Gain Perspective on Goals for Exposures (For Clinician and Client)
Having OCD while also holding to faith and spiritual commitments sometimes leads to the fear that treatment for OCD will somehow violate one’s faith or beliefs. This seems especially true for those who struggle with the OCD subtype known as scrupulosity. This is a brief “getting started” guide to assist in developing effective exposures that are also sensitive to beliefs and values.
Exposures are not just an exposure to anything that is fearful. Fear can be healthy and adaptive. When discussing exposure therapy, clinically, we are discussing the confrontation of pathological fears while reducing and ideally eliminating fear-based responses. Therefore, several principles apply:
- We operate in reality, meaning we never ask a client to do something that would knowingly violate a patient’s safety or beliefs that are supportable.
- We will teach clients from a faith perspective that:
- They need to be able to do whatever other people from their faith community can do as part of normal practice of faith.
- They should identify someone (an elder, minister, etc.) who can help them and their therapist determine what things are part of the true practice of their faith and religious community (i.e., what is normative) versus what is OCD. This person should understand OCD (or be willing to learn about it). They may want to follow the “85% rule” to help them identify what is normative. If out of 100 people from their church/temple, 85% or more do something, then it is normative. (i.e., Scripture reading, prayer, fasting, time dedicated to serving or helping, etc.)
Take the Risk to End Compulsions, Neutralizing, and Avoidance
Developing a proper understanding of obsessive compulsive disorder (OCD) along with its treatment of cognitive behavioral therapy (CBT) utilizing exposure and response prevention (ERP) is foundational to clinical work. Such treatment involves rigorous assistance in not only identifying, but eliminating compulsions.
Therefore, training a client in the following is key:
- Stopping the avoidance of people, places, things, images, etc. that trigger their religious/spiritual obsessions.
- Stopping reassurance-seeking and repetitive confessions (whether with themselves, others, God, etc.).
- Attempt to give up trying to have absolute certainty about matters of faith. Instead, faith is to be lived out by trust through the uncertainty. Drawing on the normative practices of others in their faith or religious tradition as noted above will be useful in setting guidelines, but they do not replace the actual work of learning to tolerate uncertainty, face fears, and give up compulsive behaviors.
Use your Clinical Tools (CBT, ERP, ACT, etc.)
CBT, ERP, and ACT (acceptance and commitment therapy) are robust treatments that provide many tools for clinicians and clients alike. Here are a few simple, basic tips:
- Assess first! Know what you’re working with, including the key obsessions, core fear(s), and consistent compulsions. Create a roadmap and consider any common detours (panic, depression, etc.).
- Anytime you can do a direct (in-vivo) exposure to something, do it!
- Anytime you can do an imaginal exposure to something, do it! Exposures by doing loop recordings can be very helpful.
- When you can’t do an in-vivo or imaginal exposure, use ACT and mindfulness-based strategies.
- Help clients learn to engage in their valued beliefs and commitments while simultaneously feeling doubt, uncertainty, and questioning.
- Keep assessing and reviewing with a client. What’s working? What’s not? Even for the most junior of clinicians, asking thoughtful questions and attempting to get in the client’s world goes a long way!
Offer Tips for Coping with the Uncertainty about Sin, Error, or Offending God
For those who wonder if they have sinned, are in error, failed (e.g., “What if I…?”) or aren’t sure if they have, developing a commitment to move on and go forward as if they didn’t is not helpful. If they feel that they cannot avoid compulsions or tolerate uncertainty in a given moment, assist clients in identifying doable steps to move them further towards the goal:
- Can they delay doing a compulsion or seeking an answer? (For example, wait 30 min. to seek an answer instead of immediately?)
- Can they minimize the extent that they normally go to? (For example, calling only 1 person instead of 3?)
Using ACT and Mindfulness-Based Strategies
While ERP can be highly successful without adjuncts, tools from ACT and Mindfulness-Based Cognitive Therapy (MBCT) often assist in the process. You can teach clients:
- Their goal is to allow obsessional thoughts to float through their mind without fighting the thoughts.
- When thoughts of a religious, sexual, or immoral nature come into their mind, they must reject the notion that they must fight, analyze, or control the obsessions in order to show God (or themselves) that they don’t want the thougths.
- They need to do exposures to the uncertainty, doubt, and guilt they feel.
- Don’t delay; push forward. To whatever degree they can tolerate the anxiety, distress, and uncertainty of the obsessions today, they must keep pushing themselves to go longer and further without neutralizing.
- Develop kindness/grace/patience/self-compassion in the process. No one makes a jump to completing all work in one day. No one does it perfectly. Building in acceptance is often crucial for realistic expectations.
Train Clients in What They Need to be Able to Do (and Not)
Let’s go back to the concept that exposure is not exposure to every fear, but rather to the triggers for a client that lead to problematic, disordered responses. Clinicians should offer psychoeducation early in the process of what needs to be accomplished (or not) for success. You will likely win the confidence of clients early on if they have a clear, realistic understanding of expectations.
Clients DO NOT have to:
- Do exposures that involve doing things their faith specifically forbids or says is sinful or immoral (e.g., destroy, tear, or burn Scriptures, do exposures to pornography, etc.).
- Sit in their place of worship and internally shout things in their head they consider blasphemous.
- Give up the core beliefs of their faith. However, they do need to learn how to follow the tenants of their faith and not OCD’s skewed version of faith.
- Stop attending their parish, church, congregation, synagogue, mosque, temple, etc.
- Completely stop praying (or whatever practice is normally appropriate, whether that is fasting, rest, etc.)
- Share or agree to the same religious beliefs (or non) of the therapist.
Clients will NEED to:
- Be able to sit in their place of worship and allow distressing thoughts to pass through without neutralizing.
- Learn to live in a way that is functional.
- Learn to tolerate varying levels of uncertainty, mystery, doubt, and not knowing.
- Learn to pray in a way that doesn’t feed into OCD (e.g., “God, give me grace to willingly welcome my feelings of uncertainty and to not do my rituals”).
- Follow through on their agreed-upon exposure exercises for effective treatment.
Blessings in Your Work!
Though this guide is brief in covering principles of effective and religiously sensitive exposures, it is a beginning step for therapists to consider how to best help their clients who wish/need to integrate their faith.
This edited article is updated for mental health clinicians to consider implementing effective and sensitive exposures for any client of faith. The original article was written for Christian individuals with OCD. Hopefully this document can guide you in developing effective exposures that are also sensitive to other beliefs and values. By Ted Witzig, Jr., PhD and Updated for Clinicians by Justin K. Hughes, MA, LPC