Religiosity/Scrupulosity OCD in Judeo-Christian Contexts
From the perspective of Dr. Curtis Hsia, a psychologist and a practicing Christian
Obsessive Compulsive Disorder is based upon a person’s fear of a catastrophic outcome and desperate attempts to avert that outcome. This typically revolves around a concept that is central to a person, such as one’s relationship with their parents or spouse. We’re going to discuss another core area today: one’s relationship with God.
Often described as Religiosity or Scrupulosity OCD, this variation emphasizes offending God and/or ruining one’s relationship with God. We are going to focus today specifically on Judeo-Christian belief systems and how OCD often affects those with this faith background.
We often get referrals for religious OCD, and in particular for Christians. Understanding the basics of the theology and practice of a patient’s faith is crucial to differentiate what is a commonly acceptable belief and practice within the church or synagogue and what is more likely to be an obsession or compulsion.
Those who fall into the Judeo-Christian grouping would include individuals of Jewish, Catholic, and Protestant faiths. Broadly speaking, this can also include Latter-day Saints (Mormons), Seventh-day Adventists, and other related groups. They would agree that there is one God, and He (used not necessarily to denote gender, but traditionally to reflect power and strength) is omnipotent, omniscient, just, and good. There are theological distinctives as well—for example, the Christian focus on the deity of Christ and salvation through faith, Judaism’s lesser emphasis on heaven, and Catholicism’s elevation of tradition alongside Scripture—as well as important cultural differences.
Beyond Denomination: Understanding the Individual
What is important is not only which denomination one belongs to (e.g., an Orthodox Jew would have a very different view on what is kosher than one who is Reform), but also how important their faith is and how it affects their life. For example, I have had people state they are Christians because their parents are, yet they don’t attend church, haven’t read the Bible, and don’t hold to Christian values. Conversely, I have had OCD patients say they are not Christians despite engaging in and believing all of the above because they feel guilty about sinning. Much like acculturation and ethnicity, knowing one’s background is necessary, but it is just as important to understand the individual.
Religious obsessional thinking can vary, as can the resulting compulsions. Most center either on having a theologically inappropriate thought (“I hate God”) and engaging in compulsions to negate that thought (saying three times, “I love God,” looking up Biblical verses on love), or on feeling that one’s behavior carries unintended meaning that must then be corrected with a compulsion (“I didn’t do that prayer right, which indicates to God that I don’t love Him enough to do it correctly, so I need to do it again until I get it right”).
Evidence-Based Treatment for Religious OCD
So what’s to be done? Just like other variations of OCD, treatment follows a prescribed approach based on what research shows to be efficacious. Treatment usually begins with a thorough assessment to understand not only which disorders an individual meets criteria for, but also how the symptoms function for that person (e.g., Is the depression secondary to the OCD? Even if the OCD is addressed, will the depression remain? How much insight does the individual have about their obsessional thinking? How does the person’s family help or hinder treatment?).
Once the issues have been established, a treatment plan specific to that individual is constructed, based on Cognitive Behavioral Therapy with an emphasis on Exposure and Response Prevention. Psychoeducation is imperative, followed by cognitive countering (“Where’s the evidence that God would hate you if you didn’t say ‘I love God’ in just the right way? Where in the Bible does it state how many times you have to say ‘I love God’?”). Once the patient agrees intellectually that their obsessional thinking patterns are not theologically sound, we then engage in exposure. This can range from mild (saying “I love you” with the wrong cadence or emphasis), to moderate (stating “God is ok”), to more severe (saying “I hate God”).
When Theology and OCD Intersect
While this seems straightforward, the devil is in the details. The clinician must understand what is acceptable within the patient’s faith, or perhaps even their specific congregation. Some faith traditions, such as Judaism, require prayers to be said in a very specific manner. Conversely, this can lead to compulsive behaviors that are OCD-based (reducing anxiety about doing it “right”) as opposed to engaging in the practice for the glory of God and experiencing appropriate spiritual meaning when done correctly. It is not uncommon to obtain a release of information to consult with a patient’s pastor or rabbi to clarify what is appropriate (though this, too, can become a fine line if it turns into reassurance seeking).
One should remember that religious OCD is, in many ways, no different than any other variety. It is less about the content area and more about OCD attacking a construct the patient holds as valuable: family, safety of others, and in this case, one’s relationship with God. It’s not about theology; it’s OCD about one’s theology (the issue isn’t the issue—the underlying thinking pattern is). While this can be hard to remember at times, it can also bring relief: it’s not that God doesn’t love me, nor that I don’t love God. Rather, I love Him so much, and my faith is so central to me, that this becomes an easy target for OCD to attack—and there is solid science guiding how to treat it.
About the author: Dr. Curtis Hsia is a leading expert in the treatment of OCD and anxiety-related disorders, bringing decades of specialized training and clinical experience to his practice at the OC Anxiety Center. He earned his undergraduate degree in psychology from UCLA and went on to complete his doctoral degree in combined clinical and school psychology at Hofstra University. Dr. Hsia trained directly under pioneering OCD researchers Dr. Neziroglu and Dr. Yaryura-Tobias, where he developed deep expertise in Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP). He further refined his skills as a postdoctoral fellow under Dr. David Barlow at Boston University's Center for Anxiety and Related Disorders — one of the most prestigious anxiety research centers in the country.
