Article written by Caitlin Claggett Woods, PhD, C.Psych.
This section is dedicated to spiritual and religious leaders seeking to provide support to parishioners/members of their congregation impacted by OCD and scrupulosity. The following information is designed to equip leaders in identifying OCD and effectively provide support throughout an individual’s OCD journey.
Being the Front Door
Many individuals suffering from OCD seek counsel from their spiritual or religious leaders either exclusively or prior to seeking treatment from a mental health professional. More than doctors or psychiatrists, individuals are looking to their spiritual and religious leaders for guidance on mental and emotional issues (Wang et al., 2003). As the leader of your congregation, parishioners/members have trust and familiarity with you which makes bringing concerns to you first potentially easier (Hughes, 2021). Your influence has the power to help steer an individual with OCD towards appropriate treatment and on a path to experiencing their religious traditions in a more thriving and joyful way.
Scrupulosity Amongst the Religious Community
Our data is limited but we do know that OCD occurs in about 1% of the population, or 3.3 million people in the USA —meaning 3.3 million people are trapped within the confines of their mind.
We know that anywhere from 5% to 33% of people with OCD experience disturbing thoughts associated with religion. Data from religious communities in Saudi Arabia and Egypt reveal that as many as 50% and 60% of OCD patients report religious-based intrusive thoughts (Mahgoub, & Abdel-Hafeiz, 1991; Okasha, Saad, Khalil, El-Dawla, & Yehia, 1994). In a study examining those from the general population that self-identified as Catholic, 27% scored above the cutoff of a questionnaire indicating scrupulosity of clinical severity. 36% of self-identified protestants scored above the clinical cutoff on this same measure. (Mental contamination and scrupulosity: Evidence of unique associations among Catholics and Protestants Thomas A. Fergus)
Our data is limited. But scrupulosity hides amongst our parishioners at greater rates that we know.
Overcoming Shame & Accessing Appreciate Treatment
People who live with OCD/scrupulosity experience overwhelming shame and self-condemnation. Due to the nature of unwanted intrusive thoughts, these individuals may fear to come forward to ask for help. They may not want to confide but rather hide in terror that they will be condemned for the disturbing unwanted content spiralling through their minds.
On average, an individual may experience 11 years of OCD symptoms before even speaking up about what they’re experiencing with an additional 6 years before they receive appropriate care. This amount of time is expanded if their first attempts at disclosure result in being shamed or guilted for not being spiritual enough, for not trusting enough in God, or if encouraged to self-sacrifice or punish themselves for these unwanted thoughts. Because you are the front door, you can help to decrease the amount of years an individual suffers in silence and without adequate treatment by understanding the true nature of OCD and adopting strategies to provide effective support.
Spiritual Doubt vs OCD Doubt
Doubt is a part of healthy spiritual development. Doubt begins a spiritual quest and within it initiates and grows the hunger for a connection with God. In the spiritual journey, faith follows doubt’s lead. God is the encompassing all. He is a mystery beyond our comprehension. A perpetual uncertainty that we seek to understand. We seek guidance from leaders in our religious traditions to better understand God and deepen our relationship with Him.
Having a spiritual struggle does not inherently mean that someone needs treatment through a mental health provider. But doubt driven by scrupulosity operates differently than the spiritual doubt that the average parishioner/member will experience. With scrupulosity, the parishioner/member is stuck in a never-ending loop of pursuing reassurance, seeking to fill a need of true certainty that can never be attained. The desire for absolute certainty is frantic and urgent causing an overwhelming amount of anxiety. In an effort to reduce anxiety experienced, the individual may seek reassurance for their spiritual or religious leaders. Without the ability to recognize these doubts as part of OCD symptoms, a leader may unknowingly provide accommodations or reassurance that actually fuels the condition and slows down their progress.
Where One Ends and the Other Begins
It can be difficult to determine where spiritual/religious rituals end and where OCD/scrupulosity begins. In determining this, you might consider the ways that others within the faith community engage in practices. Often individuals with scrupulosity move beyond the norm when engaging in religious rituals.
Another more personal area to consider is the reason an individual is engaging in the practice, prayer, ritual, or custom. When faith engagement is driven by OCD, religious rituals tend to be initiated due to fear, obligation, guilt, or shame. When faith engagement is driven by values, the individual is most likely leaning into meaning, joy, peace, hope, or gratitude. There are legitimate times someone must pray out of fear (such as in the midst of a traumatic event), but it is important to consider the function. You might ask, “Is the person praying for support in the midst of a fearful situation, or are they praying because they fear not praying?” Praying to seek support from the Divine is different from praying out of fear/guilt/obligation directly about not engaging in the ritual/practice. It is important to consider appropriate and customary faith engagement within the tradition.
If you believe the religious engagement is a result of OCD or if you are unsure whether this is the case, it can offer a wonderful space to collaborate with a mental health provider rather than offering accommodation/reassurance. Then, as the individual moves through treatment, you might support their clinician by asking questions like, "Where do you find joy and meaning? What is your understanding of the nature of God?" as you help the congregant re-engage with faith in a value-driven way.
What is Symptom Accommodation?
Symptom accommodation are behaviors that supporters do to enable OCD symptoms in an aim to decrease the person’s anxiety in the moment. Accommodation behaviors function like compulsions, serving to prevent or quickly alleviate the distress associated with unwanted intrusive thoughts. The only difference is that compulsions are performed by the OCD sufferer themselves, whereas symptom accommodation is undertaken by those in the individual’s support network. Symptom accommodation can include a supporter directly participating in an OCD compulsion or ritual (see below for more examples). The more that the support network can learn about their own responses to OCD, and the impact they have on the person with OCD, the more they will become empowered to make a difference!
Here are some examples of symptom accommodations for scrupulosity:
As a spiritual or religious leader, it may be that your typical approach to a parishioner/member struggling with anxiety would include providing comfort, reassurance, and a sense of safety. After all, you want to support the individual and alleviate their suffering. However, these techniques are actually counterproductive to the recovery of an individual with OCD or another anxiety related disorder. Accommodations shield the individual from the things that trigger their fears. Research consistently demonstrates that symptom accommodation is associated with increased symptom severity. Doing what comes naturally to you and comforting your parishioner/member struggling with anxiety inadvertently strengthens their disorder as opposed to decreasing their distress.
Alleviating someone’s anxiety in the moment:
- Reduces the opportunity for them to learn that their feared outcomes are not actually likely to occur.. (E.g., that saying a specific phrase, such as, "stay away demons") keeps them from becoming possessed).
- Prevents an individual from experiencing a reduction in anxiety after facing their feared situation without avoidance or rituals – that is, it interferes with the process of fear reduction over time.
- Limits an individual’s opportunity to learn to cope with distress, instead sending a message that difficult emotions (such as fear and doubt) need to be avoided and cannot be tolerated. This in turn prevents an individual from building a sense of mastery and increasing their ability to cope with stressful situations.
- Leads to decreased motivation to change. If an individual is protected from the negative consequences of their symptoms through symptom accommodation, they are less likely to engage in treatment and work towards recovery.
What is Reassurance Seeking?
One of the ways in which someone with OCD might seek to reduce their anxiety is through reassurance seeking. This is one of the most common expressions of symptom accommodation, and involves asking you lots of questions, asking the same question repeatedly, or seeking physical comfort. Reassurance seeking serves to reduce anxiety through increasing certainty about a feared situation by gaining perspective from a trusted source. Although providing answers to (often simple!) questions may seem harmless, providing reassurance serves to maintain the anxiety disorder cycle.
To identify whether a question is driven by a desire for reassurance or because the individual is actually lacking relevant information, it is important to identify the function of the question. Exploring the function behind the question with your parishioner/member may serve as a more effective method of identifying (and ultimately reducing) reassurance seeking.
To help determine the function of a question, make sure to ask:
- Why? For example, “Why do you want me to answer that question?”
- What? For example, “What will a particular answer do for your anxiety?”
Reducing accommodation is a gradual process that should be done collaboratively with the individual in treatment, their family members, and the treatment team. It is important for everyone to work together in the fight against anxiety and place everyone on the same team against the anxiety symptoms.
Steps to reduce accommodations:
Remember, reduction of accommodation is best accomplished through clear communication with changes that will be made being clearly discussed.
Reducing reassurance seeking is crucial to treatment success, and should include as many support persons as possible. When the parishioner/member comes to you for reassurance, you can try responding with the following questions/phrases to give them the opportunity to answer for themselves:
- “What do you think?”
- “Have I already answered that?”
- “Maybe, maybe not.” or “It’s possible.”
- “I don’t have an answer for that."
You can also simply point out that they are seeking reassurance, and therefore, that it would not be helpful for you to provide an answer.Again, clear communication as to how reassurance will be addressed in the future is an important aspect of accommodation reduction.
Replacing Reassurance and Accommodation with Support
Not providing someone with reassurance or accommodation when they are in distress can feel mean. However, it is important to remember that one can be empathetic without being accommodating. The use of validation can be especially helpful when a parishioner/member is struggling.
Validation refers to the provision of acceptance, support, and confirmation. It is a message to another person that their emotions, thoughts, and behaviors have causes and are understandable in the current context. Validation takes the individual’s emotional and behavioral response seriously, without discounting or trivializing their experience. Validation is non-judgmental; it acknowledges someone else’s point of view, conveying understanding and empathy without trying to fix things or disregard their experience.
Validation includes 3 important aspects:
By responding with validation instead of reassurance, you can continue to support and care for your parishioners/members while simultaneously helping them to move forward in breaking free from anxiety.
Collaborating with a Mental Health Provider:
To first understand the importance of collaborating with a mental health provider, it is useful to understand the therapist’s goal in treatment. The mental health clinician’s focus is to respect (and work within) the individual’s religious tradition. Their goal is to help the client grow in healthy faith and theology and to help them practice their faith from a place of freedom and love, rather than fear. Clinically, the therapist aims to help their client disengage and recognize their thoughts as ideas rather than facts, to change hurtful beliefs (e.g., I am unworthy of God’s love, God seeks to punish me), and to regain functioning and engagement with values.
Clergy serves an important role in someone’s recovery from scrupulosity that serves a different purpose than a mental health clinician. As a faith leader, you hold an important and influential role in the spiritual direction and well-being of your congregation. Individuals will often listen to and follow the guidance of their spiritual or religious leaders before everyone else — including family, friends, doctors, and therapists. Helping the client to gain trust in their support network and their clinician is an important role that you serve.
Further, the mental health provider may not share their client’s religious practice. As such, they may need your guidance to identify and differentiate healthy religious practice from scrupulosity.
Finally, the individual will need ongoing support and encouragement throughout their recovery journey. Recovery from OCD is incredibly challenging and requires a community of support. As the old adage goes, it takes a village. Your support can help bolster someone in continuing forward on their path.
You can offer crucial support, which includes:
- Helping individuals re-engage with faith in a value-driven way once it is separated from the OCD
- Supporting an individual who might be grieving aspects they "thought" were a part of their faith but were truly based on OCD
- Affirming a different relationship with faith than the individual had before treatment
- Helping an individual grieve what they have lost to OCD, while offering a new sense of meaning as they reclaim their life
How do I talk to my congregation or members about OCD?
OCD and scrupulosity are often accompanied by significant experiences of shame. Individuals are incredibly hesitant to speak up owing to fears that they will be judged for the content of their thoughts. There are a few ways in which faith leaders can create a welcoming space for individuals to open up about their experience.
On a wider level, it can be helpful to include mental health-related topics in sermons and homilies. Additionally, guest speakers can be brought in to offer education sessions about various mental illnesses. When parishioners/members see these topics widely discussed, it helps to reduce the stigma associated with their experience. Individually, it can be incredibly powerful to approach someone who you observe is struggling. Take them aside and share what you’ve noticed. Offer them space to open up about how they’ve been feeling. By talking, listening, and expressing your care for them you can create an opportunity to encourage someone to seek the help they need.
For spiritual or religious leaders that have been reading this, we hope you know how important you are: important in the lives of your congregation, important in their recovery, and so incredibly valued. We thank you for your service and commitment to the well-being of your community.
* Not all examples or descriptions apply to all religious traditions.