I pass by a picture of my kids and think, "Satan: they are my gift to you," my new client John, a wonderful husband, father of three and successful businessman tells me. "Why would I think that? I would never sell my soul to the Devil." On another day, he says in shame, "We are cutting shapes out of construction paper at the table and I'm thinking the Devil will make me lose control...In church finally, I'm feeling hope and then I think maybe God wants me to harm someone. I would never sell my soul; that is the last thing God would want."
I don't recoil in horror, as he does, because many other good, moral clients have told me about their own nightmarish thoughts. A chaste, Christian college freshman obsesses that his "wild" close dancing with a girl is "bad" and fails the "What would Jesus do?" test. He repeatedly replays the dance scene in his mind, hoping to reassure himself that he didn't give her false hope that he would sleep with her. A Catholic nine-year-old girl obsesses that she once spelled "God" without capitalizing it and avoids stepping on floor stains that look to her like Jesus. When she passes a math test she wasn't prepared for, she worries endlessly that she cheated, and prays to God repetitively for forgiveness.
Sufferers of scrupulosity around the world share their own versions of my clients' nightmarish thoughts. They have persistent, irrational, unwanted beliefs and thoughts about not being devout or moral enough, despite all evidence to the contrary. They believe they have or will sin, disappoint God, or be punished for failing. In response to their disturbing thoughts, they try to calm themselves by using a host of compulsions. Some repeat religious phrases; others call their pastors for reassurance. Many avoid situations-even their beloved church or temple-because it triggers their horrible obsessive thoughts.
Documentation of people with this form of Obsessive-Compulsive Disorder goes back centuries. The 16th Century theologian Martin Luther was tormented by urges to curse God and Jesus (Baer, 2001). When he prayed, Luther was obsessed with images of 'the Devil's behind." St. Ignatius, the 16th Century Portuguese Jesuit, couldn't step on two pieces of straw if they formed a cross because it would show disrespect to Christ on the cross.
Today, scrupulous Catholics, born-again Protestants, Baptists, Hindus, and others post anguished questions about their obsessions and compulsions on the internet listserv, The_Scrupe_Group. Studies show that scrupulosity is the fifth most common form of OCD after contamination, aggressive thoughts, symmetry, and somatic concerns (Foa, et al, 1995).
Some studies suggest that scrupulosity is more common among people who are especially devout, or whose religions have certain tenets, such as emphasizing "perfect" devotion or considering bad thoughts as sinful as bad deeds. Nevertheless, it affects people from multiple religions whose level of devotion varies, and even affects atheists.
If you have an occasional irrational, unwanted thought, do you have OCD? Everyone has such thoughts; people without OCD just dismiss them as unimportant and move on. If you are committed to your religion, morality, or ethics, and want to be as good as you can be, is this scrupulosity? Many devout and good people feel this way, and continually demand more of themselves, but they don't have OCD. People without OCD may try harder when they feel guilt or disappointment about something they think or do. But they are not obsessed with their failure.
OCD sufferers, on the other hand, dramatically overreact to perceived failures. They "see sin where there is none" (Nelson, Abramowitz, Whiteside and Deacon, 2006) or blame themselves for falling short of impossibly high standards. They are tortured by the intensity of their doubts about their goodness, and the belief that, therefore, they are downright bad.
Their discomfort makes it hard to dismiss the thoughts, which become sticky and hard to chase away. The persistence of the thoughts, and the frequency and anxious intensity with which they return, turn those irrational thoughts into obsessions.
Think of the obsession as a mosquito bite-it's unwanted, uncomfortable, and feels like it will never go away. In response, OCD sufferers feel they must get rid of that obsession at any cost. The result is a compulsion, and it's much like the scratching of a mosquito bite.
To neutralize those disturbing thoughts, sufferers often use a mental or physical ritual, such as repeating a religious phrase or religious act, seeking reassurance, or doing penance. The obsession may be temporarily relieved by the compulsion, but it soon returns, more powerful than ever, just like a mosquito bite itches more after scratching it than if it is left to itch for awhile.
John, my former client, obsessed about having sold his soul to the Devil in exchange for his wonderful life, and then compulsively repeated religious homilies for hours. Finally he would repeat to himself: "I am a good Christian man. I am a good Christian man."
Phillipson & Schwartz (2006) suggest that some sufferers become preoccupied with a trivial part of the religious ritual instead of the whole picture. For instance, they may focus on saying prayers perfectly instead of developing a relationship with God. They may act "more Catholic than the Pope" (for example, if confessing weekly is normal, going daily).
OCD rituals differ from devout religious practice, but it can be hard to tell the difference at first glance. In fact, many religions have behaviors that may look like OCD to an outsider.
Jennifer Traig, the author of a wry memoir, "Devil in the Details: scenes from an obsessive girlhood," describes the ways Orthodox Jewish religious rituals and scrupulosity compulsions may be mistakenly confused with each other.
"Judaism has codified a whole choreography of compulsive, compulsory gestures and tics," the scrupulosity sufferer writes. "We reach up to touch the mezuzah each time we pass a doorway. We kiss the prayer book when we close it, the Torah when we approach it, any religious object when we drop it. We cover our eyes when we say the Shema prayer, and bend, bow, and straighten when we say the Aleinu...Orthodox Judaism looks so much like scrupulosity that some psychiatrists, and my father, have asked if they might be one and the same," she teases.
"[But] there are some vital differences. Orthodox Jews are motivated by spiritual duty and rewarded by a sense of fulfillment; the scrupulous are motivated by [brain] circuitry and rewarded by chapped hands...Most scrupulous Jews tend to overlook, even violate, the bulk of the laws while observing one or two with excruciating care. Compulsions tend to come before commandments. I could violate three or four commandments in one fell swoop. I was happy to lie to my dishonored parents while breaking the Sabbath, as long as it was in the service of getting my hands ritually clean." (Traig, 2004, pp. 33-35)
Despite many rules governing life, Judaism, in fact, does not seek perfection. For instance, Orthodox Jews don't mix meat and dairy products in the same meals. But under the principle of K'zayit, they needn't worry if a drop of milk touches their meat. Likewise, "the ideal is to totally concentrate on the prayer in a perfect communion with God. [But the principle of] B'dieved, which roughly translates to second best, says that if your mind wanders while praying, keep going and don't repeat the prayer" (Grayson, 2006, p. 224).
Examples of other religions with beliefs and practices that can be mistaken for scrupulosity abound. But the anguished obsessions and compulsions, the tormenting doubt and guilt distinguish scrupulosity sufferers from morally and religiously inspired people.
Religion itself doesn't cause scrupulosity, of course: it's merely the form some people's OCD takes. OCD has an extraordinary ability to target sufferers' Achilles' heel, attacking people where they're vulnerable. OCD sufferers are thought to have an "ambivalent sense of self": for example, if their core belief is that they are bad, they'll listen more to the thoughts that "prove" that to themselves, dismissing the evidence that they are, in fact, good (Wilhelm & Steketee, 2006). Although John was a devoted family man, he focused on the bad, irrational thoughts he had about harming his loved ones.
At present researchers believe that OCD is genetic, passed down through families. People with a biological predisposition for OCD will be triggered at some point by an event, experience or environmental stressor and develop full-blown OCD. But even without that particular incident, they would be triggered eventually by some other stressful experience.
John recalled that his OCD began at the age of seven. A teacher at his Catholic school talked about a man who sold his soul to the Devil for riches. That comment triggered a fear that John had done the same. He responded with hand-washing and checking symptoms to reduce his anxiety, and continued to suffer throughout his childhood.
In high school, a psychiatrist diagnosed him with depression and prescribed Prozac, which can also reduce OCD symptoms. He took Prozac through his early 20s, when he decided he no longer needed it. His OCD symptoms ebbed and flowed for the next decade. He came to me 25 years after his OCD had begun, when work stress was wearing him down. After a colleague told him she'd had an encounter with the Devil, John became obsessional and suicidal and he knew he needed help.
When he began treatment with me, he said he wondered if his phenomenal success now--wonderful kids, wife and career--was evidence that he did sell his soul and that he would go to hell. Irrational thoughts appeared at agonizing moments.
"I'd be bathing the kids and have the thought that I wished the Devil would make me hold them under water," he said. "Or I'd be wrestling with the kids [and imagine] grabbing their throat and saying that I will sell my soul to strangle them, or putting them to sleep and hoping Satan will make me smother them with a pillow."
He repeatedly had blasphemous thoughts. He'd think: "Come to me Lucifer" and repeat to himself in horror: "You cannot take my soul. God protect me. Jesus is Lord." Or "I'm going to harm my kids. 'Satan: they're my gift to you.'" His compulsion was to repeat: "Satan, you are not my Lord. I'm a Christian man."
At the same time, hoping to quell the severe anxiety that the irrational thoughts gave him, he often sought to avoid them. He started to turn bathing them over to his wife, and refused to be near his children with a knife or a pizza cutter, both of which he'd imagined using to murder them.
John was naturally horrified by these thoughts and the fact that they occurred to him at all seemed proof that he had, in fact, sold his soul to the Devil.
John wanted to fight back to regain his family and himself. In a crash-course in reading about his symptoms, he learned that numerous studies showed Cognitive-Behavioral Therapy was highly effective in beating back OCD. But choosing to begin treatment was still a terrifying decision. The stakes seemed so high for himself and for his loved ones. What if his thought that he had sold his soul to the Devil was true and he stopped trying to win his soul back? He might go to hell. What if he was right that thinking about harming his family made him more likely to do it? Then if he didn't avoid potentially dangerous situations with them, he was risking their lives.
Yet the wise part of him knew that those obsessions came from OCD and were not true. To begin treatment and defy his OCD, he needed the courage to trust his "wise mind," as Wilhelm and Steketee (2006) call it.
People with OCD crave certainty that isn't possible: a guarantee that awful things won't happen. What's particularly challenging about scrupulosity is that it's virtually impossible to logically disprove. If you believe you'll go to Hell for thinking about sex with the Virgin Mary during Mass or not saying your prayers "perfectly," only death will provide you with the evidence. And with what feels like such high stakes-in this life and after-standing up to the OCD seems especially risky. John took a leap of faith in harnessing his wise mind to enter treatment.
Like other CBT therapists, I use two primary tools. One is cognitive therapy, which challenges the thinking errors common to OCD. The other is a behavioral treatment called Exposure and Response Prevention (ERP). With ERP, John actively encouraged those nightmarish, irrational, anxiety-producing thoughts and behaviors while refusing to use rituals to chase the anxiety away until his anxiety diminished.
Clergy can help prepare and support their parishioners in this therapeutic work. I would never ask clients to do something that they truly believed would violate their religious beliefs. But sometimes scrupulosity sufferers can resolve those concerns by meeting with clergy who are educated about OCD.
A religious leader can emphasize that perfection isn't necessary to express faith and help sufferers separate out their OCD from their devotion to God. It's also very helpful for sufferers to hear from their clergy that they are not sinning when they do exposure exercises in which they say or do things that feel unpardonable to them.
Sometimes it is helpful for a clinician to meet with a client and clergy member together, especially if the religious leader is unfamiliar with scrupulosity. (In presentations to clergy, I've found that many initially think they have never seen it in their congregants. But eventually most recall parishioners who, in fact, might suffer from scrupulosity--an infirm widow who must polish the silver daily, whether it needs it or not, for instance, or a young man who calls repeatedly for reassurance that any number of thoughts or deeds aren't sinful.)
John exhibited a number of classic thinking errors common to people with OCD.
As I noted earlier, scrupulosity sufferers often have thoughts that are no different than the thoughts the average person has. The difference is how sufferers think about their disturbing thoughts: the distorted meaning they give them and how that leads the OCD to blackmail them.
Sufferers often believe that "just having a thought means that the thought is important and requires special attention" (Wilhelm et. al, 2006, p. 9). This plays out in a couple of ways. The first is in "moral thought-action fusion." John believed he was as bad for thinking about harming his family as if he actually had done it.
In other words, many sufferers believe that having a bad thought is as sinful as doing something bad. "Individuals with scrupulosity, who by their nature impose strict moral standards upon themselves and are hyper-vigilant of moral/religious sin, might be exquisitely sensitive to intrusive sexual or sacrilegious thoughts that conflict with their belief/value system. For example, a scrupulous individual might find even the passing thought of an extramarital sexual encounter with a stranger more disturbing, and resist it more intensely, than would an individual without scrupulosity, leading to obsessional problems." (Nelson et. al., 2006)
This thinking error is harder to address for sufferers whose religions actually preach this. For instance, in the Sermon on the Mount, Jesus warns, ''You have heard that it was said 'you shall not commit adultery'; but I say to you, that everyone who looks on a woman to lust for her has committed adultery with her already in his heart'' (Matthew 5:27-28; New American Standard Version). Research indicates that many strongly religious Christians, including devout Protestants, incorporate this doctrine into their belief system (Nelson et. al., 2006). But many religious leaders emphasize that they don't expect perfection, and know that OCD forces its sufferers to replay perceived "sinful" thoughts and deeds against their will.
The second way to overestimate the importance of their thoughts is in "likelihood thought-action fusion" (Wilhelm et. al. 2006). Sufferers believe a thought will lead to action, like John worrying that if he thought about harming his family, he would be more likely to do it.
This can also show up in magical thinking: if you think about doing something it will cause it-or something else horrible-to happen. My nine-year-old client wouldn't wear red because it could lead her to the Devil, or say "down" because it could send her to Hell. Another former client was afraid to wear the earrings she'd had on when her infant had a convulsion for fear that it would cause him to have another one.
Other cognitive errors (Wilhelm et. al., 2006) include:
John learned to correct his thinking errors by challenging them with me. He also used behavior therapy as a way to challenge those thoughts in a different way: to take away their power to control him by reducing their sting.
With Exposure and Response Prevention (ERP), John learned how to tolerate his obsessions instead of running from them, which takes away the power of those thoughts. His mind and body habituated to the anxiety triggered by the distressing thoughts; he learned how to label those obsessions as OCD, not truth, and let them go. The thoughts eventually became less disturbing and then less frequent. In conjunction with cognitive therapy, it was a powerful weapon against his OCD.
ERP is the OCD sufferer's equivalent of jumping in a cold pool. In ERP, sufferers choose to accept and tolerate the initial discomfort of their bad thoughts, despite their desire to chase those thoughts away with compulsions.
Likewise, swimmers often need to accept and tolerate the cold water when they enter a pool. If they immediately jump out, they will feel relieved to be out of the cold. This quick reaction reinforces their belief that cold water is unbearable and avoiding it is the only smart move. If they jump back in periodically but always flee before they get used to it, they continue to reward the getting-out (avoidance) behavior. They've reinforced that the cold is obviously too awful to tolerate, which just increases their distress when they imagine trying again.
However, if they stay in the pool until they get used to the chill, they adjust and become more comfortable. If they repeat that exercise a dozen times a day, they reinforce the message that tolerating the cold leads to getting more comfortable. With time they get less scared of the initial disturbing chill and the irrational belief that it will last forever, and find waiting it out pays off with reduced (or even no) discomfort.
It's the same with scary thoughts. When John was afraid of thoughts of harming his children and going to Hell, he neutralized them by keeping away from the kids, and by repeating phrases about God that reassured him that he was a good Christian man. But the thoughts just kept returning and he'd have to continually avoid his kids and repeat useless phrases for minutes and later for hours.
I'd clearly determined that he was not a danger to others or to himself. So I didn't worry about having him in situations that his OCD made him feel might be dangerous for others.
We made a hierarchy of his obsessive thoughts, from the least to most disturbing. We created a thought exposure exercise for him. He listened repeatedly to a tape he recorded with a script about Satan making him harm his children. He listened to the tape, read the script he'd written for it, and re-wrote the script for a total of 60 minutes each day.
Then we added frequent quick thought exposure exercises that would trigger the anxiety. He typed "sold to D" for Devil on his Blackberry, which beeped hourly and put post-it notes with "sold to D" where he'd see them. He took his laptop to his car during work breaks and watched "The Exorcist," which triggered his anxiety.
Later we added assignments, as he could handle them, of rough-housing in a pool with them, bathing them, and using knives around them in the kitchen.
He refused to do any compulsions or safety behaviors to quell the anxiety, such as avoiding his children or repeating his reassuring phrases. He taunted his OCD with the behavioral and thought exposure exercises. As a result, he habituated to those anguishing thoughts-they stopped disturbing him as much and soon he stopped having them as much. The OCD thoughts lost their power.
After several months, he had significantly reduced his anxiety and was exhilarated at being able to regain his affectionate way with his children. However, while he'd accepted that his harm obsessions were irrational and to dismiss most of them, some remaining scrupulosity fears about his likelihood of going to hell still had a toehold.
He wrote a final script for himself for his last thought exposure exercise.
"It's Wednesday afternoon and my weekly appointment with Laurie. Only this week is a little different. [Pastor] Jane is joining us from ....church. She sits down and asks, 'So what is the issue?' Laurie goes through the medical explanation of OCD. Jane looks at me and asks, 'What does this have to do with you?'
"I respond, 'I am afraid I may have sold my soul to the devil.' Jane responds, 'It is the church's belief that if you're afraid you did then you must have done it. There is no such thing as a chemical imbalance in the brain. You are doomed to hell. You have done the unthinkable. There is no hope for you to find salvation once you have done the unthinkable.' Hearing Jane say it out loud makes me realize it must be true. I must have done it. Laurie was lying to me to make me feel better. I truly am an evil person. In my weakened state, I turn to my wife for help and explain the scenario. She backs away in total fear, yelling, "HOW COULD YOU DO SUCH A THING! YOU DISGUST ME!' She takes the kids and files for divorce. I go on to live my life in solitude, sorrow and regret, never to see my wife or the kids again."
This was his last step in overcoming his OCD and it worked. The more he listened to the tape, the more he was able to see how irrational his fears were, and to let them go. He became freed from his scrupulosity.
The bottom line is that people with scrupulosity can maintain their faith and stop being blackmailed by their OCD. A man with scrupulosity wrote to a fellow sufferer on a scrupulosity listserv:
"...It doesn't matter what you "feel" right now. Your salvation doesn't depend on your feelings. Human feelings are temporary and transient. Instead of trusting in your feelings or in your own goodness, trust his promise. "...whoever believes in him shall not perish but have eternal life." It doesn't say whoever has perfect belief has eternal life, and it doesn't say whoever is perfect has eternal life, or whoever is without bad thoughts has eternal life. You've already accepted Christ, your salvation is secure, no matter what your ocd tells you. And I believe your bad thoughts (and mine) don't matter to Christ... he sees them for what they are... a brain glitch, a chemical imbalance, etc. I've noticed that a lot of people in the group are worried that they've committed the "unpardonable" sin...But, anyone who worries about committing the unpardonable sin hasn't committed it...You've not been "cut off"... that's just an OCD lie..." (The scrupe group, 2006).