Scrupulosity OCD
The word scrupulous comes from the Latin word scrupulum, which means a small, sharp stone. In ancient Rome, a scruple was a unit of weight measurement. The idea of a small sharp stone represents the persistent pain someone may experience in their everyday life, like the pain of a pebble in someone’s shoe, except they cannot get rid of it.
When people are scrupulous, they want to be exact in the way they conduct themselves either with their religion, their morals or both. Their scrupulous mind targets what matters most to them –their morals and religious beliefs. The constant need to perfectly live their morals and religious beliefs leads them to anxiety, uncertainty, and sometimes depression.
“The details seem so important and so necessary –and indeed they are, but not to the point that they deprive us of peace. Balance is required, and therein lies the real struggle."
FATHER THOMAS M. SANTA
Moral Scrupulosity
Individuals may not belong to a specific religious denomination or believe in God. However, their OCD mind may be targeting their moral values. Their beliefs and values such as integrity, service, kindness, responsibility, charity, civility, dependability, honesty, justice, loyalty, morality, punctuality, service, trustworthiness, and truth may be some of the values OCD is targeting in their lives. This makes it difficult as they may believe their worries and behaviors Religious Obsessions: are done for the sake of their values. Inadvertently though, they may be reinforcing the OCD neural pathways.
Religious Scrupulosity
Common questions we are asked from potential clients:
What is the average age range of clients that come into your office with scrupulosity symptoms?
Most of the clients we see at our clinic who struggle with scrupulosity are young adults – ages ranging between 18 to 26. Many of them are students. Others are getting ready to go on a mission – either they have a mission call or have been asked to receive treatment before sending in their paper work. We also see clients who have returned early from their mission or who completed their mission and discovered they had scrupulosity OCD while serving.
What are some of the common symptoms you see among your clients with scrupulosity? Have you noticed any symptoms that are unique to the LDS faith (i.e., obsession with paying tithing)?
The driving force with any type of OCD, including scrupulosity, is uncertainty. Individuals struggling with scrupulosity can be worried about anything related to their religion and morals including tithing. Though tithing may appear to be clear-cut –you either pay or you don’t– it's not that simple for some people. They may struggle with decisions as to what money earned or gifted should be tithed, and question whether they have paid their tithing sincerely or not.
The most common symptom is obsessing (rumination) about present or past behaviors which may have jeopardized their standing before God. Uncertainty drives clients to obsess about whether they are good enough or worthy of God’s love and blessings, and to do something to feel better about the way they think God views them. Scrupulosity is an equal opportunity disorder, so it relates to their own experiences and what is important to them.
The best way to understand scrupulosity is by explaining the cycle:
Trigger:
Any external or internal events (i.e., thoughts, feelings, sensations, and urges) that trigger the initial thought.
Obsessions:
The initial thought will bring up additional thoughts (obsessions). Individuals will usually get caught up with the content of their thoughts related to different areas. These may include: honesty, doing missionary work, praying humbly and sincerely, obeying the word of wisdom, the law of chastity, reading and studying scriptures, obsessing about having only pure thoughts, avoiding blasphemous thoughts, serving and ministering, going to the temple, etc. Individuals struggling with scrupulosity may believe that they are not doing enough, and continually question their intentions and behavior.
Feelings and Bodily Sensations:
The obsessions lead clients to have unpleasant feelings such as anxiety, guilt, shame, frustration, hopelessness, or depression, among many other feelings. Those feelings in turn create unpleasant bodily sensations that lead them to want to do something to rid themselves of the unpleasant thoughts, feelings, and sensations.
Compulsions:
Whatever they do to find relief from those internal events are the compulsions. They may be mental or external rituals such as reviewing the past and going through every detail in their minds (past behavior, thoughts, intentions, and other internal events).
Other individuals may pray for long hours (until their prayer feels just right, humble, and sincere enough). They may pray constantly as a form of repentance. They may read and re-read verses of scripture. If they get distracted by their minds, they go back and read again. They may continually confess to their bishops to ensure they are worthy of God’s blessings and of partaking of sacred ordinances. They may check labels of food or if at a restaurant may ask for all the ingredients their meal contains to ensure they’re keeping the word of wisdom.
They may wrongly believe their anxiety is the Spirit telling them to repeatedly do something such as sharing the gospel with people every single day, which could become their focus each day. They may also confuse their anxiety with the Spirit in social/romantic situations. For example, some people get “cold feet” as their relationship gets more serious. However, when individuals experience scrupulosity, they believe the anxiety they are experiencing may be the Spirit sending them a message. They then assume that this feeling is a “sign” they should break up. They find relief from their anxiety until their next relationship.
Reassurance seeking is also a compulsion when individuals review situations in their minds to ensure they didn’t do anything wrong to offend God or others. They may experience inflated sense of responsibility (hyper-responsibility) in certain areas of their lives – where scrupulosity is targeting their fears. They may constantly ask questions to feel reassured they haven’t done something immoral and are good enough. They may also read about topics related to their scrupulosity to feel reassured they haven’t sinned or offended God.
Relief:
After performing compulsive behaviors, they may find some short-term relief from their unpleasant internal events (i.e., thoughts, memories, judgments, feelings, and sensations). The peace and comfort they experience may be short-lived until the next trigger, which gets them stuck in the cycle again.
Clients usually don’t recognize that their compulsions (internal or external rituals) to find relief from the unpleasant thoughts, feelings, and sensations is for scrupulosity’s sake -- not for love of their religion. They don’t realize that the obsessions and compulsions strengthen the scrupulosity cycle and ironically weakens their relationship with God.
What kind of help and support do you offer to clients with OCD and scrupulosity? What has been most effective?
Cognitive behavioral therapy has been the treatment of preference because the behavioral part of CBT consists in helping individuals face their fears (internal events such as thoughts, memories, images, feelings, and sensations), and respond differently (behavioral change) than they have in the past. This intervention is called Exposure and Response Prevention (ERP). This can sound scary for some, but if done with a therapist who understands the treatment for OCD and specifically scrupulosity, ERP is seen by individuals as an opportunity to respond differently and change their relationship with their internal events (i.e., thoughts, feelings, and sensations).
At Mindset Family Therapy we provide skills and tools that have been proven to be effective from CBT, ERP, and ACT (Acceptance and Commitment Therapy). We help clients understand that the goal of the treatment is not to “get rid” of unpleasant internal events (i.e., thoughts, memories, images, feelings, sensations, and urges) because they are natural events that occur in every human body. There is no delete button in our bodies and minds. We cannot control internal events the way we can some external situations.
Through ACT (pronounced as the verb to act), clients develop psychological flexibility as they practice ERP while using skills to help them become untangled from their thoughts and other internal events.
Clients recognize there is more to them than their thoughts while applying skills to take a step back from the content of their thoughts.
They connect with the present instead of being stuck in the scrupulosity cycle.
Clients learn the difference between acting on the urge to live their religion perfectly and living their religion as God would want them to.
They implement skills to accept what they cannot change in that moment (i.e., thoughts, feelings, sensations) and respond differently (ERP).
They utilize skills that help them recognize when they are moving closer to their values (who and what matters most) or away from them, and to adjust accordingly.
With the right kind of treatment, individuals are able to act on life instead of being acted upon by their scrupulous mind.
At Mindset Family Therapy, we have a passion for helping clients who are suffering with scrupulosity OCD!
References
Thomas M. Santa, Understanding Scrupulosity: Helpful Answers for Those Who Experience Nagging Questions and Doubts, Second Edition (Liguori, MO: Liguori/Triumph, 2007, 7s.
Twohig, M. P., Abramowitz, J. S., Bluett, E. J., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., Smith, B. M. (2015). Exposure therapy for OCD from an acceptance and commitment therapy (ACT) framework. Journal of Obsessive-compulsive and Related Disorders, 6, 167–173, http://dx.doi.org/10.1016/j.jocrd.2014.12.007
Twohig MP, Abramowitz JS, Smith BM, et al. Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behav Res Ther. 2018;108:1-9. doi:10.1016/j.brat.2018.06.005, https://pubmed.ncbi.nlm.nih.gov/29966992/
Twohig, M. P., Abramowitz, J. S., Smith, B.M., Fabricant, L. E., Jacoby, R. J., Morrison K. L., Bluett, E. J., Reuman, L., Blake, S. M. , Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1-9, http://jonabram.web.unc.edu/files/2018/08/Twohig-et-al-2018-ACT-ERP.pdf
