New York – Jewish Rituals And Obsessive Compulsive Disorder

New York – Scrupulosity is a term given birth to in the 1600s. Today, it is a well-documented form of Obsessive Compulsive Disorder (OCD). It is typically evident in people who believe that their religious behavior is in some way displeasing or disrespectful to Hashem. This preoccupation is often accompanied by the emotional experience of anxiety, common to all forms of OCD, as well as a presence of guilt which exacerbates the pain. The guilt in displeasing Hashem and the feeling that one can never “do it right” often contribute to an associated depressive quality in this OCD subtype. One of the great Chassidishe Rebbes, Rabbi Nahum of Stephanesht described the intertwining of these elements in Scrupulosity: “Scrupulosity is a cloak made of pride, lined with guilt and sewn with melancholia.” As a result, many engage in repetitive and excessive prayer or other religious behavior to correct the pain, as part of the disorder.

Consider the following:

* A 17-year-old yeshiva bachur worries that he cannot concentrate fully during Kriyas Shema. He repeats each word over and over in order to make sure that he pronounced it correctly. And despite his constant review of the words, he fears that he didn’t daven with the proper kavanna. He spends 50 minutes a day saying Shema and, he views the mitzva as a burden he cannot manage.

* A 22-year-old kalla from a prestigious Jewish family is tortured by thoughts of religious doubt that pervade her mind during the day. She meditates about the thoughts constantly, repeating to herself over and over that she is a Baalas Emunah, and spends hours during the day trying to prove her religious commitment.

* A 21-year-old kollel yungerman wonders if his Tefillin are on straight. He puts on the Shel Yad and readjusts it 18 times before attempting to put on the Shel Rosh. He constantly rechecks and re-examines the Shel Rosh to be sure that it is EXACTLY between his eyes, using a ruler to measure the precise space between them and the equidistant placement of his Tefillin between his eyes. The process of putting on Tefillin takes so much of his time that he often misses Tefillah B’Tzibbur due to the pressure of “getting it right.”

Although these cases seem extreme, they are some of the examples of Scrupulosity cited by the Divrei Chaim of Sanz (Shut Divrei Chaim II: 6) and the Steipler Gaon (Kriyna D’Igrisa). To the outsider, these behaviors appear to be nothing more than frumkeit. But to the person afflicted with this condition, Scrupulosity OCD takes Ahavas Hashem out of mitzva observance, leaving the individual anxious, depressed and often fearful about doing mitzvos. These Gedolim recognized the difference between healthy religious Shmiras HaMitzvos and Scrupulosity and were able to advise those who sought their wise counsel.

How can one tell when observance is standard frumkeit and when it is Scrupulosity? Psychologists have noted five key features that distinguish frumkeit from Scrupulosity:

1. When practices go further than the requirements of religious law, one might be mistaking Scrupulosity for frumkeit. For instance, if a ritual requires washing Netilas Yadim twice on each hand, the person with Scrupulosity will repeatedly wash to be sure that he covered each hand twice until the wrist, often washing twenty times or more.

2. When the person becomes overly preoccupied with a focus on a seemingly trivial part of the ritual instead of the whole picture, s/he is likely to be expressing behavior more akin to Scrupulosity. When a religious patient is more focused in prayer on “pronouncing it perfectly” instead of developing a sense of proper kavanna, the focus is more like Scrupulosity than fervent behavior.

3. Healthy and scrupulous religious beliefs do not interfere with the normal practice of the religion. Scrupulosity frequently interferes with the proper practice of religion. For instance, when a person with Scrupulosity OCD does not attend Minyan because of the fear that s/he cannot control intrusive thoughts, s/he is suffering from Scrupulosity.

4. The person with Scrupulosity spends excessive time and energy on minute, trivial aspects of spiritual life while ignoring more important aspects of spiritual life including Mitzvos Bein Adam L’chaveiro, Gemilas Chessed, Tzedaka and Ahavas Hashem.

5. The pre-occupation with doing rituals until they are “perfect,” the repetitive praying, unnecessary penance-seeking found in Scrupulosity closely resemble the typical OCD symptoms of checking, repeating and asking for reassurance. The person with Scrupulosity often demonstrates behaviors that are persistent, unwanted and repetitive.

Remember: Strong religious convictions do not cause or imply Scrupulosity. Rav Yisroel Salanter (Ohr Yisroel, Letter 25) recognized the difference between Zehirus and Scrupulosity. Scrupulosity is a type of OCD, which is a psychological disorder. In these cases, a person’s religious convictions are merely one aspect of his or her being that OCD uses to cultivate doubt and create anxiety. It is not connected to Torah observance or religious life at all. If OCD didn’t attack a person’s religious beliefs, it would surely take on a different form, whether that would be a contamination fear or a checking compulsion or another arena for OCD to unleash anxiety. Scrupulosity takes strong religious ideals and blows them out of proportion, making them distorted and corrupt.

Treatment Considerations:

One of the most successful approaches to treating Scrupulosity is with cognitive behavioral therapy (CBT). CBT therapists encourage their patients to see that their behaviors can vary and that one’s sense of self is better off being accepted rather than always being constantly critically evaluated. Given our religious culture that is constantly encouraging us to become or “be” better persons, it is easy to see how patients find it hard to navigate these new ideas.

It is not unusual for therapist and patient to consult with a patient’s Rav during this initial phase of therapy in order to sanction and help navigate this apparently “irreverent” therapy. The Rav and patient need to be assured that the treatment course is not designed to adversely impact one’s religious beliefs. Rather, they should know that treatment is solely targeting a disruptive anxiety disorder which produces seemingly devout behavior that is actually unrelated to one’s genuine degree of religious commitment. In fact, often the ability to distinguish real religiously fervent behavior from Scrupulosity often helps enhance one’s devotion to Yiddishkeit.

Often, patients balk at the idea of cognitive therapy for OCD. In the case of Scrupulosity, especially of a religious subtype, many opt for medication therapy instead. Although medication is a very powerful frontline treatment for OCD in general, it can have limited benefit for people with Scrupulosity. The medication can help reduce the experience of the anxiety but it cannot help someone change his way of thinking. This is where the cognitive therapy is most necessary and effective.

The actual treatment course for Scrupulosity does not deviate significantly from other types of OCD. Generally, a hierarchy is constructed, in which persons are gradually exposed to accelerating levels of risk. This is in accord with the concept expressed by the Chovos Halevavos that one of the principles of Zeheirus is not to be too Zahir where improper to do so.

This is an excerpt from “Mind, Body and Soul” a mental health magazine, a collaboration of Nefesh International and the Jewish Press in this weeks Jewish Press on Newsstands now.

Jonathan Schwartz, PsyD is a practicing Rav in NJ and Senior Clinical Psychologist at the Center for Cognitive Behavioral Psychotherapy (www.ocdonline.com) in Manhattan. He can be reached at [email protected]