The Scrupulosity Trap
“These thoughts are disgusting. I must stop having these thoughts. I must be an immoral person because I can’t get rid of these disgusting thoughts.”
“I didn’t intend to be dishonest, but somehow I didn’t tell everything there is to know. Since I am not 100% honest, I must be a terrible person.”
“I must make these blasphemous thoughts go away by more prayers. I need to prove that I am good. I must do it over and beyond to get rid of my impure thoughts.”
These statements are some of the recurring thoughts inside the mind of individuals with moral or religious scrupulosity, a common yet less visible subtype of obsessive and compulsive disorder (OCD). Clinically, OCD is characterized by having perceived intrusive thoughts (obsessions) or the need to perform an action or mental rituals (compulsion) to relieve the distress (e.g., anxiety usually) associated with those obsessions (American Psychiatric Association, 2022). These experiences are distressing and interfere with our daily lives. Some other subtypes of OCD include contamination, checking, repeating, counting, aggression, harm, sex, need for symmetry, and ordering (e.g., as assessed by the Yale-Brown Obsessive Compulsive Scale; Goodman et al., 1989). While these subtypes are not mutually exclusive, people with scrupulosity suffer predominantly from terrifying doubts about committing things that are wrong, evil, or blasphemous
Conscience, Values, Excess
The word “scrupulosity” has its Latin root “scrupulum” to mean “sharp stone,” an allusion to its pricking pain on our conscience (Miller & Hedges, 2008). Indeed, religious records of scrupulosity predate our modern, secular notion of OCD as a psychological disorder. As early as the second century, for example, the Jewish Mishna described excessive concerns of house cleaning before Passover (see Greenberg & Huppert, 2010, for historical examples in major religions).
Scrupulosity can have a religious (i.e., blasphemous) or secular component (i.e., ethical concerns only). Sufferers often try to do their best to live up to their conscience and personal values. These seemingly conscientious attempts are self-defeating as they seek certainty to prove “pure” intention and “clean” thoughts associated with their actions.
Studies have found that 10 to 33% of OCD samples in Western cultures have religious symptoms (Eisen et al. 1999; Mataix-Cols et al. 2002). In Middle Eastern cultures, we found that 40 to 60% of their OCD samples endorsed religious obsessions (Greenberg & Huppert, 2010). However, belonging to a religion does not necessarily “cause” scrupulosity. A study found that 18% of those with scrupulosity were without religious affiliation (Siev, Baer, & Minichiello, 2011). Complicating factors include sorting out the differences between normative religious practices and compulsions that are excessive (Siev & Huppert, 2016). For example, Greenberg and Huppert (2010) noted scrupulosity sufferers might initially be true to their religious guidance and laws (e.g., saying prayers with enough concentration in Islam or washing adequately before prayers in Judaism), but their doubts about they perceive to be enough grow to become excessive.
The doubts and concerns about wanting to do what is right can appear similar to strivings toward perfection. Indeed, it is not uncommon for individuals with perfectionism to experience OCD distress (Callaghan et al., 2024; Lunn et al., 2023). Yet, while perfectionism involves excessive concerns and unhelpful behavior to meet “perfect” yet impossible standards to quell our relational need (“I don’t matter because I am not good enough”; see Hewitt, Flett, & Mikail, 2017), scrupulosity is driven by a deep fear created by moral and religious obsessions that “I am a bad or evil person who has committed wrongful actions.”
What Treatment Looks Like
A common misconception about treatment for OCD is that the clinician will force us to do things that are possibly harmful or that we are not ready for. In the case of scrupulosity, this mistaken assumption becomes even more problematic: do we have to do horrible things in order to get better?
The short answer is “no.” In actuality, treatment looks very different, as clinicians ideally ought to proceed with cultural and religious sensitivity (Siev & Huppert, 2016). Evidence-based approaches for treating OCD include exposure and response prevention therapy (ERP; Jacoby & Abramowitz, 2016) and acceptance and commitment therapy (ACT; Bluett et al., 2014; Twohig et al., 2006). Often, therapy can be combined with psychotropic medications (e.g., selective serotonin reuptake inhibitors or clomipramine) which have been demonstrated to be effective (Del Casele et al., 2019).
In treating scrupulosity with ERP, the target is on the anxiety generated by the intrusive doubts, instead of creating certainty that the individual is “not bad.” Older theories about ERP had assumed that it works by habituation (e.g., we get used to the fear, hence the reduction; Thompson, 2009). The current research indicates otherwise: we learn to replace the experience that we are afraid of these obsessions with rituals to banish them, with a new experience that we can tolerate and survive this fear (inhibitory learning theory; see Craske et al, 2014; Jacoby & Abramowitz, 2016). Instead of working to get rid of our intrusive thoughts and eliminate uncertainty, the goal of the therapy is to strengthen this new experience of tolerance and overcoming anxiety (e.g., am I an evil person?), without the use of compulsion (e.g., prayers or mental rituals, seeking reassurance from others).
The expectation is not “my fears will go away” (the old habituation theory) at the end of each exposure and ritual prevention. Instead, it is to learn that “I will be okay because I have tolerated my doubts and can live fully without the rituals.” The clinician and the client collaborate to find opportunities to practice these exposures in situations, in real-time (in-vivo) within sessions, or through imaginal practice – again, the focus is on the induced uncertainty, not on forcing the client to commit wrongful acts.
In ACT, the treatment focuses on learning to react to the moral and religious obsessions differently. Instead of working to change and to take control of our doubts and obsessions, the clinician helps the individual with scrupulosity to let go of these struggles and make contact with the intrusive thoughts without fighting against them: these thoughts are only thoughts, nothing more (Twohig et al., 2006). When practiced with intention over time, these mindfulness and acceptance skills can disempower the moral and religious obsessions held over us and allow us to engage in life freely and flexibly, in accordance to our values and faith. In some sense, letting go without fighting is similar to the toleration of doubts without the ritual compulsion learned in ERP.
Clinicians in other orientations (e.g., psychodynamic theory) may also choose to incorporate exposure principles and techniques into their treatment. Indeed, integrative clinicians such as Paul Wachtel (2023) have argued that most therapies work more effectively through exposure in one way or another; some do so more explicitly, while others work implicitly. Enabling both emotional insight and exposure together through therapy are often more helpful in overcoming our fears and anxiety.
When to Ask for Help
When trying to be certain that “I am good” becomes so consuming that it interferes with our ability to work, love, and play, then it might be important to take a moment to slow down. For individuals with religious scrupulosity, it could be helpful to seek guidance with trusted figures within their religion to distinguish between normative and excessive practices (Siev & Huppert, 2016). Because we often find some scrupulosity obsessions offensive (e.g. those related to sex, and violence), they can lead to feelings of shame, getting us stuck in a spiral of self-loathing, depression, and making us feel even more alone. When we feel trapped in this way, it is helpful to find compassion towards ourselves and seek comfort from others.
In the case of scrupulosity, it is especially important to remember that getting help and treatment does not mean to live without our conscience (“if only we can care less, we would be happy”), to have to do things that violate our religious faith, or to give up on our moral and religious values. Rather, it is to make room for facing our most difficult doubts, to learn to tolerate and be less afraid of uncertainties, in order to help us live our lives more fully and meaningfully.
Self-Reflection
- How often do you find yourself having unwanted thoughts that feel intrusive and create uncomfortable feelings (e.g., anxiety, disgust, guilt)?
- When you have anxious and distressing thoughts, do you have routines and rituals to “neutralize” or “cancel” those thoughts? What do you find yourself doing (e.g., having a “counter-thought”; saying a prayer; repeating a mantra, etc.)?
- How often do you need reassurances from others (e.g., family, religious authority figures) that you are not immoral or a “bad” person? Has the need for reassurance gotten in the way of living your life more fully and meaningfully?
- How would you like to live differently if you are no longer consumed by moral and religious doubts? How would you rather spend your time living according to values that are important for you (e.g. talk more with your partner, play with your children)?
