Bringing It All Together – A Case Example

Here is an example from William* that will tie together a case example highlighting the points in the Implementing Specific Religious Traditions Into A Treatment Plan Without Being An Expert article. This case example is written by Justin K. Hughes, MA, LPC. 

The Pastor & Scrupulosity

William* knew he likely had OCD, but as with many clients he did not want to self-diagnose specifically because his obsessions commonly centered on whether or not he actually had a condition or not, or whether it was having weak/absent faith. There were many steps before he arrived in therapy with me, especially as a leader in ministry. His OCD took the form of classic “just right” presentations, and even some occasional contamination obsessions. However, what began to impair him was a mix between scrupulosity and just right/not just right themes. He had loved studying the Bible and theology as a Christian, and he even had a seminary degree which was a result of actual values rather than fear driving him to “have to” get a seminary degree.  

Though not unusual for core fears as far as scrupulosity is concerned, William started to feel overwhelmed because he felt responsible for the care of souls as a pastor. 

“What if I don’t truly understand______ [blasphemy/forgiveness/salvation] and I go to hell?  Or worse, take others with me?!”


I put on the assessment cap from day one. He would ask questions about my training such as, “What did your seminary teach about forgiveness?” I asked questions such as, “Tell me more about your desire to know what my alma mater taught?” This is an example of a question that got into his world but allowed me to stay objective with him. These types of questions, especially as part of a larger functional assessment, allowed me to more effectively treat William.

Building Rapport, Self-Disclosure, and Building the Foundation

Sometimes clients want to build rapport with their therapists and know they’re not alone. [CBT provides a good framework to demystify therapists. However, self-disclosure must be thoughtful and specifically beneficial for a client.] When the client sought reassurance with repeated questions about my beliefs, these were opportunities to practice lifestyle exposure and teach response prevention so he could learn in the moment not to compulse. It turned out these questions were reassurance seeking in scrupulosity.   

The client ultimately did not believe in a God who would capriciously throw him into hell because he hadn’t felt a certain way when reading the Bible or saying a prayer.  His rituals kept him stuck in questioning, asking, and ruminating on the topic, though.  

Exposure Work

We then went on to build faith-consistent exposures once he and I understood the basics through assessment.  Rumination and mental review were the key rituals he had to remove, along with occasional reassurance-seeking.  Also, the client identified that if he felt the urge to pray at the end of a session, it could be compulsive.  We then got to work on his exposure and response prevention.

Using Therapy To Thrive Mentally and Spiritually

By the point we were doing exposures, he generally understood the rationale, though he most importantly had to test that rationale through differing behaviors and mental responses.  He had buy-in because we could talk the same language (not necessarily because all beliefs were shared in common). He knew from my training and commitments I had a focus on his improvement- body, mind, and spirit. He got to work, made up and down improvement as everyone does in some way or another, but never turned back. I am happy to say he is a strong, non-impaired minister to this day guiding his flock. And oh yes, medication was part of the journey, too, for a little bit until he was doing better and his Psychiatrist identified his improvement was significant and he was ready to discontinue. This is a case that reminds me of why I do what I do.

And while every case looks different, there are core elements elucidated in this article that I can retain with any client to help them in the ways I am trained to help: to find freedom from OCD!

Thank You!

As a fellow clinician, I thank you from the bottom of my heart that you are so interested in considering how to support your clients. Keep up the good work as you assess and help them live congruently with their beliefs, faith, practices, and religious traditions.