Ted Witzig - Scrupulosity Support Group

SCRUPULOSITY:
When OCD Gets Tangled in
Religious and Moral Matters
Ted Witzig, Jr. Ph.D. – www.scrupulosity.org
Apostolic Christian Counseling and Family Services
877-370-9988 -- www.accounseling.org - info@accounseling.org

Scrupulosity? What’s that?
The word “scruple” is derived from the Latin
“scrupulus,” a rough or hard pebble that causes
discomfort if trodden on; a later meaning was a
minute apothecaries' weight, one twenty-fourth of
an ounce, so small as to affect only the most
sensitive scales. The term in English acquired a
moral interpretation of a thought or circumstance
so insignificant as to affect only a very delicate
conscience. In religious terminology a scruple is
an “unhealthy and morbid kind of meticulousness,
which hampers a person’s religious adjustment.”
Weisner&Riffel,1960
Weisner & Riffel, 1960

Clinical Definition of Scrupulosity
•Obsessions and compulsions
containing religious themes,
hypermorality, pathological
doubt/worry about sin, and excessive
religious behavior.
Abramowitz, Huppert, Cohen, Tolin, & Cahill, 2002; Greenberg & Witztum, 2001

Does Religion Cause OCD?
• “There is no evidence that religion causes OCD.
However, your religious background and
experience can influence the type of obsessional
concerns that develop in people with OCD.”
• Scrupulosity has been identified among followers
of all of the major world religions.
• The OCD will take on the characteristics of the
person’s religious and cultural beliefs.
Purdon & Clark (2005). Overcoming Obsessive Thoughts, p. 94

The Nature of the Problem
 Please remember it is possible for anyone to
struggle with a spiritual issue.
 Sometimes these struggles can lead to anxiety.
 Going through such a spiritual struggle does
not necessarily mean a mental disorder is
present.

Abramowitz and Jacoby (2014)
A Cognitive
Behavioral
Model of
Scrupulosity

Examples Of
Scrupulous Symptoms

• Some of the obsessional thoughts below may
appear to be reasonable thoughts for a religious
person.
• The issue occurs in that person with
scrupulosity is not able to move through the
doubt and go on and, instead, becomes fixated
and distressed.
Note:

Intrusive Religious Thoughts
• Worrying you didn’t repent right.
• Worrying you might be praying to Satan instead of
God.
• Worry about numbers like 666.
• Worry you will worship an idol.
• Worrying about if you fully had peace when you gave
your vows before your baptism.
• Worries about fasting.
• Worrying about whether you are feeling peaceful
enough to know you have peace with God.

• Worrying about whether you are feeling peaceful
enough to know you have peace with God.
• Fearing you have not made a complete enough
confession.
• Worrying you have not been able to make restitution
perfect enough.
• Worry about committing blasphemy against the Holy
Spirit.
• Feeling that you are “unworthy” to take communion
or worrying that you might not have taken care of
everything before taking communion… even if you
aren’t sure what you need to do make it right.

• Worrying that you may have forgotten to repent for
something.
• Worrying that you have committed the unpardonable
sin.
• Worrying about the verse warning to “set no unclean
thing before my eyes.” Oh no! What does that apply
to?
• Fears about dressing immodestly

Intrusive Thoughts about Moral Issues
• Motive Doubting
• Worrying you have been deceitful (or just lied).
• Worrying about whether you motives are pure.
• Reasoning backwards that if you feel uncertain, you
must have done something wrong.
• Worrying that you might have omitted something
from your confession in effort to make yourself look
better than you really are.
• Intrusive Sexual Thoughts or Thoughts of
Harm
• Worrying you get sexually aroused around children.
• Worry you may be gay.
• Worrying you might accidentally touch a child in the
wrong way.

“Reduced ability to perform
religious activities, achieve
religious goals, or to experience
religious states, due to a
psychological disorder”
Clinically Significant
Religious Impairment
Hathaway (2003) p. 114

Urges & Images
Urges
• Feeling you might yell out a cuss word in church.
• Feeling like you just gave a person “the finger.”
Images
• Having horrifying images of blasphemy.
• Sexual images of a religious figure.

Behavioral Compulsions &
Reassurance Seeking
• Confessing things over and over again to other people.
• Seeking reassurance from others about whether you
sinned or not, etc.
• Refusing to sign your signature if you haven’t read
every word on a document.
• Calling people back to ask for forgiveness for things
you might have done…. and they didn’t know the
problem occurred.
• Looking things up in the Bible to see if you have
committed blasphemy against the Holy Spirit (for the
unpardonable sin).
• Having to fold you hands in a certain way or else God
will not hear your prayers.

Mental Rituals/Neutralization
• Trying to undo bad thoughts by thinking a good thought
after a bad thought.
• Replaying situations over and over again to see if you
sinned or not.
• Repeating words in your prayers such as saying, “In
Jesus’ name, in Jesus’ name, in Jesus’ name” Amen.”
• Asking God for forgiveness over and over again just to
be sure you didn’t forget to ask… again.
• Trying to analyze and figure things out again and again
in order to try to gain certainty.
• Confessing the same things to God over and over again.

Normal Religious Practice
Vs.
Scrupulosity
What differentiates the two?

Healthy Faith vs. Scrupulosity
1. Fear: A healthy faith is not associated with
debilitating worry and fear.
2. Entangling: The more you focus on
scrupulosity, the more entangling it is, and the
worse it gets. It creates stress.
3. Non-responsive: Scrupulosity is not
responsive to spiritual interventions.
• For example, for the scrupulous person spiritual
interventions (e.g., confession) may produce momentary
relief, but the symptoms will return.
Ciarrocchi(1998);Greenburg
(1984);Abramowitz(2002)
Ciarrocchi, 1998; Greenburg, 1984; Abramowitz et al., 2002

Healthy Faith vs. Scrupulosity cont’d
4. Distress: People enjoy and want to engage in
normal religious practices, whereas people with
scrupulosity perform the rituals to reduce
anxiety/distress due to some feared consequence.
5. Overdoing: The individual’s practices far
exceed what is required by the particular
religious group.
6. Interferes: Scrupulosity interferes with normal
religious practice (e.g., the person does not attend
church, does not partake of communion because
of obsessional worries, etc.).

7. Narrow: The individual’s beliefs and practices
become very narrowly focused on “getting it
right” and he or she loses sight of deepening their
relationship with God.
8. Overlooking: The individual may focus so
much time and energy on perfectly performing
rituals that he or she overlooks more important
aspects of faith (e.g. doing good toward others).

9. OC-Cycle: Scrupulosity closely resembles other
subtypes of OCD in that there is an overt focus on
compulsions (repeating prayers, checking,
multiple confessions, reassurance seeking) in
response to distressing intrusive, unwanted and
repetitive thoughts, images or impulses.
10.Other OCD: People with scrupulosity often
have other symptoms and/or subtypes of OCD.

Aspects of Treatment
• In many ways, the treatment of scrupulosity is very similar
to treating other forms of OCD.
• Additional time and attention must be given to
understanding and respecting the client’s religious beliefs.
• Collaboration with family members and clergy is an
important aspect of treatment.
1. Accurate diagnosis
2. Assessment of OCD symptoms (including the PIOS)
3. Education of client/supporters about OCD and its
treatment
4. Collaboration with clergy, as needed
5. SSRI Medication started, if needed

Aspects of Treatment cont’d
6. Cognitive Treatment
• Assessment of obsessive-compulsive belief system
• Challenging cognitive distortions
• Stopping mental rituals
7. Acceptance and Commitment Therapy (ACT)
• Learning to come to the present moment and to not
fight with thoughts
• Learning cognitive defusion skills
• Focusing on living in a way that is congruent with
values
8. Behavior Therapy - Exposure and Response Prevention
• Assessment of patient readiness of ERP
• Pushing past avoidance
• Ending reassurance seeking
9. Relapse Prevention/Maintenance

Desired Characteristics of the
Core Treatment Team
1. Family member or close friend
• Willing to learn about OCD.
• Willing to stop accommodating the OCD.
• Willing to stop providing reassurance.
• Willing to attend sessions, as needed.
2. Physician/Psychiatrist
• Who will listen to your situation and treat you kindly.
• Who understands medication dosing for SSRIs with
OCD and, specifically, primarily obsessional forms of
OCD that often require higher dosages.
3. Clergy
• Willing to learn about OCD/scrupulosity.
• Will not accommodate the OCD or give reassurance.

The Core Treatment Team cont’d
4. Counselor
• Who knows how to treat OCD using cognitive-behavior
therapy with ERP and ACT.
• Willing to communication and collaborate with your
clergy person.
• Understands that OCD/scrupulosity is a mental health
condition and does not blame your spirituality.
• Note: It is important that Release of Information forms
are signed so these individuals can talk to each other, as
needed.

Family Involvement
• Research shows that emotional over-involvement
and criticism from family members negatively
affect treatment and lead to higher relapse rates.
• Family members need to identify and stop any and
all reassurance giving and compliance with the
patient’s compulsions.
• Educate family members about OCD, how to be
both supportive and firm (without being critical).
• Be ready and willing to attend counseling sessions
with the person with OCD.

Obsession
Thinking Errors/
Catastrophic
Interpretation
Distress
Compulsion/
Neutralization
Temporary relief
with increased
sensitivity to the
obsession
Uncertainty

Overestimation of Threat
• People with this belief feel like something bad
might happen at any time.
• They tend to worry about the most catastrophic
outcomes.
• They overestimate how likely catastrophic things
are to occur.

Inflated Sense of Responsibility
• They may believe they are responsible to foresee
and prevent harm from coming to themselves and
others.
• They worry about the consequences that might
happen if they don’t take action.
• They believe they are responsible for possible
negative outcomes.

• Their desire is for everything to be clearly black
and white.
• They find uncertainty about things to be very
scary.
• They believe ambiguity, change, and newness are
threatening.
• They want to maximize predictability.
Intolerance of Uncertainty

• People with these beliefs have very high, rigid
standards for themselves (and often others).
• They are worried about making any mistakes and
feel like they need to know everything for certain.
• Often believe there is one right way for everything
to be.
• Find it difficult to rest if they cannot achieve
perfection.
Perfectionism

• People with these beliefs pay too much attention
to their thoughts and believe having certain
thoughts means something bad about their
character.
• e.g., “The fact I had these thoughts means I must be an
immoral person.”
• They believe having a thought is the same thing
as doing the action.
• They may believe having a thought makes it
more likely for something to occur.
Over-importance of Thoughts

• They believe they should have perfect control
over all of their thoughts.
• They try very hard to suppress their thoughts
and push thoughts they don’t like out of their
minds.
Control of Thoughts

Coping Statements for
Scrupulosity

Dealing with Doubt and Uncertainty
1. Faith is not the absence of feeling uncertain. Faith is
going forward through the uncertainty.
2.OCD wants me to believe that uncertainty and doubt
are dangerous. While uncertainty is uncomfortable, it
is not dangerous, and I can tolerate it.
3.My faith is what I believe, not what I feel.
4.Feelings are not facts.
5.OCD will always bring up another What if . . . ? Trying
to nail down all of the What if . . . ? questions will lead
me down a path of never feeling good enough or
certain enough.

Dealing with Doubt and Uncertainty Cont’d
6. I can have faith and still feel uncertain. Mark
9:24, “…Lord, I believe; help thou mine
unbelief.”
7. God loves me completely, even when my feelings
are uncertain and clouded by doubt.

Dealing with Intrusive Thoughts
1. Even though they feel real, intrusive thoughts (i.e.,
distressing thoughts or images with violent, sexual,
or blasphemous content) say nothing about my true
character.
2. The goal of the intrusive thoughts is to shock and
scare me so I try to suppress or “fix” them. My goal is
to identify them as “intrusive thoughts” and move on
instead of fighting with them.
3. Having an intrusive thought does not make it more
likely for me to act on it.
4. God understands that intrusive thoughts are
distressing to me. He understands OCD better than
anyone!

Dealing with Intrusive Thoughts Cont’d
5. OCD wants me to believe that worry, anxiety,
and compulsions will protect me spiritually. That
is all part of the trick OCD wants me to believe.
6. OCD wants me to fight with my thoughts and try
to control and suppress them. OCD knows that
by getting distressed and fighting with the
thoughts I will refill the “gas tank” in the
obsessional engine and keep it running.
7. Trying to prevent myself from ever having
certain thoughts, images, and feelings only
makes them worse.

Tips on Moving Forward
1. One of OCD’s biggest tricks is asking me the
question, “What if this fear isn’t from OCD and it
really is a serious issue?” Whenever this thought
(or one similar) comes, I will treat it as OCD and
not try to figure it out.
2. I will pray to God for grace and strength to
accept/move on from intrusive thoughts without
figuring them out and fight doing compulsions,
neutralizing, or avoiding.
3. My goal is to “starve” OCD by not giving
meaning to intrusive thoughts or doing
compulsions.

Tips on Moving Forward Cont’d
4. I have two choices: (1) to chase after a feeling of
certainty that never comes or (2) to choose to move
forward through the uncertainty.
5. My goal is to focus on doing the tasks that I need to
be doing in the present moment (studying, cooking,
talking to a friend, working) instead of focusing on
trying to figure out the uncertainty or fear.
6. I need to focus on the present moment and allow my
thoughts to come and go.
7. Trying to figure it all out only makes it worse.
8. God understands that I don’t understand.

The Goal of Treatment for OCD
According to Mark Freeston:
• “To set the goal of treatment at zero
thoughts is a setup to make the person’s
first obsessional thought significant and
upsetting.”
• The most reasonable goal is: “Some
thoughts of varying intensity and frequency
with relatively little upset and no
interference in day-to-day living.”

Principles of Effective and
Religiously-Sensitive Exposure

Get Perspective on your Goals for Exposures
• You need to be able to do whatever other people
from your church/denomination can do as part of
normal practice of faith.
• Identify someone (elder, minister, etc.) who can
help you and your therapist determine what things
are part of the true practice of your faith and church
community (i.e., what is normative) versus what is
OCD. This person should understand OCD (or be
willing to learn about it).
• The 85% rule can also be used to help you identify
what is normative (i.e., typical behavior or practice).
If out of 100 people from your church, 85% or more
do something, then it is normative.

Take the Risk to End Compulsions,
Neutralizing, and Avoidance
• You must stop avoiding people, places, things,
images, etc. that trigger your religious obsessions.
• You must stop reassurance seeking and repetitive
confessions (whether that is to others or to God).
• You must give up trying to have absolute certainty
about matters of faith. Instead, live out your faith
by trusting God through the uncertainty.

Use your CBT, ERP, and ACT Tools
• Anytime you can do a direct (in-vivo) exposure to
something, do it!
• Anytime you can do an imaginal exposure to
something, do it! Exposures by doing loop
recordings can be very helpful.
• When you can’t do an in-vivo or imaginal
exposure, use ACT and mindfulness-based
cognitive therapy.

Coping with the Uncertainty about Sin or
Offending God
• If you wonder if you have sinned (e.g., “What if
I…?”) or aren’t sure if you have, then you need to
move on and go forward as if you didn’t. Do the
next right thing.

Using ACT and Mindfulness-Base
Cognitive Therapy
• Your goal is to allow obsessional thoughts to float
through your mind without fighting them.
• When thoughts of a religious, sexual, or immoral
nature come into your mind, you must reject the
notion that you must fight, analyze, or control the
obsessions in order to show God (or yourself) that
you don’t want them.
• You need to do exposures to the uncertainty,
doubt, and guilt you feel.

Don’t Delay; Push Forward
• To whatever degree you can tolerate the anxiety,
distress, and uncertainty of the obsessions today,
you must keep pushing yourself to go longer and
further without neutralizing.

What You Do (and Do Not) Have to Do
• You do not have to do exposures that involve
doing things your faith specifically forbids or says
is sinful or immoral.
• You do not have to destroy, tear, or burn your
Bible.
• You do not need to do exposures to pornography.
• You do not have to sit in church shouting things in
your head you consider blasphemous at the
preacher. But, you do need to be able to sit in
church and allow the thoughts you fear are
blasphemous to pass through without
neutralizing.

What You Do (and Do Not) Have to Do (cont.)
• You do not have to give up the core beliefs of your
faith. But, you do need to learn how to follow the
tenants of your faith and not OCD’s skewed version of
faith.
• You do not have to leave or stop going to your church.
But, you do need to learn to live in a way that is
functional.
• You do not have to completely stop praying. But, you
do need to learn to pray in a way that doesn’t feed into
OCD. (e.g., “God, give me grace to push through my
feelings of uncertainty and to not do my rituals”).
• You do not have to share or agree to the same
religious beliefs as your therapist. But, you do need to
follow through on your agreed-upon exposure
exercises.

Additional Resources: Scrupulosity
 Free Downloadable Resources:
1. ACCFS: www.scrupulosity.org
2. Ian Osborn, MD: http://ocdandchristianity.com
3. International OCD Foundation: www.iocdf.org
•Books
1. Purdon, C., & Clark, D. (2005). Overcoming
Obsessive Thoughts. New Harbinger.
2. Osborn, I. (2008). Can Christianity Cure OCD?: A
Psychiatrist Explores the Role of Faith in
Treatment. Brazos
3. Hyman, B., & Pedrick, C. (2010). The OCD
Workbook. 3rd Ed. New Harbinger.

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