"God Forbid"

by Steven Phillipson, Ph.D.

Clinical DirectorCenter for Cognitive-Behavioral Psychotherapy

Scrupulosity: The over-concern for doing the correct thing both in Gods eyes, and that of the law.
Obsessive Cop!lsive Disorder is concept!ali"ed as having three types or categories. The ost traditional type is that of the
observable rit!ali"er. #n these people, rit!als generally involve behaviors which are designed to !ndo or escape threats$ s!ch as
containation or chec%ing rit!als to prevent soe disaster. #n this type, the predoinant concern is the protection of ones own well
being and safety. The second ost predoinant for of OCD, which is &!st recently beginning to receive a odic! of attention, is
the p!rely obsessional for of OCD, or technically the non-observable rit!ali"ers, which # refer to as the P!re-O.
The 'rd category of OCD, which has received rear%ably very little attention, is act!ally the one in which treatent is ost diffic!lt
and convol!ted. # refer to this type of OCD as the (esponsibility OC, which encopasses two s!btypes. One s!btype is scr!p!losity,
while the other s!btype is over-concern with the well being of others. )oth s!btypes essentially entail an e*aggerated need to defend
ones character fro agreagio!s self deprication or disrespect fro others.
Scr!p!losity is a ter given birth to in the +,--s aongst the religio!s onastic priests of the tie. #t was observed that certain
priests never felt as if they engaged in their daily religio!s rigors to a satisfactory level. These people were preocc!pied with the
concern and fear that they were not satisfying God.s need for the to display love and or reverance in an ade/!ate way. Typical
rit!als that were observed in that tie involved the need to pray in an e*act way, or to pray achieving an e*act level of eotional
intensity. 0o!r h!ndred years later scr!p!losity is a well-doc!ented for of OCD. #t is typically evident in persons who have an
over"ealo!s concern that their behavior or tho!ghts ay in soe way be displeasing, or disrespecting to God. (epetitive and
e*cessive prayer contin!e to plag!e those persons with this type of OCD. Scr!p!losity also can involve the need to adhear to a strict
code of val!es or ridigidly follow the ethics of a law abiding citi"en.
This preocc!pation involves not only the traditional e*perience of an*iety, which is a feat!re predoinant in all fors of OCD, b!t
the presence of g!ilt as an additive coponent f!rther e*asserbates the pain and coplicates treatent s!ccess. OCD obvio!sly is
associated with a two part process. There is the !psetting or threatening tho!ght and this tho!ght is !s!ally iediately followed by
treendo!s an*iety. 1ltho!gh this is the pervasive pairing of OCD there are occasions where the originating tho!ght can prod!ce
g!ilt, anger and or depression.
The Scr!p!losity type of OCD ta%es on any different anifestations. There are those people who will e*perience an intr!sive
tho!ght that involves soe disrespect to God or to religio!s ites or ideals. The spi%e involves the threat that an irreverent idea, or
an incoplete prayer co!ld creates the ris% of potential displeas!re of God, and therefore that ones spirit!al afterlife will be affected
negatively.
Soe e*aples of scr!p!losity are as follows2
1n orthodo* 3ewish an wa%es !p and perfors his orning prayers. 4e perfors his prayers in a very slow and deliberate way, his
goal being to a%e s!re every syllable of every word e*presses his ost sincere and profo!nd e*perience of love for God, and
respect for God. 5ach orning, as his effort to achieve this perfect sincerity is played o!t, his ind finds oents or words which
ay not copletely deonstrate an ade/!ate ao!nt of love and reverence for God. 1t this oent, his ind dictates that he !st
start the prayer over again fro the beginning, and go thro!gh it to the point of absol!te perfection.
1s wee%s and onths go by, the tas% of achieving the perfect prayer becoe increasingly diffic!lt, and his life is disr!pted in his
ability to go to wor% on tie, or to foc!s on other life atters. This person re/!ests fro a rabbi that his wife be allowed to perfor
the orning prayer for hi, and that he be given special perission to s%ip this prayer in its entirety. This person is given perission
by the (abbi to have his wife perfor his orning prayer , however within a onth his ind creates other ideas that threaten his
sense of well being and relationship to God.
1nother e*aple involves an altar boy, who in ch!rch sees the 6irgin 7ary, and e*periences intr!sive tho!ghts abo!t the 6irgin
7ary.s genitalia. 8hen these intr!sive tho!ghts appear to the altar boy, he feels treendo!s g!ilt, disg!st and shae. 4e feels
copelled to pray to God for forgiveness. 4e then attends confession in order to have this apparent sin reoved fro his so!l. 1fter
a few onths, the priests fro his parish s!ggest that the altar boy infor his parents that he sees a psychologist.
Scr!p!losity need not foc!s on ones involveent in a religio!s sense. Soe people have scr!p!losity in ters of their concern for
reaining within strict rigors of legal standards and societal ores.
1 patient, who is an attorney, felt the need to chec% his briefcase everyday to ens!re that he was not stealing a pencil or a blan% piece
of paper fro his law fir. This person wo!ld go to e*traordinary lengths to a%e s!re that all oneys in his poc%et or wallet were
acco!nted for as being his own, and not accidentally ta%en or placed there by soeone else. #n this for of scr!p!losity, there is still
an indicting aspect where the person ight consider hiself legally corr!pt, with or witho!t the presence of there being a religio!s
threat, or indictent to his character.
1 coplicating feat!re of this for of OCD is that it tends to be accopanied with a specific type of personality str!ct!re, in which
patients tend to view theselves and the world aro!nd the, in a very rigid and perfectionistic way. #t sees that with this s!bset of
OCD, not only is there an an*io!s need to achieve a sense of perfect harony in ones religio!s and9or oral beliefs, b!t there is also
pervasive pattern of perfectionis and of being &!dgental in other aspects of living. There is a chance that when a person has this
for of OCD$ they also have an accopanying personality disorder, referred to as Obsessive Cop!lsive Personality Disorder
:OCPD;. #t is essential for ental health professionals to create differential diagnoses in order to ens!re that the standard protocol for
treating this for of OCD possibly ta%es into acco!nt the less rigoro!sly st!died treatent, which attends to the patients personality
str!ct!re.
The aspect of this personality condition often and alost entirely involves a secondary threat, of what # call Character 1ssassination.
1 woan # wor%ed with had tho!ghts that her love for her child, or her love for God, was not s!fficient, and therefore she was
orally corr!pt.
4er rit!als wo!ld involve constant reass!rance fro persons within the clergy, and fro faily ebers, to ens!re that her love and
attention towards her child, along with her religio!s practices fell well within what wo!ld be considered an ade/!ate deonstration
of devotion.
1 woan is involved in a 8eight 8atchers eating progra. She feels the need to report her every dietary choice. On occasion,
/!estions will arise as to whether she has acc!rately reported the ao!nt of b!tter she ight have placed on a bagel. <!estions also
ens!e to whether shes been +--= disclosing and honest in giving an acc!rate acco!nt if sall portions of her food ight fall off the
plate. She is incapacitated in telling stories by the need to a%e s!re that shes incl!ded every detail, lest she be acc!sed of being
withholding inforation while not being copletely honest and disclosing.
The additional eleent of >g!ilt? or >character threat? can be as copelling and distressing as the ore predoinant an*iety feat!re
of OCD.
1 patient cae to e, and started Pro"ac at the onset of treatent. 8ithin one onth, the an*iety related to her scr!p!losity was
copletely gone, yet her attachent to perforing rit!als was not at all affected beca!se of her g!ilt, and her need to rid herself of
the potential for her character indictent.
8ithin scr!p!losity, iss!es of absol!te honesty in the spo%en word, and absol!te legality in ones life choices, can becoe disr!ptive
in the hyper-"ealo!sness with which people feel copelled to live within. Persons who s!ffer fro scr!p!losity in regards to being
honest will often engage in tie-cons!ing rit!als, in which they feel the need to review e*changes that were ta%en place on an
interpersonal level. This review is intended to g!arantee that there were no instances of providing isleading or false inforation. #n
this regard, persons once again feel the threat of g!ilt if they conveyed inforation that ay have daaging effects to those who
listened to the. Theres also a heightened scr!tiny following any conversation where the person will strictly eval!ate whether or not
they have, !nbe%nownst to the, !ttered an obscenity or soe offense to the listener. This also tends to occ!r in written lang!age to
these people, s!ch that they will chec% any correspondence repeatedly to ens!re that when it leaves their control, theres no
isleading inforation, or no v!lgarities incl!ded in the correspondence.
Persons who have a hyper vigilance abo!t legal constraints will engage in a rigidly controlled lifestyle in which they feel copelled
to avoid any potential legal conflict. 1 coon anifestation within this for of OCD involves persons who are hyper-vigilant to
ens!re that their written inforation not contain any plagiaris, or contain ideas that are not !ni/!ely their own. This deterination
to reain copletely within the ethical g!idelines, seen as >not cheating?, can anifest theselves in people placing footnotes on
any written correspondence in which they identify that they have been assisted in their writing by soething as coonplace as a
spellchec%er on their cop!ter. Once again, in these fors of OCD, there is a cobination of the an*iety d!e to not %nowing
whether one has stepped across the line in their orals or legal standards, and the g!ilt of having violated the law, violated innocent
others, or Gods will. #n developing a treatent pac%age, these iss!es give rise to the potential that a patient not find it easy to
differentiate between their an*io!s inds copelling threats, and their own potential rigid and high oral standard.
This for of OCD has the potential, ore so than others, to involve what is called Overval!ed #deation. Typically patients s!ffering
fro OCD are logically aware that the threats that they enco!nter are irrational and !nli%ely. This dichotoy of tho!ght, where on
one hand they feel copelled to perfor a rit!al, and on the other hand are aware that the originating threat is irrational, prod!ces a
great deal of t!roil.
8ith Scr!p!losity, there is an increased ris% that the patient is not f!lly aware in a logical way that the threat is of an irrational
nat!re. #ts as if the disorder has ta%en over the part of the ind fro irrational tho!ght.
The tendency to overval!e the irrational threats and consider the logical and &!stified can diinish the prognosis of treatent
s!ccess.
Treatment Considerations.
0or that patient with scr!p!losity OCD, a ore intense ris% is perceived d!ring the co!rse of treatent. This ris% involves not only
their well being, b!t also the ris% of disapproval fro God. This perceived heightened ris% tends to prod!ce a greater level of
resistance fro the patient to perfor the e*pos!re e*ercise, which is a necessary part of treatent. These e*pos!re e*ercises !st
be approached in an aggressive, deterined anner, in order for clinical o!tcoes to be positive.
1ltho!gh edication is a very powerf!l frontline treatent for Obsessive Cop!lsive Disorder, it can soeties have liited
benefit for persons with Scr!p!losity when the e*istence of this overval!ed ideation is present.
The treatent co!rse for overval!ed Scr!p!losity does not deviate significantly fro other types of OCD. Generally, a hierarchy is
constr!cted, in which persons grad!ally are e*posed to grad!ally accelerating levels of ris%. This involves increasing levels of ris%
that their character ight be negatively &!dged. 5*pos!re e*ercises at the lower level ight entail things li%e a person sapling a
grape at a deli, and then wal%ing away, as if they.re disapproving, b!t in their heart %nowing they.re stealing a grape. 1nother
e*aple of an e*pos!re e*ercise ight entail a patient ta%ing off a very sall piece of paper, and littering on the street. 1n e*aple
of a ore iddle range e*pos!re co!ld involve a patient repeating to hi or herself thro!gh the day, that the 6irgin 7ary ight not
have been a virgin.
)eca!se this for of OCD involves the d!al-barrel threat of an*iety, pl!s character indictent, it is often recoended that a patient
receive soe e*pos!re to the ore philosophical cognitive principles that disp!tes the belief or notion that people have definitive and
specific characters. The principles of cognitive therapy hold that h!ans are fra!ght with iperfection and diversity. D!e to this, it is
not considered adaptive for h!ans to attept to assess their stat!re overall, ego, character or place in God.s eye. Cognitive
principles enco!rage patients to perceive theselves as generic h!ans, witho!t an additive sense of goodness of character. #nstead,
patients are enco!raged to see that their behaviors can vary, and that ones sense of overall self is best off being accepting, rather than
eval!ating.
# can ass!re yo! that this therape!tic goal reains one of the ost challenging within Psychology. O!r society, school syste, and
religio!s instit!tions contin!e to be fra!ght with ego based philosophies which enco!rage people to becoe good or better persons.
These ideas create a greater s!sceptibility for ones ego or stat!re to be hared or diinished.
#t is not !n!s!al that professionals within the religio!s co!nity, s!ch as priests, rabbis and inisters, are called in the initial
phases of therapy to sanction the seeingly irreverent nat!re of this therapy. #t is helpf!l if these religio!s professionals have soe
%nowledge of OCD, so that they can !nderstand that the treatent co!rse is not designed to have any ipact on religio!s beliefs and
devotions. They sho!ld be aware that treatent is solely targeting a disr!ptive an*iety disorder, which prod!ces >seeingly? devo!t
behavior that is really !nrelated to the gen!ine degree of devotion to religio!s principles.
#t is not !ncoon that persons are referred for therapy by significant others, or those within the clergy, d!e to the tendency for
those with Scr!p!losity to not perceive their e*cessive behavior as being dysf!nctional.
Some Final Thoughts.
#t is of the o!tost iportance that therapy be directed towards increasing the client.s tolerance of abig!ity and ability to increase
the level of ris% ta%en in relation to OCD. Clinical wor% can foc!s on assisting the client towards developing a greater tolerance of
discofort associated with the an*iety and g!ilt. #t is being willing to tolerate s!ch discofort that leads to recovery. #t is also
parao!nt to !nderstand that the goal of therapy is not to have the painf!l associations go away, b!t rather to loo% !pon the as
challenges to anage. This is one of the ost diffic!lt concepts for the patient to grasp with since ost people who coe to therapy
believe that their proble is that they have the tho!ghts, rather than not anaging the an*iety arising as a f!nction of the tho!ghts, in
a way which is adaptive.
#t is critical to reeber that with OCD, attepting to escape the an*iety or g!ilt prod!ces the greatest daage psychologically. The
tho!ghts theselves, while !npleasant, are s!rvivable, where the attept to escape is endless. #t is the escape attept that distorts the
s!fferer.s behavior and adversely affects his or her ability to f!nction in the world. @ot being willing to face the spi%es, sets the
individ!al !p for f!rther attac%s of the disorder.
On an enco!raging note, once a client a%es the decision to resist the spi%e, it is li%ely that the discofort will dissipate within a
fairly brief period of tie, often +--A- in!tes at ost. Those who have &!st beg!n therapy soeties find this hard to believe.
0resh in their eories are iages of ho!rs, and soeties days, spent agoni"ing over soe spi%e, or getting a rit!al right.
Thro!gh tie, patients becoe aware that it is their abivalence and !ncertainty abo!t whether or not to give in or not to a spi%e that
prod!ces the prolonged agony. 1s long as one waiver in the decision to resist, the ind is enco!raged to prod!ce ore propts of
an*iety and g!ilt. Siilarly, it is not helpf!l once within the throws of the disorder, for an individ!al to a%e a decision to resist
giving in and then spend their tie onitoring their an*iety and waiting for it to s!bside. That, too, increases the probability that the
disorder will contin!e to create propts as spi%es. Chec%ing to see if the discofort is still there %eeps the connection open to the
an*iety and g!ilt prod!cing tho!ghts. Bltiately, the goal of therapy is to see that both the disr!ptive tho!ghts and the an*iety are
irrelevant. This can be achieved thro!gh altering ones indset, and behavior with respect to these e*perients.
1ltho!gh soe behavioral e*ercises ight see e*tree, recovery is facilitated when the patient perfors these e*ercises in a way
which is aggressive and conscientio!s. #t is enco!raged that clients overcopensate in regard to hoewor% assignents, which is
opposite to the deands of the disorder. #.ve often !sed the >)ent Pole? analogy in e*plaining this to clients. #n order to straighten a
etal pole that has been bent in one direction, yo! !st bend it bac% to an e/!al degree in the opposite direction. Over siplified as
this analogy is, it e*presses the !nderlying principle related to the rationale for the e*treity of these e*ercises.
)y not only disregarding the disorders deands, b!t ta%ing the e*tra step of !pping the ante or challenging it even f!rther, clients can
ost effectively regain their e/!ilibri!, the freedo, and obtain cofort in perforing the ro!tine tests of daily living of which
they have be deprived by the disorder. The disorder deprives people of the aforeentioned and treatent can help the obtain those
bac%.
#n concl!sion, the factor that disting!ishes soeone who is siply conscientio!s or concerned, fro one with (esponsibility OC or
Scr!p!losity, is the ao!nt of an*iety and9or g!ilt that she9he e*periences in not perforing the tas%, or good deed. #f the occasion
were to arise, where we were to observe soe potential ha"ard in the street, we have the freedo to as% o!rselves Cif # were not to
perfor this good deed, what eotions wo!ld # e*perienceDC #f the answer is a significant ao!nt of an*iety or g!ilt, or a strong
feeling that yo! are less of a person, for failing to act as yo!r conscience dictates, this is a strong indicator that yo! s!ffer fro
(esponsibility OC, and it ight be in yo!r best interest to see% professional help.
Dr. Steven Phillipson, Ph.D.
www.ocdonline.co