Scrupulosity OCD Treatment Shouldn’t Be a Hard Sell

This article, written by Kevin Foss, MFT, discusses Scrupulosity, a religious and moral subtype of OCD. It was originally published through Psychology Today.

The case for enthusiastic and confident ERP for religious OCD treatment.

Years ago, I worked with a woman named Sandra who suffered from Scrupulosity, a religious and morally focused form of Obsessive Compulsive Disorder. She was a very devout woman in her mid-20s and on the surface was successful as an advertising professional, outgoing, charismatic, and passionate about her relationship with God.

She initially noticed the disorder when feeling pangs of guilt if she told a minor lie, like saying she got to work at 9 a.m. when in reality she got to work at 9:04, or when she was in high school and would notice attractive guys and immediately have to recall the verse about “taking all thoughts captive” in order to avoid progressing into truly lustful thoughts.

When I began working with her, she had been suffering with Scrupulosity for nearly 10 years. Her symptoms had progressed to the point that she was hardly able to focus at work, her compulsive religious rituals had begun taking hours out of her day, and she had been avoiding church as the pressure to accommodate her fears had made religious services too overbearing.

In session, she would cry for nearly the entire time, expressing fears that she was disrespecting God all the time. She noted that when reading anything, she could not look back to previous lines without praying for forgiveness and confessing her devotion to God. Sandra feared that looking back to previous lines was reminiscent of Lot’s wife looking back to the city of Sodom as it was destroyed in the book of Genesis; an act in direct disobedience to God’s command. This was just one of the rituals that led her to finally seek treatment.

Religious Scrupulosity causes sufferers to become mentally and emotionally consumed by matters of faith and morality. They can become overwhelmed by fear that they have committed some terrible religious offense and must then strive to atone for this real or perceived infraction.

OCD is often called the doubting disease. It is a cycle of unwanted, intrusive thoughts, feelings, mental images, or urges that cause the sufferer tremendous anxiety and uncertainty. In order to alleviate this doubt and fear, OCD sufferers feel they must do some specific mental or physical action, ritual, or avoidance in order to restore a sense of personal comfort and perceived safety. Typically, these compulsions start small and simple, like knocking on wood or briefly double-checking a lock, but they can quickly escalate into hours of routine.

The first few sessions of treatment for OCD typically cover the basics of Cognitive Behavioral Therapy and Exposure and Response Prevention. Together, combined with medication and mindfulness, they are considered the gold standard of treatment for OCD. Sandra and I began by discussing the importance of challenging the legitimacy and facts involved in the feared thoughts in order to develop a more rational grounding as we proceed through treatment. This all went well, and Sandra was more than happy to tell me how she didn’t believe that her actions were the same as Lot’s and that deep down she didn’t believe she was actually doing anything wrong by looking back while reading. article continues after advertisement

All was progressing well until we began discussing Exposure and Response Prevention. Through ERP, clients are asked to progressively face their fears by intentionally doing actions, or thinking thoughts, that they fear will cause some harm to them or someone else (Exposure) all while resisting anything that would neutralize the anxiety or provide reassurance that they are not in danger (Response Prevention). A brief example I offered to Sandra is for someone to face their fear of getting sick by touching a doorknob with their bare hands and then resisting washing their hands.

This is where treatment hit a wall with Sandra, and where it hits a wall with many Scrupulous clients. Sandra feared that if she were to earnestly participate in treatment, despite her rational objections to the veracity of her feared thoughts, she might actually be sinning, be in open defiance of God’s will, and therefore be punished as her fear suggested. In short, despite her logical consideration of her fear, what if her fear was true?

People suffering with Religious Scrupulosity struggle with the ERP process because they fear that exposure therapy will result in a genuine sin, convey that they are OK with sin and that they do not respect God or God’s will. Furthermore, Scrupulosity sufferers are generally knowledgeable of their faith’s doctrine and Biblical texts, so they are quick to present chapter and verse explaining why they should avoid exposure and give in to compulsive acts. Despite my reminders of clients’ logical arguments, they respond with “But you never know” and “But what if God mistakes my intention in the exposure and I’m now really guilty of sin?”

OCD thoughts are Ego Dystonic, meaning they go against what the person actually wants and values. A Scrupulous person is tortured by thoughts that do not reflect their genuine beliefs, their intentions or desires, nor the true state of their faith. Compounding this, OCD sufferers often experience something called Thought-Action Fusion, which is where the sufferer believes their thoughts hold the same value as an action or that simply having a thought will increase the likelihood that the content of the thought will manifest in reality. article continues after advertisement

Herein lies the trap that many Scrupulous people fall into, which was also true for Sandra. OCD aside, she was passionate about her religious conviction and drew a wealth of personal value from her faith. So, to do anything that could potentially put that into question or undermine it was experienced as possibly damaging her practice of faith, challenging her fundamental belief in God, or leaving her vulnerable to shifting beliefs and a slippery slope into sin.

Unfortunately, Sandra dropped out of therapy due to her fear-based concern that ERP would cause more harm than relief. This is a common story for many in OCD treatment, especially for those with Religious Scrupulosity.

Sandra, like many others, could be very reasonable in the face of her anxious thoughts while also falling victim to Thought-Action Fusion and the OCD voice. Her OCD whispered to her that she needed certainty about her standing with God, her position in the hereafter, and the consequences of her actions before attempting the treatment that could have helped her reconnect to a genuine relationship with God free from OCD’s distorted vision. Instead, her fear won out.

Her story, however, does not have to be your story. ERP is not the enemy and destroyer of faith. Staring down your fear and taking purposeful steps toward your fear is not a sin. It is uncomfortable and frightening, but it is not something that disconnects you from God.

For those of you afraid of doing ERP, I want to offer you a few reminders and tips. Hopefully, they serve as an encouragement to try ERP and challenge your Scrupulosity. article continues after advertisement

1)   Engaging in treatment is an act of faith.

For those afraid that God will somehow misunderstand why you might intentionally allow a fearful and unwanted thought to linger, much less intentionally think about it, consider this. When you do ERP, you are trusting that God is who He says He is—an all-knowing, compassionate, and loving God who knows your true intentions, wants you to be free from the pain of OCD, and would want you to do the right treatment.

2)   Feelings aren’t facts.

When you saw that cute boy or girl in junior high school, the butterflies in your stomach and starry-eyed stupor you fell into didn’t mean that they were your soul mate. Similarly, that gut punch, sweaty palms, and heart-racing feeling isn’t always evidence that you are willfully sinning. Just because you feel anxious and afraid doesn’t always mean you are doing something bad. Exposure feels like you are surrounded by fire alarms while not seeing a fire. The feelings are false alarms, and ERP helps you to learn how to accept and ignore the alarms so you can get back to living your life.

3)   You won’t believe everything you think.

Part of ERP is making space in your mind for uncomfortable, controversial, or taboo thoughts instead of fighting to suppress them. Doing so will not slowly erode your moral character or flip you 180 degrees into a world-class sinner. It is not a virus that will infect you upon contact. Instead, you will learn that you can gently allow for the thought and feeling to visit you for a period of time and then move on, and it won’t take you with it. article continues after advertisement

4)   You may not get all the answers, and that’s OK.

If you have questions about God, the meaning of life, and what’s truly God’s will in all situations, you aren’t alone. There is a lot to misunderstand about God, and faith is confusing. Theologians and philosophers have been trying to answer these questions for thousands of years, and if they have been unable to figure out all the answers, and continue to live their lives, then perhaps we can cut ourselves some slack.

5)   Doubt isn’t the enemy.

The cognitive and emotional states of doubt and uncertainty are natural parts of learning and development. We grow, both personally and spiritually, when we challenge what we currently know when we ask, “what if the things I think are wrong and there is a better way?” Truth stands up to scrutiny, and we should not fear that truth will burn down when we expose it to fire. Instead, give yourself permission to consider controversial positions, sit with prickly feelings and thoughts, and trust that you will come out on the other side stronger and more confident in who you are and what you believe.

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