by Zachary Appenzeller, PsyD & Patrick McGrath, PhD
If you think about it long enough, it should not come as a surprise to you that some people who have OCD are tormented by uncertainty surrounding their own morality. While religious scrupulosity may encompass a fear of acting in ways that are inconsistent with respective religious doctrines, Moral Scrupulosity revolves around the fear that one may act in ways that are inconsistent with their own moral compass, or what they deem as “good” or “bad” by society’s standards. The irony is that a person who is terrified about whether they are a “good” or “bad” person is likely to be amongst the most kind and caring individuals in our society. As we know, OCD loves to pick on the areas of an OCD sufferer’s life that they value most, such as doing well by others. If being a “good” person wasn’t so important to the individual, perhaps the uncertainty of it would not be so disturbing to them. Be that as it may, where there is a seed of doubt, compulsions are all the soil, sun, and water OCD needs to grow and consume a person’s life. In fact, Moral Scrupulosity can often be an underlying (and frequently overlooked) silent partner to the more common subtypes of OCD.
But how does that work you might ask?
As an example, those with harm obsessions experience intrusive, unwanted thoughts of hurting themselves or others. In its purest form, their fear is driven by the uncertainty that they may “lose control” and do something that could cause harm. However, when Moral Scrupulosity is on board, the presence of harm obsessions, and the related fears, are often ancillary to the core fear that these very thoughts may make one an inherently “bad person.” While on the surface we may visibly observe the same compulsive behaviors and avoidance in both subgroups of sufferers, the morally scrupulous individual’s fear may be held at a deeper level. They often judge themselves and may also fear the judgment or evaluation from others were they to become privy to the thoughts, images, or urges. Not only is this possible, but it is a lot more common than you might think.
If you have Moral Scrupulosity, you may not only be disappointed in yourself for the doubts that you experience, such as, “What if I do not love my partner in 30 years the same way I do now?” You may also be overwhelmed with guilt for the harm that it could cause your partner if you were to potentially not love them in 30 years the way you do now. It is the guilt and shame that you may experience, the judgment that you may incur, and the uneasiness that you have about the uncertainty of all of it, that causes such distress. It is that doubt and uncertainty of how someone may judge you that may lead those with Moral Scrupulosity to often jump to the worst case scenario – “No one likes me, I harm people emotionally, and I do not ‘not like it’ enough, and that makes me a bad person who deserves the negative judgements or evaluations.”
Our work with morally scrupulous individuals has taken on many other forms and is often eye-opening for people. Here is an example of a typical conversation that we have had with patients referred to us for “contamination obsessions,” only to discover that their concerns were more rooted in Moral Scrupulosity.
Patient: I do not want to touch something and get a germ on me.
Clinician: And what are you afraid might happen if you did?
Patient: Then I may be the cause of it being transferred to another surface where another person will touch it and get ill.
Clinician: What if that were to happen?
Patient: Then I would be responsible, and they would hate me for it.
Clinician: How would they know it was you?
Patient: They may not, but they would hate the person that did it, so it would still be directed at me, and I would feel guilty as well, knowing that I somehow had a negative impact on someone’s life.
Clinician: And what would that mean about you if that were to happen?
Patient: That I would be to blame, and I would be a bad and irresponsible person who doesn’t care about others. I don’t think I could live with myself if I didn’t do everything I could to prevent bad things from happening to others. It’s why I wash my hands so much.
This guilt for having a negative impact (real or potential), is where Moral Scrupulosity lives. The impact can be on oneself, on others, or even inanimate objects (Ex. “If I throw this plastic bottle out in the trash and not in a recycling bin, then I am contributing to the death of the planet and am a horrible, callous, and careless person.”).
The main issue in all the above examples is guilt, and OCD does love to blame. The problem with guilt is that there is always a reason to feel guilty about something. We saw people grapple with guilt during the BLM protests – “I want to be out there and protest to show my support for equality, but what if I cough and give everyone there COVID” (OCD also loves a damned if you do and damned if you don’t situation).
We have recently been talking about our justice system in sessions with some of our Morally Scrupulous patients. In our system of justice, you are innocent until proven guilty. However, in the court of OCD, you are just guilty and there is no way to prove you innocent. Take this one step further because OCD DEMANDS that you be proven innocent, but in our justice system you are either guilty or not guilty – no one has ever been judged to be innocent of a crime. And, to quote the movie Dumb and Dumber, OCD says, “So you’re telling me I’ve got a chance!” to still be guilty? Well, then I will take that chance and raise you one compulsion.
Compulsive Self-Shaming/Self-Criticism
A 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 living with uncertainty. While exchanging anxiety and uncertainty for shame and sadness does not 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. In this scenario, as people begin to disengage from compulsions and learn to live with uncertainty, they may experience a sense of immorality due to fears that they are disappointing themselves or others (I.e., Now that that obsession does not bother me so much, does that actually mean that I like or want it?). These individuals believe that if they can at least feel badly about their shortcomings, then maybe they will not make the same mistake twice. In defining themselves as “bad” or “guilty,” it puts an end to their perpetual internal debate of “What if I am a bad person” and gives a definitive answer – YES, YOU ARE! When patients engage in consistent self-shaming, it can also act as a constant reminder to be on guard to prevent potentially doing something that may offend others in the future.
Treatment
Exposure and Response Prevention (ERP) is the gold standard treatment for OCD. So, what does ERP look like for Moral Scrupulosity? In short, patients will develop a hierarchy related to their scrupulous concerns and approach these triggers that provoke anxiety and uncertainty without engaging in avoidance or frantic efforts to relieve their doubt or guilt. These individuals must accept their actions and tolerate the possibility that they may be wrong, viewed as bad, or could be judged as immoral some day in the future. No amount of compulsive reasoning/rumination, prayer, reassurance, apologizing, analysis, research, avoidance, acts of “goodness” to make up for their “bad behaviors,” or thought suppression leads to certainty or long-term relief, and all simply contribute to the maintenance of anxiety, fear, shame, disgust, and guilt. Imaginal exposures or worst-case scenarios can also be utilized to address feared outcomes that may not be able to be addressed with in-vivo work (Ex. Fears of going to jail in the future for an act you did in the past that seemed innocent back then but is now frowned upon, etc.)
In summary, we believe that people can learn that their lack of certainty about their thoughts or images or urges can co-exist with living a happy, fulfilling life. OCD is not a moral compass that anyone ought to follow to navigate through their life.