OCD Scrupulosity: Spiritual Direction through the Stages of Recovery

Article first appeared in Presence: An International Journal of Spiritual Direction, Volume 19, No. 4.

Melissa Braaten

How Not to Fast

Fasting is hard to do well.  I ran into the guidelines for Catholic Lenten fasting during my first year as a graduate theology student at the University of Notre Dame in South Bend, Indiana, USA.  I took the rules very seriously: no more than one full meal and two “snacks” on a fasting day.  What qualified as a “snack” was ambiguous, so I spent a lot of time worrying: how small did my bowl of cereal have to be to qualify as a snack?  Did it have to be half the size I would normally eat?  Less than half?  Could a snack consist of bread and carrot sticks if they were both small amounts?  What if I was subconsciously making my full meal bigger than normal since I was hungry?  The carrot stick went back and forth from the refrigerator to the plate, indecisively.

I soon learned about other ways to mess up Lent as well.  On Fridays during Lent Catholics are supposed to avoid eating meat, which started to occupy my mind around Tuesday.  At that point, I would begin to plan my meals so that any leftovers containing meat would be eaten by Thursday, so as to avoid possible mistakes.  I knew that forgetting and accidentally eating those chicken leftovers on Friday would not get me in God’s bad graces.  But still, wasn’t that just being irresponsible, if mistakes could be avoided?

You may be thinking that my approach to Lent was rather abnormal.  My preoccupation with rules and religious perfectionism are due to scrupulosity, a condition which is often (as in my case) a manifestation of Obsessive Compulsive Disorder (OCD).  OCD is an anxiety disorder that affects around 1 in 100 adults (“How many…”).  “Obsessive” refers to the struggle with reoccurring thoughts that trigger strong anxiety reactions in the person with OCD.  “Compulsive” refers to the compulsively performed “rituals” through which people with OCD cope with the anxiety produced by their obsessions.  Although these rituals provide short term relief, over time they intensify the anxiety reaction and can severely interfere with a person’s quality of life.  Although commonly portrayed in the American media as a fear of contamination or an obsessive need for order[1], OCD can also take the form of moral or religious perfectionism, known as scrupulosity.   Unlike genuine religious discipline, scrupulosity is a state of tormenting anxiety, arising from doubt about possible sins or unknown imperfections.  The anxiety felt by scrupulous persons when they are “unsure” about their moral or religious standing is so great that they go to great lengths to arrange their lives so that doubt is minimized—for me, if that meant throwing out chicken leftovers on Thursday to avoid “accidents,” so be it.

How does a spiritual director know to suspect scrupulosity, rather than genuine religious fervor or strict but healthy spiritual discipline?  My recommendation is to look into the spiritual directee’s eyes and face.  Someone seeking spiritual direction who is in the throes of scrupulous anxiety will appear scared, desperate, unusually rigid and difficult to persuade, and possibly ashamed.  Individuals in this situation are scared because their minds are confronting them with a fear of damnation that is so intense they think it must carry weight.  They are afraid that if they don’t receive reassurance from someone with religious “authority” (often a minister or spiritual director), they will go crazy or have a nervous breakdown as a result of the anxiety.  Driven by this fear, these spiritual directees are desperate to hear the spiritual director say the right words that will relieve their suffering.  They will often appear rigid, because OCD will not allow them to trust the things the spiritual director (or their own minds) tells them are reasonable.  In the moment, they are unable to think and judge clearly, because the emotional centers of the mind have usurped control, and most types of executive functioning are impaired.  Nevertheless, OCD does not take away the sufferer’s reason or good judgment – it simply pushes them out of the driver’s seat.  While all of this emotional frenzy is going on, individuals with OCD usually still know (or at least suspect) that these fears and behaviors are abnormal, disproportionate, and contrary to the genuine faith they once experienced.  Because of this insight, people with OCD are often deeply ashamed of their behavior.

Another characteristic that spiritual directors may notice is that scrupulous individuals can sometimes be “cured” of their anxiety almost instantaneously when the spiritual director offers the right word of reassurance or performs a requested ritual.   When this happens, it is because the reassurance or ritual has accomplished the necessary “compulsion” to relieve the sufferer’s “obsession.”  The correct compulsion works on the sufferer’s mind like a drug, relieving the overwhelming anxiety and inducing a euphoric sense of relief.   The spiritual directee is grateful, the spiritual director feels successful, and all appears well—until the next obsession hits, with an even stronger urge to apply to the spiritual director for relief.  This dynamic provides temporary “quick fixes” to the sufferer’s anxiety but does not move them any further along the road to recovery.  In addition, it can quickly lead to dependency and the souring or rupture of the relationship.  I encourage spiritual directors who find themselves in this situation to actively refer the spiritual directee to mental health therapy, and to consult with mental health professionals on setting appropriate boundaries with the individual.  Directing should not continue until this support is in place.

My experience with OCD did not begin at Notre Dame as a graduate student, or even as a Catholic.  Diagnosed at the age of 9, my OCD began as a germ obsession with hand washing rituals.  As a teenager, when I became involved in an evangelical Christian church and youth group, my OCD morphed into intense religious scrupulosity.  As an evangelical, I worried about the authenticity of my conversion, my obligation to evangelize, and maintaining my sexual purity.  When I later became a practicing Catholic, the obsessions changed, but the OCD didn’t.  The anxiety finally became so crippling that I was almost ready to leave graduate school (where I was studying theology – a subject ripe with triggers!) and move home with my parents, when I finally got help.  Since that time, I have been on an arduous but encouraging journey through many stages of recovery, accompanied by competent spiritual directors and mental health professionals.  Here is a road map of the path I took out of this quagmire to greater mental, emotional, and spiritual health.

Stage One: Your Spiritual Task is to Get Better

The most important thing that a spiritual director can do for spiritual directees crippled by OCD scrupulosity is to help them identify what is going on and to encourage them to seek professional mental health services.  OCD is a physiologically-based mental illness for which there is effective treatment.  Spiritual directors should view an individual with OCD scrupulosity as a person of genuine faith whose faith has become partially or completely paralyzed by this disease.  In order for their faith to heal, grow, and eventually flourish, the symptoms of OCD need to first be addressed and alleviated as much as possible.

A spiritual director and mental health professional working in collaboration provide the type of wholistic, wrap-around services needed to really support an individual suffering from OCD scrupulosity.  The chemically-based brain disease and the individual’s deepest values and beliefs are so messily intertwined that to treat each in isolation is artificially reductive.   In my case, my spirituality provided both the content of my OCD and the strength to overcome it.  Ineffective therapists sometimes only saw the former.   On the other hand, spiritual directors who were not knowledgeable about OCD sometimes inadvertently enabled the compulsive behaviors.  Sharing confidential information will require written permission from the client/spiritual directee, but the partnership is worth the effort.

Scrupulosity has been recognized pastorally for centuries, long before psychology understood OCD, and historically, the method of direction for scrupulous persons was that the spiritual director (usually a priest, rabbi, or other religious authority) decided the norm of religious behavior for the individual.  Scrupulous individuals were required to be absolutely obedient to a spiritual director, and were forbidden to seek advice elsewhere.  This helped to contain the scrupulous behavior so that the individual could function better.  For sufferers in early stages of recovery, a modified form of this system may be the best way to help limit some of the most egregious or damaging compulsions.  The spiritual directee,  spiritual director, and mental health therapist can collaborate to come up with a set of “norms” that the spiritual directee agrees are representative of their religious community.  The spiritual directee agrees to work to contain a certain behavior at the “norm,” rather than at a compulsive level.  The therapist can provide targets that meet or approach the norm, and holds the client accountable to them.  For example, if the client is compulsively going to confession every day to confess trivial or imagined sins, they are given permission to go only once a week (or perhaps this target is approached gradually in stages).  If the client is compulsively evangelizing to every person they meet because they fear hell if they don’t, the therapist asks them to only evangelize three times a week.  The behaviors that are limited are those that are interfering with the client’s life, and by containing them, the process is taking the responsibility for making a judgment off the client and giving them permission to be less extreme in their behavior.  This type of support can provide a measure of relief and can help a client to cope with the demands of life.  Of course, the client is responsible for limiting his or her own behavior: individuals with OCD should never be physically prevented from engaging in compulsions.   This process is essentially the beginning of Exposure and Response Prevention, a type of Cognitive Behavioral Therapy used to treat OCD which will be discussed in more detail in the next section.

During this process, a spiritual director can help the spiritual directee by encouraging them to follow the therapist’s prescriptions and by helping the spiritual directee make sense of the experience and how it is affecting their spiritual health.  While the spiritual directee may be feeling a tremendous amount of anxiety and guilt, they may also be experiencing hope.

There a couple of important things to keep in mind when treating someone in this initial stage of recovery.  The first is that people suffering from scrupulosity hate their scrupulosity and hate performing their compulsions[2].  All OCD compulsions are done to ward off “possible” disasters, not for any enjoyment or satisfaction.  When the client/spiritual directee is required to limit their behaviors, they are getting permission to do what the healthy part of them already wants to do.  Another thing to remember is that OCD is a powerful disease and that clients/spiritual directees may often fail in containing their behavior, and usually feel very ashamed when this happens.  As a spiritual director, you can be the most supportive by encouraging and pushing them to do things that are hard, but not judging or being harsh or disappointed when they fail.

A final complication in the early stages of recovery is that sufferers of OCD sometimes have a hard time believing that they have OCD, and can be very resistant to seeking treatment from mental health professionals.  Treating what feels like a “spiritual” problem with medication or therapy can feel like a spiritual “cop-out,” and people with scrupulosity are not people who like to take the easy road.  Often, being told that there might be a physical cause of their suffering will resonate and provide a lot of relief, but, like everything else, they will doubt it!  If a spiritual directee refuses to seek treatment, you can only patiently stay firm in letting them know that you see their suffering, your ability to help is limited, and that you believe that their primary spiritual task at the moment is to get better. If any signs of dependency/enabling exist in the relationship, or if the spiritual director does not feel competent to set appropriate boundaries with the spiritual directee, direction should be stopped until such a time that collaboration with a mental health therapist is possible.

Stage Two: The Trials and Blessings of Exposure and Response Prevention

The twentieth century brought new hope for OCD sufferers with the development of a simple, yet effective form of treatment called Exposure and Response Prevention (ERP) therapy.  ERP is really nothing more than a process of desensitization to the anxiety caused by doubt.  The OCD sufferer is exposed to something that triggers doubt or anxiety (for someone with a germ obsession, they may have to touch a doorknob or something else of uncertain cleanliness).  After this exposure, the patient’s anxiety will build rapidly.  Under normal circumstances, the person would perform a compulsion to relieve the anxiety before it became intolerable.  In ERP, the client (at first accompanied by the mental health professional) will resist performing the compulsion.  Anxiety will continue to mount, but at a certain point, it will eventually drop off.  The goal is to get the client to sit out the anxiety until it goes away on its own.  In addition to teaching the client that the compulsion is not necessary to relieve the anxiety, this process has a physiological effect on the brain of desensitizing it to the trigger.  Eventually, if ERP is done properly and consistently, the same triggers will produce less and less anxiety, and the person will find it increasingly easy to resist performing the compulsion.

Of course, this is all easier said than done.  Mental health professionals will report that while ERP is extremely effective, it also has a high rate of non-compliance and drop out.  Simply put, the therapy works, but it is difficult and painful, and many people give up.  This is not surprising, since it requires someone to face their biggest fears, allow the anxiety to take them over, and to do nothing but wait.  Often therapists will recommend the OCD sufferer get established with an effective medication regimen before beginning the hard work of ERP.  This was the path that I took.  Medication was enough to help me manage my symptoms for many years and gave me enough relief that I could contemplate therapy, but the real recovery began when I started ERP.

How does ERP work with religious scrupulosity?  It took me a long time to figure out how to “expose” myself to an effective trigger, since my fears centered around sin, judgment, and hell.  Having someone touch a toilet and not wash their hands is a little different from asking someone to commit a sexual sin and not repent.  Because of the difficulties inherent in designing effective exposures for religious scrupulosity, communication between therapist, client, and spiritual director is essential.  It is important that the therapist does not ruin the client’s trust by asking them to do something that actually does violate an accepted “norm” of the client’s religious community.  For myself, my most effective exposures were generally done in situ rather than in the therapist’s office, and usually involved refraining from some sort of checking or safety behavior that I otherwise would have performed.  For example, for I while I struggled a great deal with an obsession about crumbs of the Eucharistic host left on my hands after receiving communion.  I knew this was a scrupulous worry, especially since the wafer hosts used at my church don’t actually leave crumbs.  I found an effective exposure to be not looking at my hands after receiving communion.  Sometimes I would even wipe them on my clothes, so that I would have to deal with the doubt of wondering whether this time there might have been a crumb.  Other exposures I designed for myself included not praying for forgiveness if a doubt about some religious tenet went through my head, limiting emails to my spiritual director (to avoid asking for reassurance), and limiting the number of times I would make the sign of the cross when passing by a church.  Each of these exposures meant a cold sweat and white-knuckled anxiety the first few times, but it got better.

Given that the work of ERP is intensely painful, yet gradually empowering, it is a fertile field for spiritual growth.  I found that performing ERP forced me to confront certain inescapable truths about the human condition: finitude, the inevitability of doubt and ambiguity, and the fact that real faith requires trust and risk.  During this stage of recovery, a spiritual director can provide valuable encouragement to the client/spiritual directee to persevere with treatment, and to see ERP as a spiritually valuable task.  Instead of offering to God my obsessive rituals, I began offering to God my willingness to bear the ambiguity and to undergo the exposure.  As the ERP began to lower my anxiety reactions to triggers, I felt more in control of my life and my faith.  Having gone through it myself, I believe that a person with scrupulosity undergoing ERP with well-trained support from a mental health professional and a spiritual director cannot help but mature spiritually.

As ERP progresses, the client should be encouraged to develop their own exposures.  As a guideline for what is acceptable, they should be encouraged to look at the “norm” of the average faithfully practicing person of their faith community.  For example, the average faithful Catholic does not examine their hands for crumbs of the Eucharistic host after receiving communion.  Originally the “norms” are discussed between spiritual director, therapist and client/spiritual directee, and the latter feels more confident because they feel the norms have been “approved” by the spiritual director.  As the individual’s recovery progresses, they should be encouraged to make their own judgment of what the “norm” is, based on what they see around them, and to act on that judgment prior to any consultation.  The overall movement is for the spiritual directee to act more and more on their own interior judgment, with less external reassurance and affirmation from a spiritual director or authority.  That is, after all, how most healthy religious persons operate on a day to day basis.

One additional caveat: this stage of recovery can be greatly complicated if the individual is involved in a faith community whose norms tend to be extreme.  One of the troubles with religious scrupulosity is that there will always be individuals and groups whose norms are extreme or fringe, and can make scrupulous behavior look necessary or justified.  This makes it extremely difficult for an individual to successfully move through this stage, since the sufferer has to believe that their behavior is not normal in order to be motivated to change it.  I encountered some of this when I was struggling though ERP while in graduate school at Notre Dame: as a graduate student in theology at a relatively conservative Catholic university, I was surrounded by a number of individuals whose approach to Catholicism was more scrupulous than average.  This made my recovery at this stage much more difficult.  The effect of this was somewhat mitigated when I became involved in other Catholic communities outside of the university where I got to experience other types of norms.  The best thing a spiritual director can do is to encourage a spiritual directee in this situation to broaden the range of people they interact with within their faith tradition as much as possible.

Stage Three: Tapping into Motivation with Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) is a more recent form of therapy that is being used for OCD.  I began the clinical portion of my recovery with medication and ERP, although after I learned ACT I used both forms of therapy together, and found that they complimented each other very well.  In many ways, ACT allowed me to fine-tune my practice of ERP so that my exposures felt more meaningful and authentic.

Acceptance and Commitment Therapy can be used to tap into a patient’s motivation for therapy.  In ACT, the person with OCD spends time exploring and creating a list of values: for example, “family” or “being hospitable to others.”  Then the patient must be very realistic about how their OCD compulsions are interfering with those values.  For example, one of my values was “to have a healthy view of God”, and clearly many of my compulsions (like examining my hands for crumbs of the communion wafer) did not lead me to that end.  I remember another reflection where we wrote two eulogies…for ourselves!  One eulogy was the one that would reflect my life if OCD ran unchecked, while the other was about the life I would have if I lived fully in accord with my values.  These exercises were extremely revealing, because this is where it finally became clear to me that my scrupulosity was leading me where I did not want to go.

During the experience of anxiety (with or without deliberate exposure to a trigger), ACT emphasizes “accepting” the experience of the anxiety, rather than trying to resist or “fix” the feeling, which leads one to perform compulsions.  In addition to cultivating acceptance, mindfulness, and a certain detachment from the experience of anxiety, the clients also motivate themselves to persevere by committing to living in accordance with their values (which are supported by not performing the compulsion).  There are exercises for ACT that are very much like guided meditations, and bear a lot of resemblance to monastic practices of thought watching and mindfulness that I have encountered.

I found that this type of therapy was especially helpful for “intrusive thought” obsessions, which are common in scrupulosity.  This is where a person has an “intrusive” (unwanted) thought about something they consider bad or sinful.  The resulting effort to purge the mind of the “harmful” thought inevitably results in wedging the thought more and more firmly into one’s consciousness, and generates a great deal of anxiety. The ACT method of acceptance, detachment, and thought watching are essentially identical to monastic methods of dealing with intrusive thoughts during prayer, or intrusive thoughts that the monks found “sinful.”

Since ACT is relatively new, it may be difficult for an individual to find a mental health counselor who has been trained and really understands how to perform this therapy.  Many of the “exercises” in ACT have been adopted into mental health counseling from the field of spiritual direction (guided meditation, mindfulness exercises, thought watching exercises, reflection), and a spiritual director might be interested in incorporating ACT-like practices into their work with a spiritual directee suffering from scrupulosity.  However, before attempting to do these exercises with a scrupulous spiritual directee, the spiritual director should be in collaboration with the therapist about which practices might be appropriate and how the spiritual directee has, might, or is responding to these practices in therapy.  In addition, the spiritual director should only attempt those practices which are ordinarily used in spiritual direction.

Why all the caution, if these practices are already common currency in spiritual direction?   The practices may be familiar, but an individual with OCD may experience them very differently.  I certainly did, leaving many poor youth pastors and retreat directors flummoxed.  To begin with, a person with OCD scrupulosity going through a guided meditation will probably react to certain “intrusive thoughts” with a degree of anxiety that other spiritual directees will not experience.  The spiritual director must understand the phenomenon of intrusive-thought obsessions in order to be prepared to accompany a spiritual directee through any sort of meditation.

Another aspect of an OCD sufferer’s experience that a spiritual director may not be aware of is the prevalence of mental compulsions in scrupulosity.  Many individuals with OCD scrupulosity perform mental rituals to dilute the anxiety caused by an obsession or intrusive thought.  Prayers, invocations, repetitions of words, imaginative “cleansings”—all of these can serve as compulsions if they are used to relieve a certain type of anxiety.  Obviously, mental compulsions are very difficult to identify and track, even for the sufferer.  It is possible to spend a meditation session performing mental compulsions and reinforcing the scrupulosity!

In collaboration with a mental health professional, a spiritual director can provide valuable support to the spiritual directee by helping them to interpret the spiritual connections or benefits of their experience of ACT.  Here are a couple of examples to illustrate what I mean:

  • Individuals with scrupulosity who suffer from intrusive though obsessions struggle to distinguish between “having” a thought and “willing” or “affirming” a thought.  There are many spiritual practices and traditions of contemplation that affirm and teach this distinction.
  • The “acceptance” in ACT involves cultivating openness and compassion towards one’s experience.  This trait is recognized in some spiritual traditions as “meekness of heart.”
  • The focus on living according to one’s values helps to move the “norms” by which the individual is making judgments inward.  Before, they had to rely on the norms set by the “average” faithful to govern their behavior, but now they are in a place to reconnect with their own, personal values, and to discern what those would look like without scrupulosity.  This process has spiritual benefits beyond simply motivating therapy, because the spiritual directee is forming and becoming more sensitive to their own conscience.

Stage Four: Making Meaning Out of Recovery

Some individuals with scrupulosity leave their faith communities while in the throes of their disease, putting all the blame for their suffering on the religious community itself.  I have met many of these painfully wounded people who have suffered a lot and continue to suffer from their bitterness.  Some may leave during therapy if they cannot find healthy norms to aid in their own recovery, or if they discover that their own values are not, in fact, compatible with their religious community.  My disillusionment came later.  With my life back in order, and my OCD mostly under control, I was able to reflect back on all the experiences that should not have happened, all the well-intentioned ministers and pastoral workers and religious institutions who inflamed my scrupulous tendencies by their own immature faith. I felt betrayed, angry, and sad.  While I chose not to leave my faith community, I knew I needed some healing of my soul. I needed to accept what I had been through and to forgive others for their weaknesses.  I needed to make some meaning out of my recovery.

In 2011, I attended a seminar at the International OCD Foundation’s annual conference titled “Life after OCD.”  I was saddened to hear stories of people who had recovered from OCD, only to find themselves falling into deep depression.  Having finally experienced some relief from their symptoms after successfully undergoing ERP, they were finally in a place to look back and reflect on their experience.  Many of these individuals found themselves to be still deeply wounded and struggling with a sense of loss.  Some had lost decades of productive life; some had lost their marriages; some had become estranged from their families; some had lost their careers, all to the ravages of OCD.  I, too, felt a sense of grief and loss looking back at the years that OCD had made a train wreck of my faith.  How could that faith that initially brought me such comfort and inspiration also have been the site of so much trauma and suffering?

One of the most powerful supports that got me through the earlier stage of ERP was when I joined a professionally-led OCD support group.  I was extremely reluctant to join until my therapist wisely hinted that some of the other participants might benefit from the experience and wisdom I had to offer.  That really shifted my perspective.  It was very powerful to see myself as a person who had something valuable to offer from my experiences, rather than as a weak person always needing the help and support of others.

This same perspective is what helped me to move beyond my sadness and to make meaning from my recovery.  I decided to become more involved in the International OCD Foundation and I have met some wonderful people there.  I have also been inspired to write.  One of my goals is to write and publish books about spirituality and scrupulosity.  Another OCD advocate, Jeff Bell, has written a book describing the role that “meaning making” and seeking a greater good played in his own recovery (When in Doubt, Make Belief: An OCD Inspired Approach to Living with Uncertainty).

The goal of spiritual direction for a spiritual directee in this stage of recovery is to accompany them on a journey of reflection, meaning making, healing, and reconciliation.  They may need to reconcile feelings of betrayal from their faith community, God, or perhaps individuals in their lives (family or friends) who were not able to support them through their trials the way they would have liked.  There is a lot of forgiving and acceptance to be done at this stage.  In addition, encouraging the spiritual directee to connect with other OCD sufferers, or to find a way to give back to the OCD community, can be an incredibly powerful tool for making meaning.

It is quite possible that an individual at this stage will no longer need the support of mental health professionals.  If the spiritual director does not have training or experience working with OCD, they should be very open about their lack of knowledge and look to the spiritual directee as an expert on their own disease and clinical treatment.  An OCD sufferer who has advanced to this stage of recovery will be very knowledgeable about the dynamics of their condition.  Deferring to the spiritual directee’s expertise is important because the dynamics of OCD and OCD treatment are very different from other types of mental/behavioral issues that spiritual directors may have more experience with, such as addiction, abuse, depression, or other anxiety disorders.  What works for an individual suffering from addiction, for example, helping them to avoid trigger situations, will exacerbate OCD symptoms.  Treating a mature spiritual directee as an expert on their condition is also an empowering stance that helps the individual make meaning from their experience: they are able to educate their spiritual director!

Stage Five: Intimacy with God and Practical Mysticism

In the later stages of recovery, the spiritual directee’s genuine faith and diseased scrupulosity have become disentangled enough that they can work towards more typical goals of spiritual direction.  Now the spiritual director can accompany the individual further on the journey than the mental health professional can, because spiritual direction has a higher goal: spiritual growth, deepening interiority, and growth in relationship with a higher power.

Scrupulosity is a vicious canker on a relationship with God.  The voice of scrupulosity is always promoting safety, certainty at any price – and usually the price it exacts is trust, hope, joy, and love.  Like other forms of spiritual canker, it is avaricious, and its appetite will grow in proportion to which its demands are fed.  Like other faces of evil, it disguises itself as an angel of light, promising great spiritual benefit by insulating its victims from the “threat” of sin and damnation.  People suffering from scrupulosity prior to recovery are controlled by the voice of a cruel tyrant, and without some wider perspective and some recovery, they often mistake this voice for the voice of God!

From the perspective of spiritual accompaniment, all of the work done towards recovery has served not only to improve the spiritual directee’s quality of life, but also to remove a great impediment to a deeper relationship with God.  Entering this stage in my own recovery (a stage I am just now exploring and looking forward to deepening), I do not find that I am starting back at square one, having removed the obstacle of scrupulosity from my faith.  Instead, I find that in the process of recovery I have already traversed a great spiritual distance, and perhaps the process has prepared me for a deeper relationship with God than I would have arrived at by an easier route.  Looking back, if I could change things so that I never suffered from scrupulosity, so that I never had OCD, would I?  Probably.  No matter how much I have grown through recovery, any taste of the anxiety caused by my disease prevents me from ever seeing it in a romantic light.  But I accepted a long time ago that I don’t get to make those choices.

As I explore a deepening relationship with God, I am finding that the locus of the “norms” that I use to guide my behavior has changed once again.  I am far more aware of my own values and the value of my experience than I ever was before, so I still feel guided by my interior values, but now there is more of an openness to “suggestions” that come from prayer and conversation with God.  This is possible now that I am more confident in discerning the voice of God from the unhealthy voice of scrupulosity.  In earlier stages of recovery, it was important to have an objective standard by which to judge the thing that I felt “led” to do, because these leadings were often motivated by anxiety.  Now I am able to be open to some of the surprising and delightful ways in which God chooses to lead me.

Final Considerations

I wanted to offer a few final considerations for those engaged in spiritual direction with a spiritual directee who is struggling with OCD scrupulosity.

The first is to be honest with yourself and your spiritual directee about your experience and your capacity to accompany them on this type of journey.  A spiritual director without any experience or training in working with individuals with OCD should refer the spiritual directee to a more experienced colleague, or at least to seek relevant professional support.  Individuals with OCD are usually extremely perceptive.  If you want to win their trust, you need to be honest about what you don’t know.  In the case of scrupulosity, this also applies to knowledge about the individual’s specific faith tradition, if they have one.  Many individuals with scrupulosity would do well to seek spiritual direction from someone in their own faith tradition, for two reasons: 1) It is important that their spiritual director understand the community norms and pressures their spiritual directee is struggling with and 2) The spiritual director will have to have a certain amount of religious “authority” in the eyes of their spiritual directee for the spiritual directee to trust them in the early stages of recovery.  I have always preferentially sought direction from individuals in my own tradition for these reasons.  If a spiritual director does not have the same faith background as their spiritual directee, they should be very honest about this and should collaborate with someone who is knowledgeable about the spiritual directee’s tradition.  Without knowing the details of a community’s norms and expectations, it can be hard to tease out genuine faith from scrupulosity, and even more difficult to help the spiritual directee and therapist come up with suitable exposure exercises for ERP.

Another important consideration (already mentioned) is the need for establishing healthy boundaries.  A person who is struggling with scrupulosity, especially in the early stages of recovery, can be compelled by anxiety to break social and professional boundaries in their need for reassurance.  Establishing and communicating healthy boundaries is extremely important to protect the relationship between spiritual directee and spiritual director, but it also has a therapeutic effect of limiting compulsions.  This can be hard to do for a client in extreme distress, which is another reason for a spiritual director to be knowledgeable about OCD.  Individuals with OCD have a great deal more control over their behavior than they think they do, and (unless the individual poses a danger to his or herself or others, or is in such as severe state as to require hospitalization) having to wait to talk with a spiritual director, or being denied “reassurance” will not cause them any harm.  In fact, waiting is generally beneficial, since the anxiety will go down on its own without the compulsion (reassurance), and the spiritual directee will be in a better place to reflect on what happened.

Finally, it is important to keep in mind that OCD is a chronic mental illness for which there is effective treatment, but no cure.  Symptoms tend to wax and wane throughout a person’s life, and can be exacerbated by stress.  In the process of my recovery, my symptoms have become very minimal, although I continue to take medication and to meet with a spiritual director (who is also a mental health counselor) regularly.  I have the impression, however, that a recovery as dramatic and relatively linear as my own is not very common.  Some individuals with OCD scrupulosity may spend years or decades in the earlier stages of recovery.  Progress in the reduction of symptoms often involves setbacks and regression, as well as periods of great emotional and spiritual clarity.  Nevertheless, it is my hope that what I have learned from my experience will be useful for spiritual directors to support their spiritual directees in whatever place they are currently in.


Bell, Jeff.  When in Doubt, Make Belief:An OCD-Inspired Approach to Living with Uncertainty.

Novato, CA: New World Library, 2009.  Print.

Ciarrocchi, Joseph. The Doubting Disease: Help for Scrupulosity and Religious Obsessions.

Mahwah, NJ: Paulist Press, 1995.  Print.

“How Many People Have OCD?” International OCD Foundation Website.  International OCD

Foundation, 2012. Web. <www.ocfoundation.org>

Van Noppen, Barbara, et al. “Life After OCD.” International OCD Foundation Annual

Conference.  Sheraton San Diego Hotel & Marina, San Diego, CA.  31 Jul. 2011. Panel Discussion.

Recommended Reading

What You Need to Know About Obsessive Compulsive Disorder. International OCD

Foundation. 2012. Brochure.

(Available online at www.ocfoundation.org/uploadedFiles/WhatYouNeed_09.pdf.  This is a good introduction to OCD in general.)

Ciarrocchi, Joseph. The Doubting Disease: Help for Scrupulosity and Religious Obsessions.

Mahwah, NJ: Paulist Press, 1995.  Print.

(This book is both a self-help manual for someone looking to use ERP to manage scrupulosity and an interesting history of the pastoral treatment of scrupulosity prior to modern psychology.)

Suggested callouts:

  • Unlike genuine religious discipline, scrupulosity is a state of tormenting anxiety, arising from doubt about possible sins or unknown imperfections.  (pg 2)
  • [S]ufferers of OCD…can be very resistant to seeking treatment from mental health professionals.  Treating what feels like a “spiritual” problem with medication or therapy can feel like a spiritual “cop-out.” (pg 7)
  • I found that performing [Exposure and Response Prevention therapy] forced me to confront certain inescapable truths about the human condition: finitude, the inevitability of doubt and ambiguity, and the fact that real faith requires trust and risk.  (pg 10)
  • Many individuals with OCD scrupulosity perform mental rituals to dilute the anxiety caused by an obsession or intrusive thought.  Prayers, invocations, repetitions of words, imaginative “cleansings”—all of these can serve as compulsions if they are used to relieve a certain type of anxiety.  (pg 14)
  • I was saddened to hear stories of people who had recovered from OCD, only to find themselves falling into deep depression… Some had lost decades of productive life; some had lost their marriages; some had become estranged from their families; some had lost their careers, all to the ravages of OCD. (pg 16)
  • People suffering from scrupulosity prior to recovery are controlled by the voice of a cruel tyrant, and without some wider perspective and some recovery, they often mistake this voice for the voice of God! (pg 18)

[1] Well known characters in U.S. media would include Adrian Monk [Monk], or Melvin Udall [As Good As it Gets]. Back

[2] This is an important distinction between OCD and other disorders [i.e., impulse control disorders, Obsessive Compulsive Personality Disorder] that may involve similar rituals or perfectionism. Back

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