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Scruples: Ethical considerations: Moral principles that guide or inhibit action
Scrupulosity: The over-concern for doing the correct thing both in God’s eyes and the eye’s of the law.
Obsessive-Compulsive Disorder is conceptualized as comprising three distinct categories. The most widely known is the observable ritualizer who engages in particular behaviors to escape or undo such threats as contamination or theft. In this type of OCD, the predominant concern is the protection of one’s own wellbeing and safety. The second type of OCD is the purely obsessional form or the non-observable ritualizers, known more commonly as the Pure-O.
The third type of OCD which is most difficult to discern and diagnose seems to be most difficult to treat. It is known as the Responsibility OC and seems to comprise two subtypes: The first is Scrupulosity and the second is known as Over-concern with the Wellbeing of Others. Both subtypes entail a need to defend one’s character from self-deprecation or disrespect from others.
Scrupulosity is a term given birth to in the 1600s amongst religious monastic priests of the time. Certain priests seemed to feel that they never engaged in their daily religious prayers to a satisfactory level. These people became preoccupied with the concern and fear that they were not satisfying God’s need for them to display their love and reverence to Him adequately. As a result, many sought to pray in an exact way or to achieve an exact level of emotional intensity in prayer. Today, scrupulosity is a well-documented form of OCD. It is typically evident in people who believe that their religious behavior is in some way displeasing or disrespectful to God. This preoccupation is often accompanied by the emotional experience of anxiety, common to in all forms of OCD as well as a presence of guilt which exacerbates the pain. As a result, many engage in repetitive and excessive prayer or other religious behavior as part of the disorder.
Thus, the “typical” cycle of OCD is compounded in the case of Responsibility OC. As in other OCD subtypes, there is an upsetting or threatening thought which is followed by tremendous anxiety. However, in Scrupulosity (Responsibility) OCD there is a guilt and depressive component as well. The person experiences an intrusive thought that involves some disrespect to religious items or ideals. The spike involves the threat that an irreverent idea or an incomplete religious practice could displeasure God who needs the pure practice performed perfectly, whereby failure to perform properly would adversely affect one’s spiritual afterlife. The guilt in displeasing God and the feeling that one can never “do it right” often contribute to an associated depressive quality in this OCD subtype. One of the great Hassidic masters, Rabbi Nahum of Stephanesht described the intertwining of these elements in Scrupulosity: “Scrupulosity is a cloak made of pride, lined with guilt and sewn with melancholia.”
Some examples of Scrupulosity include:
An orthodox Jewish man wakes up and performs his morning prayers. He is meticulous, making sure that he recites every syllable slowly, his goal being to express his sincerest and profoundest love and reverence for God. However, each morning as his effort to achieve this sincerity is played out, his mind finds sections of the prayers where he mind not have had the proper intention and he begins the prayers anew, hoping to achieve absolute perfection. As the days and months grow longer, so does the length of time that it takes the man to pray, hindering his ability to spend time with his family or to get to work on time. Feeling anxious, he finds himself spending hours after prayers asking the Rabbi if a potential mispronunciation might require him to start over yet again, relaxing only after the Rabbi tells him that he is finished. He soon develops more anxiety over the degree of religiosity of the Rabbi and begins seeking and applying more stringent rulings in regard to his prayer and other religious practices.
A Catholic alter boy sees the Virgin Mary’s picture in the windows of the church. He looks up during services and experiences intrusive thoughts about the Virgin Mary’s genitalia during mass. As he experiences these thoughts, he feels tremendous guilt and shame. He engages in lengthy prayer and heavy penance in order to appeal to God for forgiveness. He then attends confession in order to have the sin removed from his soul. Sometimes he will confess three or four times A DAY!
Scrupulosity need not focus on a person’s religiosity. Some have scrupulosity in terms of their concern for remaining within strict rigors of legal standards and societal mores.
An attorney feels the need to check his briefcase everyday to make sure that he was not stealing a pencil or a sheet of paper from his law firm. This lawyer would take meticulous account of every dollar in his wallet repeatedly throughout the day to guarantee that all monies there were indeed his own and not placed there by someone else. If he found an unaccounted-for dollar or pen on his person, he would be come anxious and frantically check to see where he might have “cheated” someone during his day.
In the above example of scrupulosity, there is an indicting aspect where the person considers himself guilty, but the guilt is in respect to his societal responsibility to keep the law instead of feeling a religious threat toward God.
One of the complicating features of this form of OCD is that it tends to be accompanied by a certain personality structure which causes people with this disorder to view themselves and the world around them in a very perfectionistic way. This personality style seems to add to the anxious need to achieve harmony in one’s religious beliefs, a component of pervasive perfectionism and judgmentalism in other aspects of living. There is often an accompanying condition referred to as Obsessive-Compulsive Personality Disorder (OCPD) that can compound the condition. The aspect of personality most often associated involves a secondary threat known as Character Assassination in which a patient feels “threatened” or “guilty” unless reassured that, indeed, they are acting appropriately.
A 26 year old Female Baalat Teshuvah (Jewish female who had become more observant) was concerned that she did not observe the Jewish rituals of family purity properly and that as a result, she did not properly love her husband. Her rituals would involve seeking constant Rabbinic approval of her practice of the rituals and of her devotion to her husband.
The additional element of “guilt” or “character threat” can be as compelling and distressing as the more predominant anxiety feature of OCD.
A recently married Hasidic male Talmud scholar was concerned that his bride’s neckline on her blouses was too low for his religious standards. He became preoccupied with thoughts that if she did not raise it, the low neckline would be an indication of a future home of substandard religious observance which terrified him. At the same time, he feared discussing the issue with his wife for fear of offending her and not being the “ideal husband.” He would ruminate about and zealously review his conversations with her to guarantee that he did not accidentally upset her.
Within scrupulosity, issues of absolute honesty in the spoken word and in one’s life choices can become disruptive in the hyper-zealousness within which people feel compelled to live. Patients with scrupulosity in regard to being honest will often engage in time-consuming rituals in which they feel the need to review all conversation of an interpersonal nature. The review is intended to guarantee that were no instances of providing false or misleading information. In that regard, the patient feels the threat of guilt if s/he conveyed information that may have had damaging effects on the listener. Others experience a scrutiny following a conversation where they will review whole conversations to be sure that no obscenity or other offensive comment was offered unbeknownst to the speaker. This occurs in writing as well, where many will check correspondence repeatedly to insure that there was no misleading information or vulgarities included in the correspondence. One of our former patients had to repeatedly trace every letter of any message he took, to guarantee that he didn’t “accidentally curse anyone out” angering God.
Scruples or Scrupulosity??:
Whereas in other cases of OCD, patients are logically aware that their experienced threats are irrational and unlikely, in Scrupulosity there is an increased risk that the threat is of an irrational nature. The religious or legal consequences (or threats) of the thought have made its irrational nature difficult to discern the scruples from scrupulosity. This is common, especially in groups with strong religious beliefs because the person with this form of OCD is often mistaken for one with an enhanced drive to spirituality and God. However, psychologists have noted five key features that distinguish scruples from scrupulosity:
When practices go further than the requirements of religious law, one might be mistaking scruples for scrupulosity. When a religious group’s members act “more Catholic than the Pope” it is likely that we are looking at behavior characteristic of Scrupulosity. For instance, if a ritual requires attending confessional once a week, the person with Scrupulosity will try to attend confessional once a day or more.
When the person becomes overly preoccupied with a focus on a seemingly trivial part of the ritual instead of the whole picture, s/he is likely to be expressing behavior more akin to Scrupulosity. When a religious patient is more focused in prayer on “saying it perfectly” instead of developing a relationship with God, the focus is more like scrupulosity than scrupulous.
Healthy and scrupulous religious beliefs do not interfere with the normal practice of the religion. Scrupulosity frequently interferes with the proper practice of religion. For instance, when a person with Scrupulosity OCD does not attend services because of the fear that s/he cannot contain intrusive thoughts, s/he is expressing scrupulosity.
The person with Scrupulosity spends excessive time and energy on minute, trivial aspects of spiritual life while ignoring more important aspects of spiritual life like engaging in charity and helping others who are in need.
The pre-occupation with doing rituals until they are “perfect”, the repetitive praying, vigilant ritual preparation and unnecessary penance-seeking found in Scrupulosity closely resemble the typical OCD symptoms of checking, repeating and asking for reassurance. The person with Scrupulosity often demonstrates behaviors that are persistent, unwanted and repetitive.
Remember: Strong religious convictions do not cause Scrupulosity. Scrupulosity is a type of OCD, which we see as a neurobehavioral disorder. That means that it must be built upon a biological predisposition. A person’s religious convictions are merely one aspect of his or her being that OCD uses to cultivate doubt and create anxiety. If OCD didn’t attack a person’s religious beliefs, it would surely take on a different form, whether that be contamination fear or checking compulsion or another arena for OCD to unleash anxiety. Scrupulosity takes strong religious ideals and blows them out of proportion, making them distorted and corrupt. But that corruption is not always apparent to the person with Scrupulosity who places serious stock in these personal, tainted religious threats. The tendency to overvalue these irrational threats and to consider them logical and justified (Overvalued Ideation) can diminish the prognosis of treatment success.
Treatment Considerations:
The patient with scrupulosity OCD (especially of the religious type) is more likely to perceive an intense risk during the course of treatment. The risk concerns not only the patient’s wellbeing but the risk of disapproval from God as well. This perceived risk is likely to produce greater resistance from the patient to perform exposure exercises which are a necessary part of the treatment. The exposure exercises must be approached in an aggressive, determined manner if the clinical outcomes are to be positive.
Because this form of OCD includes both anxiety and character indictment, it is often recommended that a patient receive some education about cognitive therapy. The principles of cognitive therapy are based upon the notion that humans are fraught with imperfection and diversity. Therefore it would not be adaptive for a human to stake his entire existence on his personal assessment of his standing in God’s eye. In other words, cognitive therapists encourage their patients to see that their behaviors can vary and that one’s sense of self is better off being accepted rather than always being constantly critically evaluated. Given a society and a religious culture that is constantly encouraging people to become or “be” better persons, it is easy to see how patients find it hard to navigate these new ideas. Therefore, it is not unusual for therapist and patient to consult with a patient’s clergyman during this initial phase of therapy in order to sanction and help navigate this apparently “irreverent” therapy. Clergy and patient need to be aware that the treatment course is not designed to adversely impact one’s religious beliefs. Rather, they should know that treatment is solely targeting a disruptive anxiety disorder which produces seemingly devout behavior that is actually unrelated to one’s genuine degree of religious commitment. In fact, often the ability to distinguish real religious behavior or scruples from scrupulosity often helps enhance one’s devotion to his religious principles.
Often, patients balk at the idea of cognitive therapy for OCD. In the case of Scrupulosity, especially of a religious subtype, many opt for medication therapy instead. Although medication is a very powerful frontline treatment for OCD in general, it can have limited benefit for people with scrupulosity where the existence of Overvalued Ideation is present. The medication can help reduce the experience of the anxiety but it cannot help someone change his way of thinking. This is where the cognitive therapy is most necessary and effective.
The actual treatment course for Scrupulosity does not deviate significantly from other types of OCD. Generally, a hierarchy is constructed, in which persons gradually are exposed to accelerating levels of risk. This involves increasing the level of risk that the patient’s character may be negatively judged. Exposure exercises at a lower level might entail things like taking off a small piece of paper and littering on the street. An example of a more moderate range exposure could involve the limiting of the recitation of a prayer to only once, knowing that the prayer might not have been uttered with full intensity or having patients repeat to themselves repeatedly throughout the day that the Virgin Mary might not have been a virgin.
Often, people with Scrupulosity are referred to by family, significant others or by the clergy due to the tendency for those with scrupulosity to misperceive their excessive behavior as functional.
A final thought (or two. Does the number really matter?)
It is of the utmost importance that therapy be directed toward increasing the patient’s tolerance of ambiguity and ability to increase the risk in relation to the OCD. Clinical work focuses on assisting the client towards a greater tolerance of discomfort associated with the anxiety and the guilt. The ability to tolerate the discomfort leads to the recovery. In addition, one must recognize that the goal of therapy is not to make these painful associations go away. Rather, therapy is there to help people manage the anxiety that arises as a result of these associations in a way that is adaptive.
It is critical to remember that in regard to OCD, attempting to get out or avoid the anxiety or guilt (“Escaping”) produces the greatest psychological damage. The thoughts, while unpleasant, are survivable but there is no end to the process of escape. Actually, it is the escape attempts that distort behavior and affect the person’s ability to function in his or her own world. Escaping the spikes sets the individual up for further attacks of the disorder.
Having said that, once a person makes the decision to resist a spike, the anxiety usually dissipates within a fairly short period of time – usually no more than 10 to 20 minutes at most. This is usually unbelievable to new patients who have been agonizing for days in order to properly ritualize in order to avoid the pain of the anxiety. Over time, it becomes apparent to the patient that it is the ambivalence to the uncertainty of giving in to a spike that produces the most anxiety. Similarly, constant checking and waiting for the anxiety to come (Anticipatory Anxiety) makes the anxiety attacks more severe and more intense.
Ultimately, the goal of the therapy is to see that both the disruptive thoughts and the anxiety are irrelevant. This is achieved through the changes to one’s mindset that occur in conjunction with the treatment and its homework exercises. Although the exercises may seem extreme, recovery is achieved when the patient approaches the exercises in a way that is aggressive and conscientious. It is like a bent pole which, in order to straighten, needs to be bent to an equal degree in the opposite direction. Although somewhat oversimplified, the analogy expresses the underlying principle of this type of therapy and helps explain the rationale for the extreme behavioral exercises and exposure. By taking the extra step of challenging the disorder demands even further, patients can effectively regain their freedom and comfort in performing their routines of daily living which have proved elusive due to this disorder. Treatment facilitates the return to normalcy, and restores the freedom and comfort.
It seems that the primary factor in determining Scrupulosity is the amount of anxiety and/or guilt that s/he experiences when not performing or doing the “right” thing. If you have the opportunity to do a good deed and note that not doing it would cause you “too much” anxiety or guilt or that passing up the opportunity would be indicative of your poor character for failing your conscience, you might be suffering from Responsibility OCD and it might be in your best interest to seek professional help. |
