Recognizing and Counseling People Who Have Scrupulosity
Sometimes it's difficult to tell the difference between people of strong religious faith and those whose intense religious observance is actually a form of OCD called Scrupulosity.
A type of OCD known as Scrupulosity involves irrational moral or religious obsessions and corresponding compulsions, or rituals. Religious Scrupulosity can be of particular concern to clergy, because it is sometimes difficult to separate what is “normal” religious devotion from this form of OCD.
Many people are committed to their religious, moral, or ethics standards and try to be as “good” as they can. In some cases, individuals are hard on themselves, constantly demanding more religious or moral perfection in their daily lives, but they don’t actually have OCD. Sufferers of Scrupulosity, by contrast, have persistent, unwanted thoughts and beliefs (obsessions) about not being moral or devout enough, even though there is no evidence to support their fears. They are convinced that they have sinned in the past or will sin in the future, will disappoint God, or be punished if they fail to be “good enough.”
In response to these obsessions, people engage in compulsions, or rituals, to try to reduce the anxiety created by their fears. Rituals may include repetitive praying, repeating religious phrases, asking for forgiveness or even calling a religious leader for reassurance. Therefore, it is imperative that members of the clergy understand what Scrupulosity is and how they can help people who reach out to them.
One of the first steps in understanding Scrupulosity is being familiar with several of the symptoms of this type of OCD. While some of the following may not pertain specifically to your religious beliefs and practices, it is hoped that you will be able to draw appropriate parallels to your particular faith.
Symptoms of Scrupulosity can range from obsessive fears that a person is in league with the devil to religious rituals that involve praying for hours on end.
Obsessions about religious matters may include any of these forms (this is not an exhaustive list):
- Thoughts or fears of having sinned, being unworthy of salvation, of going to hell, or of being particularly evil; sometimes includes fears that the affected person has sold his or her soul to the devil at some time in the past;
- Fears that prayers have been said incorrectly or parts have been left out;
- Thoughts that sins have been committed or that God is displeased about certain actions, and atonement should be made;
- Fears that one has broken a religious law related to speech, dress, food preparation, modesty, etc.;
- Fears that one has lost touch with God or his or her beliefs;
- Belief that one isn’t religious enough and must practice his or her religion more, or more perfectly, or it “doesn’t count”;
- Repeated blasphemous thoughts or images; fears of saying something blasphemous during prayer, meditation, or other religious observances (all of which “contaminate,” and therefore negate, the value of these activities);
- Intrusive thoughts (including sexual thoughts) about religious figures or God; and
- Fears of being or becoming possessed by evil spirits or the devil.
Rituals related to religious Scrupulosity include actions performed excessively, such as (again, the following is not an exhaustive list):
- Praying or performing religious rituals for an extended period of time, e.g., for many hours a day (may need to ensure that rituals are performed “perfectly” or enough);
- Continually asking for God’s forgiveness; repeatedly confessing perceived sins, either to God through prayers or to a religious leader;
- Constantly mulling over one’s words or actions, wondering if the words had double meanings of a sacrilegious or blasphemous nature or if the behavior was sinful;
- Trying to cancel out “bad” thoughts with “good” thoughts or more religious thoughts; trying to “make up for” bad thoughts by thinking the same number of good thoughts;
- Saying prayers a certain number of times (may be a magical number or a multiple of a magical number), or (in some religions) making the sign of the cross a specific number of times before, during or after praying;
- Repeatedly asking religious leaders or authorities the same question about religious practices to be sure that one understands the answer completely; asking for reassurance about whether certain words or actions are sinful; and
- Avoiding certain people, places, events or objects that may trigger obsessions and compulsions related to Scrupulosity (e.g., avoiding a statue of a religious icon that triggered sexual thoughts about the religious figure).
It’s important to note that Scrupulosity may also involve irrational moral obsessions and corresponding compulsions, or rituals. Individuals with moral Scrupulosity concerns may fear getting in trouble for making an error (which either hasn’t actually happened or is unlikely to happen) for which they would be punished. Thus, a student taking a test in school may fear that he somehow cheated and therefore rips up the test to reduce his anxiety. Or a businessman who has submitted a travel voucher may fear that his report was off by a penny, asks for the report back, and checks and rechecks it for hours.
Treatment for Scrupulosity
The treatment for Scrupulosity involves Cognitive Behavior Therapy (CBT), sometimes in combination with medication. CBT is comprised of two components: Exposure and Response Prevention (ERP) and Cognitive Therapy (CT). With ERP, the individual gradually confronts his or her obsessions while trying not to perform the usual rituals. By doing so, the person with OCD slowly builds up tolerance to the thoughts and associated anxiety as he or she retrains him or herself by not responding with compulsive behavior.
A person may have obsessions, for example, that Satan is telling him to forget about God and do Satan’s bidding. During the exposure part of ERP, this individual may be asked by his therapist to listen to a tape-recorded script for one hour each day in which Satan is trying to persuade him to stop praying and start saying bad things about God. With response prevention, the individual is asked to refrain from performing any rituals such as saying prayers or repeating religious mantras to negate the anxiety created by the exposure. With repeated exposures, the anguishing thoughts should become less upsetting and may even disappear.
Cognitive Therapy, the second technique involved in CBT, helps an individual identify and modify patterns of thought that cause anxiety, distress or negative behavior. In other words, CT helps patients understand that the brain is sending “error” messages. Through Cognitive Therapy, the person learns to recognize these errors and confront the obsessions by responding to them in new ways. Thus, a person who believes that having a thought about praying to the devil is the same as actually doing it might be challenged to view the thought as just that – a thought. The person might also be encouraged to make positive self-statements such as “Just because I’m thinking something doesn’t mean I’m really doing it.”
How to Counsel an Individual with Religious Scrupulosity
Perhaps most important of all is that you become educated about OCD, in general, and religious Scrupulosity, in specific. It is critical to understand that this form of OCD has nothing to do with a person’s true religion or faith. Religious obsessions are, in fact, biochemical aberrations caused by OCD, and therefore do not reflect a person’s real thoughts.
When religious leaders are unaware of what OCD is, the concerns of the person seeking help may be met with criticism, skepticism, or deemed as nothing to worry about. In the worse case scenario, an uninformed clergy member may tell the sufferer that he or she really is sinful and must improve his or her religious practices. The person may even be instructed to do penance for his or her sins, worsening the belief that he or she has truly done something wrong. When it is unknown that OCD is at the root of a person’s difficulties, even the most sympathetic clergy member can become frustrated and annoyed by someone who constantly asks questions or seeks reassurance. Learn more about OCD.
As a member of the clergy, you can also help individuals who suffer from religious Scrupulosity by stressing that they do not have to be “perfect” with regard to every aspect of their faith. You can also help them try to separate out their faith or devotion to God (or one’s deity) from the OCD, emphasizing that the OCD forces them to experience “sinful” thoughts and deeds against their wills.
You may also be called upon to help an individual who suffers from religious Scrupulosity during the Cognitive Behavior Therapy process. The person’s cognitive behavior therapist may ask you to attend a therapy session, for example. If you are unfamiliar with Scrupulosity, a meeting of this nature could be extremely informative and render you more capable of helping not only this individual but also others in the future.
Another way in which you might assist is by counseling an individual who is about to embark upon CBT. It may be very helpful to hear from you – a respected and trusted individual – that although he or she likely will be asked to do or say some things within the context of ERP that feel wrong or unpardonable, they do not constitute sinning; indeed, they are necessary to overcoming OCD.
In an article on Scrupulosity, Dr. Fred Penzel, an expert in the field of OCD, describes three points that he makes to individuals with religious Scrupulosity who are starting ERP that may be helpful to you, as a clergy member, as well. (See the full article “Let He Who Is Without Sin:” OCD and Religion on this web site):
1. If God or one’s particular deity is all-knowing, it would be understood that the sufferer is completing ERP exercises not to be irreverent, but rather to break from the OCD.
2. The obsessions and compulsions associated with Scrupulosity are inappropriate and must be changed in order to engage in more appropriate religious observances.
3. ERP exercises may require the individual to do or say things that feel sacrilegious but that must be done to free themselves from the OCD to help them return to more meaningful religious practices.
How to Help Family Members and Friends of Individuals with Religious Scrupulosity
In many cases, family members and friends become extremely involved in the rituals of the person who suffers with religious Scrupulosity. They may become involved in rituals by taking their loved one to church every day to attend confession, for example. Or they may help him or her avoid objects, people, or places that trigger religious obsessions (e.g., drive to the store using a route that bypasses a particular church). Family members believe they are helping their loved one by assisting – or accommodating – OCD and may not know what else to do to keep peace in the household. Unfortunately, when people accommodate OCD, they actually reinforce OCD behavior – making it easier for OCD to get stronger and keep its grip on their loved one.
To better serve family members of individuals with religious Scrupulosity, you can learn about how they can stop accommodating OCD in the home. You can also learn about a number of other ways friends and family members can help their loved one, and at the same time, take care of themselves. The Friends and Family section of this web site contains a wealth of information on this topic.
In sum, your ability to distinguish between a psychiatric illness and sinfulness may make all the difference in the world for individuals who suffer from religious Scrupulosity as well as their families and friends.