This is the second installment of a multi-part series on Scrupulosity, a specific variation of Obsessive-Compulsive Disorder (OCD) that focuses on religious and moral perfectionism.  This article focuses on how one can learn to identify and challenge common cognitive distortions seen in Scrupulosity.  Please note that this article will focus exclusively on religiously-focused Scrupulosity, and that future installments will address Moral Scrupulosity.

Scrupulosity in OCD

Cognitive Restructuring can be a valuable component of treatment for Religious Scrupulosity in OCD

Scrupulosity is a type of Obsessive Compulsive Disorder (OCD) rooted in irrational, distorted thoughts (obsessions) related to one’s religious beliefs, morals, or personal ethics.  An individual with Scrupulosity experiences these unwanted thoughts as being at odds with their faith, their relationship with God, or their moral and ethical values.

As with all types of OCD, the individual with Scrupulosity responds to their obsessions with compulsive behaviors that they employ in an effort to reduce, eliminate, or reverse their unwanted thoughts and the anxiety they cause.  Scrupulosity becomes a clinical issue when an individual’s behaviors are motivated by a desire to control anxiety rather than the pursuit of a genuine connection to their faith, morals, or ethics.

Cognitive Distortions in Religious Scrupulosity

The basic thesis of Cognitive Therapy is that much of our emotional suffering is the direct result of our unrealistic and irrational thoughts, which are called cognitive distortions.  In the case of religious Scrupulosity, these cognitive distortions focus on one’s alleged spiritual  failings.  The most effective tool in treating the cognitive distortions experienced by those with religious Scrupulosity is a specific type of Cognitive Therapy called Cognitive Restructuring.  This technique focuses on helping the client develop three primary skills:

  1. Building awareness of the problematic obsessive thoughts
  2. Identifying how these obsessive thoughts are irrational and distorted
  3. Consistently challenging the distorted thoughts with more objectively realistic thoughts

It is important to note that cognitive distortions are not unique to Scrupulosity, nor even to OCD, but rather are faulty ways in which all people may at times misinterpret thoughts, feelings, situations, and interactions.  Some examples of common cognitive distortions seen in religious Scrupulosity include:

All-or-Nothing Thinking (Black and White Thinking)

    • “I had a passing thought about Satan, so I must secretly be a devil worshipper.”
    • “I mispronounced a few words when I was praying today, so I must have angered God.”

Catastrophizing

    • “Because I had a thought about sex with someone other than my spouse, God will send me to hell.”
    • “I accidentally left out a detail at confession earlier this week, so God will surely judge me as unworthy of heaven.”

Discounting/Minimizing the Positive

    • “Even though I have consistently and earnestly tried to live my life according to my faith, I had that one blasphemous thought, so I must be a terrible person.”
    • “I volunteer at church every week, but I’m a selfish person because I can’t volunteer today.”

Emotional Reasoning

    • “My prayer wasn’t good enough because I didn’t feel totally connected to God.”
    • “I feel like my donation doesn’t count because I don’t have a ‘giver’s heart.’”

Magical Thinking

    • “I had a “bad” thought while praying, so my mother will go to hell unless I repeat my prayers perfectly and without bad thoughts.”
    • “If I’m late to church, God will punish my children.”

Should/Must Thinking (Perfectionism)

    • “I should only have pure thoughts.”
    • “I must follow all religious laws 100% literally.”

Selective Abstraction

    • “I’ve heard The Wizard of Oz is a wonderful family film, but it includes wizards and witches, so we better not watch it or else the kids and I may go to Hell.”
    • “Bob is a wonderful husband and father who treats me and the kids great, but he is from a different denomination, so I might not get into Heaven.”

As these examples illustrate, those with religious Scrupulosity experience distorted thinking in many different ways related to matters of faith and spirituality. For example, with “emotional reasoning”, an individual’s thinking is guided by their feelings rather than rational logic.  A scrupulous person who is going through a difficult relationship breakup may feel depressed or apathetic as an important religious holiday approaches.  As a result, they may come to the irrational conclusion that their lack of spiritual fervor is evidence that they are a bad follower of their faith tradition because they are insufficiently excited about the holiday.

Notice the exaggerated conclusion based on a simple feeling!  Rather than rationally concluding that a significant life stressor is impacting their mood, they obsess that it is evidence of some sort of spiritual failing.  As a result of this faulty logic, they may resort to numerous compulsive behaviors, including:

  • Compulsively praying in an attempt to ensure that they are right with God.
  • Repeatedly going to confession in order to alleviate their perceived guilt.
  • Excessively asking others for reassurance about their alleged transgression and/or what they should do about it.
  • Avoiding the religious holiday altogether in an effort to dodge further triggers and reminders of their obsessive thoughts.

Cognitive Restructuring for Religious Scrupulosity

The first step in cognitive restructuring is to keep a log of the obsessive thoughts that are causing one’s distress. The goal of this log is to develop more awareness of the specific content of one’s irrational and distorted thought patterns.  When the obsessive thoughts are logged, they can then be progressively questioned and challenged.  For example, an individual with religious Scrupulosity may think “I had a sexual thought about my attractive co-worker today, so now I will go to hell”. Once they notice that the thought may be distorted, they can begin to look for the evidence for or against the accuracy or reasonableness of the thought.

If you find yourself troubled by an unwanted thought related to your faith, you would benefit by asking your self some questions about this thought, including:

  • Is the feared outcome of this thought consistent with typical, contemporary teaching of my faith?
  • Would the average person in my synagogue, church, mosque, temple, etc., agree with my conclusions?
  • Is the anticipated outcome or consequence in proportion to my actions?
  • When I have had this thought in the past, have the consequences that I fear actually come true?

If the answers to the above questions are “no”, then it is likely that your unwanted thoughts are significantly distorted.  If that is the case, the next step is to challenge your distorted thought with one that is more reasonable and rational.

For example, you may have the painful, unwanted thought that God will punish your children because you arrived late for church.  But your fellow parishioners would most likely say that this belief is not consistent with your faith’s teachings, and that such a result would be a grossly disproportionate consequence to the simple act of arriving late for church.  And upon reflection, you may realize that you have had this anxiety-provoking thought many times before, and yet there is no evidence that your children are being punished by God.

The long-term goal of cognitive restructuring is to develop the habit of challenging your irrational thoughts rather than just blindly reacting to them.  That said, it is also important to stress here that, though the goal of this exercise is to challenge your irrational thinking, that doesn’t mean you will arrive at a place in which you have absolute certainty about your unwanted thoughts.  Human life is full of uncertainty, and nowhere is that more obvious than in matters of “faith”.

The ultimate goal of therapy for all forms of OCD, including religious Scrupulosity, is for the sufferer to learn that, despite the lack of 100% certainty, they can peacefully co-exist with their unwanted thoughts without doing compulsions.  So while it is most likely an exaggerated and distorted thought, and your children probably are not going to be punished by God merely because you were late for church, you aren’t God and you cannot know for sure what will happen in the hereafter.  Your goal is to accept that uncertainty, and go about the business of life.

In short, our obsessive thoughts are possibilities, not probabilities, or even likelihoods. Once the thought is challenged, and the counterpoint to the automatic negative thought is noted, we take a risk and go forward in life without giving into the urge to do a compulsion. This takes the courage found in the margins between possible and probable, which is forever unknown. At the risk of making the pun, it takes faith to risk the possible outcome when that outcome is possible, though uncertain.

It is also worth noting that, for those desperate to find relief from their spiritual suffering, cognitive restructuring has the potential to become a compulsion in its own right.  It is imperative that individuals with religious Scrupulosity be acutely aware of their excessive desire for certainty, and that they resist the urge to misuse cognitive restructuring as a means of trying to eliminate doubt.  An additional concern is that, while cognitive restructuring is a helpful technique, it is not meant to replace Exposure and Response Prevention (ERP), which is the behavioral component of CBT, and is the most important tool employed in the treatment of all forms of OCD, including religious Scrupulosity.  Future installments of this series will address ERP in-depth.

Also, allow us to note that, before beginning the process of therapy, both the client and therapist should be aware that the result of engaging in CBT for religious Scrupulosity may not be limited to a reduction in distorted thoughts.  An additional result may be that the individual begins to challenge their global interpretation, experience, and practice of their faith. While this does not necessarily mean a loss of faith, it may mean that the individual transitions away from an excessively dogmatic view and practice of faith, and towards a less rigid interpretation.  It may also mean that the individual will develop a lifestyle without some of the specific practices that they previously found so vital to their faith, or even an entirely new perspective towards their faith.

Therapy in general, including CBT treatment for religious Scrupulosity, can dramatically influence one’s life for the better, but that can only happen with acceptance of potentially difficult change. Cognitive Restructuring, coupled with Exposure and Response Prevention, can be extraordinarily helpful in freeing people from the pain of religious Scrupulosity.  We highly encourage doing this work with a trained psychotherapist who understands the process, and is willing to work within the context of your specific religious tradition. That does not mean he/she will always agree with your faith, or conduct therapy in a manner that strictly reinforces its doctrines. However, it does mean that you should take time to explain to your psychotherapist how you experience your faith, your understanding of it, and what you are hoping to get out of treatment.

Lastly, we encourage you to communicate with a trusted spiritual advisor (priest, rabbi, imam, etc.) who is willing to work with you and your therapist on developing appropriate behavioral interventions that honor your religious tradition, while at the same time challenging your distorted approaches to it. With introspection, willingness, and the hard work of therapy, you will be able to more comfortably experience any unwanted thoughts you have on your spiritual journey.

To read part one of this series on Scrupulosity in OCD, click here.

To read part three of 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.