This is the third installment in our ongoing series on Scrupulosity, a sub-type of Obsessive-Compulsive Disorder (OCD) focused on religious or moral perfectionism. This article focuses exclusively on identifying and challenging common cognitive distortions seen in “moral” Scrupulosity.
Previous articles in this series have focused on religious Scrupulosity, which is most easily described as a pattern of intrusive, unwanted thoughts related to one’s religious beliefs. These unwanted thoughts are counter to the sufferer’s faith, and lead them to perform compulsive behaviors in an attempt to nullify or extinguish the anxiety they experience related to these thoughts.
Conversely, the obsessions experienced in “moral” Scrupulosity are focused not on matters of faith, but rather on one’s personal sense of morals and ethics. Those suffering with moral Scrupulosity experience commonplace thoughts, feelings and actions that they misinterpret as being evidence that they are ethically flawed or morally bankrupt. As with all sub-types of Obsessive Compulsive Disorder (OCD), those with moral Scrupulosity seek relief from their anxiety through various compulsive and avoidant means in an effort to ensure that their obsessive fears do not come true. In other words, they perform compulsive behaviors that they hope will prevent or eliminate the feeling that they are a “bad” person.
Moral Scrupulosity presents unique challenges that make treatment more ambiguous and difficult in contrast with religious Scrupulosity. For example, religious faiths have codified rules for approved beliefs and behaviors that can be verified via scripture, or by consulting with certain authority figures (priests, rabbis, imams, etc.). Conversely, there are no fixed, objective definitions of “good” and “bad”, or “right” and “wrong”. In times of doubt, individuals with moral Scrupulosity have no specific religious text or church elder to whom they can turn for counsel. Their personal belief system – their “moral compass” – is generally based not on religious scripture or orthodoxy, but rather has developed over time through their upbringing and experience. Thus, for those with moral Scrupulosity, determining precisely what is “right” or “wrong” can be exponentially more difficult. At the same time, those suffering with moral Scrupulosity often have a rigid, perfectionistic belief that they must strictly adhere to their personal moral code in all matters, regardless of the situation or context. Failure to do so is often considered unacceptable, no matter how slight the infraction.
Cognitive Distortions in Moral Scrupulosity
As with all forms of OCD, the most effective treatment for moral Scrupulosity is Cognitive-Behavioral Therapy (CBT). The main cognitive tenet of CBT is that irrational and unreasonable beliefs (known as cognitive distortions) influence subsequent feelings and behaviors. The central tool used in correcting these faulty beliefs is Cognitive Restructuring, which helps the sufferer to gain a more realistic perspective in three ways:
- Building the sufferer’s awareness of their obsessional thought patterns
- Identifying how their obsessional thoughts are distorted and unrealistic
- Challenging these cognitive distortions with thoughts that are more rational and realistic
Some examples of cognitive distortions commonly experienced by those with moral Scrupulosity are:
- All-or-Nothing Thinking (Black and White Thinking)
- “I may have heard someone talking about part of the test yesterday, so I’ll be a cheater if I answer any of those questions.”
- “If I accidentally under-report my income by $100 on my taxes, I’m committing major tax fraud.“
- Discounting/ Minimizing the Positive
- “It doesn’t matter that I often give money to homeless people – I’m a horrible person because I didn’t give any money to a homeless person today.”
- “I am a terrible person because I didn’t prepare as well as I usually do for my team presentation at work.”
- Emotional Reasoning
- “I am a bad wife because I noticed another man who is attractive.”
- “It would be really mean and unforgivable if I gave my classmate constructive criticism about her assignment.”
- Should/ Must Thinking (Perfectionism)
- “I must always tell the truth, no matter what, because it’s the right thing to do.”
- “I should never drive over the speed limit, no matter what.”
- “If I don’t remind my wife to wear her seatbelt, she’ll be in violation of the law and it’ll be my fault.”
- “I cannot watch the movie Free Willy because it’ll mean I’m supporting harm to Killer Whales.”
The goal of cognitive restructuring is to challenge and replace irrational, fear-based beliefs with thoughts that are more reasonable, realistic, and objective. For example, one can challenge the belief that they should never find anyone but their spouse attractive with a more realistic thought that it is normal to find other people attractive, and that what really matters is what one chooses to do in response to those feelings. Likewise, one can challenge the thought that they are a cheater because they heard other students talking about an exam by reminding themselves that they studied hard, and already knew the answers to the questions that were on the test.
It is worth noting that the process of cognitive restructuring has the potential to become a compulsion in its own right. When challenging your distorted thinking, it is important that you not compulsively review either your obsessive thoughts, or your cognitive challenges to those thoughts. The goal is to quickly establish whether a thought is in fact distorted, and if so, to challenge it with a more balanced thought. If you find yourself repeatedly evaluating whether your cognitive challenge is “good” or “right”, it’s a good bet that you are inadvertently using cognitive restructuring as a compulsion.
Ultimately, the long-term goal of cognitive restructuring is to stop blindly accepting the irrational thoughts that present themselves to your mind, and to instead develop a pattern of challenging them. With conscious effort, your mind’s default position will shift from unquestioning acceptance of distorted thoughts to a more realistic way of thinking that is based on reason rather than fear.
Common Challenges in Cognitive Restructuring for Moral Scrupulosity
Of course, this process is not as simple as it sounds. The human mind loves to create disastrous scenarios, and it is likely to take repeated effort over time to change well-established thought patterns. Furthermore, reality is not as cut-and-dried as logic. For example, take the issue of driving no higher than the speed limit. Most people would agree that, as part of being a responsible member of society, it is generally a good idea to follow traffic laws. And if you don’t, you may get a speeding ticket with a hefty fine, or worse, have an avoidable accident.
However, in some situations it may be advisable to break the law and go above the speed limit, such as in the case of exceptionally fast moving freeway traffic. Even the DMV would advise you match the average speed of others on the road. In other situations, such as an emergency drive to the hospital or some other life-threatening scenario, driving faster than the posted speed limit may actually be a matter of life and death.
These exceptions to the rule illustrate the grey-area nature of real life. Simply put, there are some situations where not being entirely “good” or “right” is preferred, or even necessary. It is also worth noting that bringing logic and reason to emotion may not always change a feeling – try to reason your way into, or out of, loving someone. Now imagine the difficulty of challenging a thought for which there are no codified laws, such as being honest with your spouse, or exhibiting responsibility towards others.
As this suggests, given the inherent ambiguity of trying to “live right”, challenging cognitive distortions will only get one so far in managing moral Scrupulosity. As noted above, in contrast to religious Scrupulosity, moral behavior has no standard doctrine for behavior or belief. For example, a common belief is “It is wrong to kill another person”. But in the case of war or self-defense it may be necessary. Likewise, most people believe it is wrong to steal. But if your family is starving to death, stealing may be the most noble option possible.
A more common moral ambiguity faced by many people in America is the matter of “tipping” for services rendered. By American standards, most people consider tipping a “good” thing to do. However, there is no hard and fast rule for the amount one should tip – 10%, 15%, 20%? If you ask ten people, you are likely to get ten different opinions, including variations based on the type of service being rendered, and how well the service was provided.
But a person suffering with moral Scrupulosity may be obsessively concerned with how much to tip, and with the criteria by which that decision is made. Their belief is that they must tip the “right” amount. It is a moral imperative. Furthermore, their anxiety may be exacerbated by their exaggerated fear of harming the person providing the service – “what if the waiter can’t pay his rent because of my tip being inadequate?”. All this concern over a gesture that by all objective measures is optional.
The Role of Values In Cognitive Restructuring for Moral Scrupulosity
Effective management of moral Scrupulosity ultimately comes down to making choices based on one’s motivation for action. In short, are your actions done because you prefer acting a certain way, and prefer a certain outcome, or because you are trying to avoid feelings of distress and anxiety related to your irrational fears. For individuals in the throes of moral Scrupulosity, simple everyday decisions are often based not on choice, but on fear. Do you tip 20% because it makes you feel good to support the hard work of others, or because tipping less would result in your feeling guilty, anxious, or fearful? Since a firm standard does not exist, it seems reasonable that one should act in accordance with their true values, while accepting the potential costs of upholding those values (such as feeling short-term guilt, or worrying that others may possibly think you’re stingy).
In order to guide your choices by your values, you first need to evaluate both the intended action, and the perceived consequences of alternative choices. If you are suffering with moral Scrupulosity, consider asking yourself these questions when faced with a situation in which you are experiencing moral ambiguity:
- What does my OCD say will happen if I don’t do my compulsion?
- What has been the outcome in previous situations in which I have experienced this moral concern?
- Objectively, what is actually the most likely outcome?
- What do I fear it will say about my character if I do something different?
- Who or what suffers if I make my choice based on my fearful obsession?
- What other possible choices can I can make in this situation?
- What about my choice do I actually care about and want in my life?
- Is my choice in this situation based on my true values, or on my fear of experiencing anxiety or discomfort?
- What might I gain by choosing my action based on my true values rather than on fear?
Using these questions to evaluate a fear-based thought can help you decide if that thought is a cognitive distortion. And if your proposed action and its outcome do not align with your life goals and values, you can choose to instead accept the anxiety that comes with experiencing your irrational, distorted thought. The alternative – guiding your life with the goal of anxiety avoidance – will typically lead to an abandonment of the life you actually want.
Integrating Cognitive Restructuring, Values, and Behavioral Change
Taking control over your behaviors can be emotionally difficult, especially when what you have been doing “feels right” (even if it costs you time, money, energy, or relationships). The ultimate aim of treatment for moral Scrupulosity is to accept and tolerate temporary discomfort in order to gain eventual freedom by acting according to your true goals and values. A decision to do something different is entirely up to you, and will be motivated by your evaluation of the costs of avoiding anxiety versus the benefits of going against your fears by making bold, personally valuable choices.
If you determine that your behavioral responses to your irrational thoughts are out of sync with your values and character, the next step is to begin exercises to progressively challenge and change your actions in response to your fears. The best approach to this is a CBT technique called Exposure and Response Prevention (ERP), which is the most effective method of promoting both a tolerance of irrational feelings of anxiety, and a long-term reduction in distress. ERP for Scrupulosity will be discussed in greater detail in a following article. In the meantime, if you are suffering with moral Scrupulosity, remember that your excessive anxiety is an exaggerated response to feared, irrational thoughts. The path to freedom is to challenge these thoughts, accept short-term discomfort, resist giving in to compulsive behaviors, and act in accordance with your true goals and values.
To read part one of this series on Scrupulosity in OCD, click here.
To read part two in this series on Scrupulosity in OCD, click here.
•Kevin Foss, MFT and Tom Corboy, MFT are licensed psychotherapists at the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of Obsessive-Compulsive Disorder (OCD) and related anxiety based conditions. In addition to individual therapy, the center offers four weekly therapy groups, as well as online therapy, telephone therapy, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.