by Mubeena Mirza, LCSW (adapted from article by Patrick McGrath, PhD & Zachary Appenzeller)
Scrupulosity is not a faith problem; it is an OCD problem. OCD tends to latch onto the things most important to an individual - including faith. For those practicing Islam, OCD might impact a person’s belief and also how they perform mandatory and supererogatory rituals.
The Main Issue: Doubt
OCD is called “the doubting disorder”. The main issue in all OCD themes is doubt. You may be confident in your belief in Allah, the Prophet Muhammad (p.b.u.h.), The Last Day, etc. This perceived confidence might actually be the highest that it has ever been. However, OCD does not care. Any doubt is perceived as catastrophic and it must be eliminated. OCD can interrupt any belief system and lead people to excessively pray, research, debate, confess, or seek reassurance.
All of this reveals one thing – doubt is doubt, and you can doubt anything. You can doubt your belief in something, and you can doubt your lack of belief in something as well. As a parallel, someone suffering with Hit and Run OCD could not believe that they ran someone over on their way to work, their OCD will get them to doubt that and wonder if they did, even to the point of getting into their car and driving around looking for the body at the expense of potentially losing their job.
So, if someone can doubt their belief that they did not hit someone, they can also doubt their belief in Islam. To alleviate that doubt, you may seek reassurance by repeating salah (prayer). You may repeat verses from the Quran until you feel certain that you pronounced every letter correctly. Sometimes, you may ask scholars, family members, or trusted friends for reassurance with questions about fiqh (Islamic rulings). You could repeat wudu (ablution) until its feels “just right.” You may even avoid eating out of the home for fear of accidentally ingesting something that is not halal. However, as with anything, there can be no certainty or perfection in our religious practices.
No Matter What You Believe, OCD Can Wiggle In
No matter what it is that you do or believe, your OCD can wiggle its way in and make everything feel overwhelming. It can amplify doubt to the nth degree. It can cause the best day ever to become the worst day ever, and it can lead to discomfort and pain and anguish - and then punish you for not being 100% confident in whatever it is you do or believe in.
A fairly common and harmful compulsion that cuts across themes of scrupulosity is compulsive self-shaming/self-criticism. This presents as repeated self-defeating statements that serve an avoidant function of sitting with uncertainty. While exchanging anxiety and uncertainty for shame and sadness doesn’t sound like much of a tradeoff, at least shame is “certain”.
This is a maladaptive way by which individuals can put their doubts to rest, albeit temporarily, only for obsessions to inevitably come back. The OCD cycle continues, now with lower mood and decreased self-worth as an added byproduct. It should be noted that self-shaming can also increase with time as individuals engage in ERP, where they begin to disengage from other compulsions and experience a sense of immorality or doubts that they are disappointing God (these feelings are to be expected because you are facing the fear/doubt/uncertainty of these things).
Some individuals believe that if they can at least feel bad about their possible shortcomings, then maybe, just maybe, they might receive Allah’s mercy. At the very least, resigning themselves to the eternal hellfire, defining themselves as “bad” and their beliefs as “wrong”, put an end to their perpetual internal debate over whether or not their lack of a belief in Allah is correct. When patients engage in consistent self-shaming, it can also act as a constant reminder to be on guard (hypervigilance) to prevent potentially doing something that may offend Allah. Some may even have the belief that if they can consistently remind themselves how bad they are, then this may prevent them from doing something bad in the future.
Exposure and response prevention (ERP) is the gold standard treatment for Obsessive Compulsive Disorder.
So, what is ERP?
Exposure and response prevention is a process of exposing a person to their fears, and encouraging them to use skills to reduce and eliminate compulsive behaviors. Individuals will develop a hierarchy of the triggers that provoke their anxiety and doubt. They will begin low on their hierarchy and they will learn to sit with their discomfort without engaging in efforts to reduce their doubt. This process inherently eliminates avoidance behaviors and encourages a person to live with discomfort and move on with valued actions.
What does ERP look like for Muslims suffering with OCD?
Treatment begins with identifying the content of intrusive thoughts, the specific feelings of distress, and the compulsive behavior that a person engages in to reduce distress. The client will then rank their triggers from the most distressing to the least. Then they will begin exposures.
With respect to exposures, a person will identify specific triggers that are within the boundaries of Islamic law, whilst still triggering doubt that a person can be doing something imperfectly. A clinician will work to develop an understanding of Islamic law and can consult with an Islamic scholar. However, the point of ERP is to introduce doubt. An example of an exposure is the following: a person may be asked to perform the necessary portions of wudu without an attempt to find certainty that all areas were covered with water.
With respect to response prevention, it is very important that the client makes an effort to eliminate compulsions because every compulsive behavior works to reinforce the OCD cycle. Response prevention may look like limiting the time it takes to make wudu. It can also include eliminating asking for reassurance from religious scholars. Additionally, a person can work with a therapist on reducing mental compulsions such as checking one’s memory to be sure that prayer was completed perfectly.
In summary, we believe that Muslims can learn that their lack of certainty about their belief in Allah and their performance of previous practices. These issues can go unsolved while still being a faithful and devout person. You can be a practicing Muslim while accepting uncertainty through the treatment of OCD.