance oneself from sin (Mishnah Avot, 1:1).” – pg. 386.
  • “If necessary, the therapist can try to establish that for individuals with OCD, distancing from sin has become a goal in its own right, ironically more than serving God, and therefore tolerating acceptable risk of sin facilitates the service of God.” – pp. 386-7.
    • Very true.
  • “…most religions have a concept of forgiveness for sins, which inherently suggests that one will inadvertently sin.” – 387.
    • Yes, though I am not sure this is particularly helpful to the scrupulous. I know that Scripture indicates that I will sin, that I am not perfect but am being perfected by God, yet the question that always haunts is, “Am I willingly giving in to this sin?” At some level it seems that I must be willingly giving in to the sin…so I am not sure I can see it as an “inadvertent sin.” Again, this is depressing but also freeing – in that I am again pressed back in dependence upon Christ rather than myself for justification and perfection.
  • “…it can be more effective to evaluate the relative value in (a) striving to achieve good acts and a positive relationship with God and to religion by accepting a risk of sin, versus (b) excessive and distressing pursuit of absolute avoidance of one sin at the expense of other sins or opportunities for positive religious experiences (e.g., excessive ritualistic prayer interfering with religious study or at the expense of helping others).” – pg. 387.
    • This echoes my thoughts on the commission of sins versus the omission of sins and that it can be demonstrated to the scrupulous that they are entering into more sins of omission by embracing their scrupulosity than they would otherwise commit actively.
  • “Imaginal exposure is particularly indicated when OCD fears are difficult to confront or disconfirm in vivo, and can be helpful in treating scrupulosity in general, and in leading patients to tolerate acceptable risks. In such cases, the goal of the imaginal exposure is to create scenarios that depict engaging in relatively low-risk behaviors that end up causing extreme consequences. For example, one might create a script in which the patient refrains from cancelling a negative thought with compulsive prayer, opting for the long-term goal of satisfaction with life and religion instead of compulsive behavior to neutralize the risk that the thought was truly sinful. The scenario would continue based on the patient’s idiographic fears—that eventually the community rejects them for being evil, that they die and are judged to damnation for not having repented for that one thought, or that the decision to risk sin initiated a downward spiral into a life of sin. Conducted as such, imaginal exposure is an exposure to the feared consequence, but also a means for experiential cognitive challenging. In the context of imagining the consequences of sin, the patient may recognize their efforts to avoid even the possibility of inadvertent sin as excessive or inconsistent with their religious beliefs.” – pg. 387.
    • I wonder, do those without OCD/scrupulosity feel the same anxiety as I (and I suspect other scrupulous individuals) feel when simply reading this?
  • “…outside the context of treatment, clergy can inadvertently or unknowingly make recommendations that perpetuate a religious OCD patient’s anxiety. Unhelpful responses from clergy include telling a patient that they will burn in hell for evil thoughts that must be purged, suggesting that more meaningful or intensive prayer or study of their religious canon will reduce intrusive thoughts, stating that psychologists have no business dealing with issues related to spirituality, suggesting rituals to cancel intrusive thoughts…, suggesting that the patient is correct in not taking risks of sinning, and encouraging overt avoidance. In other cases, the clergy provides direct reassurance in a way that facilitates the vicious cycle of obsessions and compulsive reassurance seeking.” – pg. 387.
    • It is important for us as ministers to humbly engage those we are ministering to. It is too easy to apply blanket methods of interacting with those struggling spiritually, whereas each individual requires the unique ministry God allows us to provide via the power of His Holy Spirit.
    • If we are good listeners, I think we will hear many of the subtleties in folks problems and more readily address the problems they are actually facing rather than the problems  we project or infer upon them.
  • “To whatever extent possible, we encourage the patient to stop asking any questions related to their OCD concerns and instead to accept the doubt…” – pg. 389.
    • It is important for a minister to refuse to enable the scrupulous. Not only can this consume all the minister’s time, but it will have no beneficial patient (other than some short-lived and ultimately negative relief).
  • “Sara reported that she understood that she needed help, although at many times she wished she just were not Jewish, in which case she would not have such problems.” – pg. 389
    • I can echo that. “If I was not a Christian I would not have to struggle with not…”
  • “The therapist asked the patient whether (a) others agree that such risks are forbidden, and (b) whether there were other things she was not doing that were preferable to continual cleaning and washing rituals.” – pg. 390.
  • On pg. 390 the authors discuss constructing a fear hierarchy in which we rank how severely each potential action or thought causes anxiety and then attempt to battle these thoughts/actions. This seems like a very useful tool in treating OCD generally and scrupulosity specifically.
  • “These instructions shifted the burden of proof from demonstrating that something was permissible (e.g., via consultation with the rabbi) to demonstrating that something was questionable before asking.” – pg. 390.
    • This goes along with the Ten Commandments for the Scrupulous.
  • “It was communicated that she needs to learn to “trust her soul” (i.e., to trust her implicit intuition) and not seek explicit reassurance by asking questions, checking, washing, or mental reviewing.” – pg. 391.
    • I am not sure I would want to use the phrase “trust her soul” but rather “trust God.” The scrupulous attempt to remove all doubt – but their is always doubt and risk. This may in part be a failure to trust oneself (as created in the image of God) but also is a failure to trust in God (who created us and will communicate us in strong enough means to exemplify His message).

Footnotes   [ + ]

1. I am not suggesting that we should follow all the traditions of the ages, but I do think that it is a mistake to write off what has been learned in prior generations.
2. Though if the leader(s) of the community are scrupulous, it is possible that they will only be matching the intensity of the religious community.
3. By this I mean prayer in which my sole attention and energies are focused on prayer, not the “always” praying that many others think of, which to my scrupulous mind oftentimes seems too close to “not praying.”
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