Evidence-based Treatment of Scrupulosity for a Religiously Affiliated Person
By Casey Moore and Danielle Miller
Note: Beverly is a fictitious client created for this paper.
Precipitating Events and Reason for Referral
Beverly is an 18-year-old Caucasian, cisgender female attending Wheaton College in Illinois. When Beverly started college two months ago, her advisor and some professors suggested she see the campus pastor based on extreme comments and trouble socializing with her peers. The advisor reported she said her peers “would burn in hell” for having sex before marriage and repeatedly asked them how often they sin.
Initially, Beverly was excited about an opportunity to connect with the campus pastor; however, she was confused when he recommended she see a college counselor. She reluctantly went to her first counseling session, where her counselor introduced a subtype of OCD known as scrupulosity. Her counselor explained the term ‘scrupulosity’ refers to seeing sin where there is none and that some call it a ‘phobia concerning sin’ (Ciarrocchi, 1995, p. 5). She referred her to an OCD specialist. Beverly felt confused about this and asked her parents for guidance. Her parents were also confused and hesitant. Because of this, they made an appointment with the campus pastor, who assured them he would be involved in her treatment. After this meeting, they spent a week fasting and praying. Eventually, they decided it would be okay for Beverly to see an OCD therapist.
Beverly’s faith is extremely important to her. Beyond expressing this, this is primarily evidenced by her hope to be a pastor and her heavy involvement in church and community-based ministry groups. Beverly does not partake in secular activities or culture and often isolates herself from her peers. According to these peers, she can come across with a “holier than thou” attitude and has struggled to maintain friendships. Beverly’s family and pastor are beginning to worry that Beverly’s excessive fear of sin, punishment, and disappointing God may harm her development and enjoyment of life. She frequently says she doesn’t do things because “God wouldn’t approve.” She also notes these thoughts are “non-stop” and “frightening.”
Psychosocial History
Education and School History
Beverly graduated from St. Mary’s Baptist School in 2021 with a 3.9 grade point average. She enjoyed high school and learning more about God but did not spend much time with people her age. She reported feeling the happiest when helping out the pastors and ministers at her local church. She worries about what to major in and does not think she needs to be in college, as “you don’t need a degree to be a pastor.” Her merit scholarship at school requires her to maintain a 3.5 grade point average, and she says her parents want her to get her degree to enhance her work in ministry.
Employment History
Beverly works as a youth minister on her college campus. This usually occupies around 12 hours of her week as she plans outings, meals, and lessons for the campus ministry group. Before this, she saved money babysitting for several families at her church.
Living Arrangement and Social Support System
Beverly lives at home with her family and commutes to Wheaton weekly to attend classes. Both of her parents lived in the dorms and found the social community at Wheaton spiritually enriching and enjoyable. They encouraged her to live on campus and had hoped Beverly would finally be able to make friends now that she was in an entirely Christian community. Beverly was adamant that living at home was “God’s plan for her,” as she found it inappropriate and sinful that men were allowed in the women’s dorms during the daytime. Her parents reluctantly honored her wish to live at home.
Her parents encouraged her to join the freshman-year activities. After one event, she told her parents she would not be returning as “nothing was pleasing to God about playing games while listening to secular music.” While Beverly’s parents are proud of their daughter, they are also confused and unsure how to balance her understanding of sin with their own. Beverly’s social support is her family, pastors, and a couple of older women at her home church, whom she sees as mentors.
Family History and Relationships
Beverly is the eldest of three daughters. Her sisters are 15 and 10 years old. Both of her parents grew up in Chicago and went to Wheaton College, where they got married their senior year. Her mother is a nurse, and her father is a journalist. They are both devout Christians and “seek God’s will” in every major decision they make as a couple. They value community, family, and spreading God’s word.
They expect their children to follow in their footsteps and be active church members. They plan for all three of their daughters to attend Wheaton College. As parents of three daughters, they have always stressed the importance of sexual purity, including modesty and abstinence. They have a family Bible study every night and have never sought outside support other than pastoral guidance for any family challenges.
Prior Treatment
Beverly has not had any prior treatment as she sees no merit in seeking support outside prayer and the church community. She is largely unfamiliar with the field of psychology and is unsure what therapy entails. She is skeptical but willing to try therapy since her pastor strongly believes this is what God would want for her.
Assessment
Considering Beverly’s religious background and symptom presentation, screening for obsessive-compulsive disorder with scrupulosity presentation was indicated. Scrupulosity is a common subtype of OCD specifically characterized by “pathological guilt or obsession associated with moral or religious issues” that often includes compulsive moral or religious observance and is highly distressing and impairing (Miller & Hedges, 2008, p.1).
The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), developed in 1989 by Wayne Goodman and colleagues, is a semi-structured clinical interview with a symptom checklist and a 10-item severity scale. The severity scale measures the dimensionality of obsessions in Items 1-5 and compulsions in items 6-10. For both obsessions and compulsions, clients are asked to rate impairment in terms of time, interference, distress, resistance, and degree of control on a scale from 0 (no symptoms) to 4 (extreme), resulting in a severity score from 0 to 40 and respective subscales from 0 to 20 for both obsessions and compulsions. The Y-BOCS has good psychometric properties and is widely considered the gold standard for determining OCD symptom severity (Nelson et al., 2006).
The Penn Inventory of Scrupulosity (PIOS) is a clinically validated, 19-item, 5-point Likert scale self-report measure developed to detect scrupulosity symptoms in OCD clients. The PIOS includes two subscales. One subscale measures fear around committing a religious sin; for example, “I am afraid of having sexual thoughts.” The other subscale measures fear of punishment for God; for example, “I worry that God is upset with me.” Statements are scored on a 5-point scale from 0 (never) to 4 (constantly). Individuals are also asked to describe their religious devotion from 0 (not at all devoted) to 5 (very strongly devoted) (Nelson et al., 2006). It is important to note that while the PIOS has been found to predict scrupulous obsessions in Christian patients accurately, the tool is less reliable for other religious groups and nonreligious persons (Huppert & Fradkin, 2016).
Beverly was provided both the PIOS and the Y-BOCS during her intake session. On the Y-BOCS, she scored a combined score of 33, indicating extreme symptom severity. She scored 19 on the obsessions subscale and 14 on the compulsions subscale. On the PIOS, she scored 74 out of 76, highly suggesting the presence of scrupulous symptoms.
Diagnostic Impression
According to the diagnostic criteria outlined in the DSM-5, Beverly’s symptoms meet the criteria for Obsessive-Compulsive Disorder (OCD) 300.3 (F42). Beverly also displays both obsessions and compulsions surrounding her religion, which is why we provided her with the PIOS. The DSM-5 defines obsessions as consistent and recurrent thoughts, images, or impulses that are intrusive and typically cause anxiety or distress. The individual then responds to the obsessions by trying to neutralize or suppress them with another thought or action, known as a compulsion (American Psychological Association, 2013). When an individual engages in compulsions, whether they are mental or behavioral, they are seeking to reduce or extinguish their anxiety or distress (American Psychological Association, 2013). It is important to note that these compulsions are time-consuming, excessive, and cause clinically significant distress or impairment of daily functioning (American Psychological Association, 2013).
Beverly reports that she constantly thinks of God and how to please Him by avoiding sinful activities or thoughts. Research indicates that “the core fear across religions within scrupulosity is related to a fear of sinning” (Huppert & Siev, 2010, p. 383). Beverly is not alone in the types of fears she has, as “displeasing God, going to hell and devil worship are common obsessional themes among scrupulous devout Christians” (Huppert & Siev, 2010, p. 383). When asked how she knows if her thoughts are pleasing to God or sinful, Beverly begins to sob, confessing, “She fears all of her thoughts are sinful because she believes that if she does not know if they are sinful, then they must be sinful.”
She also expressed that sometimes her thoughts terrify her. She was reluctant to share these private thoughts but eventually shared that she sees images of the devil and God yelling at her. Beverly expressed that she does not know where these thoughts and images come from and believes it means God cannot save her. She fears that God is going to punish her or send her to hell because of her thoughts. It is clear that for Beverly, “the shame of having bad thoughts is magnified because of their perceived sinfulness” (Baer, 2002, p. 109). Beverly’s obsessions and preoccupations with sin and punishment are causing significant distress and anxiety in her life.
Beverly shared that the only time she feels relief is when she is on her knees in prayer, often begging God to take away the disturbing images and forgive her for ever having such sinful thoughts. She said she spends her free time at her church or volunteering because she feels fairly confident that these activities are pleasing to God. However, when prompted further, she began to question herself (a common OCD characteristic), wondering if her motivations were wrong and, therefore, sinful. OCD is characterized by discomfort with the unknown, often coined “the doubting disease.” Individuals with scrupulosity OCD often “feel uncertain about religious experiences and do not find reassurance through the normal means available to them” (Ciarrocchi, 1995, p. 5).
When asked what else relieves her, Beverly shared that “talking to her parents and pastors about her thoughts and behaviors makes her feel better because they reassure her that God loves her and she is not engaging in sin.” Beverly quickly adds that they always tell her that if she fears she has sinned, she must ask God for forgiveness. Beverly shared, “This has been an ongoing conversation with her parents since she was little, and she constantly asks God for forgiveness throughout the day.”
It is clear that Beverly obsesses over her thoughts and actions and then engages in compulsions by immediately repenting. Beverly seems to experience compulsions through prayer, repentance, avoidance of non-church-related activities and people, and reassurance from her parents, pastors, and mentors. All of these internal and external behaviors temporarily provide Beverly relief from her distress while also perpetuating her OCD cycle and limiting her day-to-day experience.
Differential Diagnosis
Beverly’s presenting symptoms also meet some of the criteria for generalized anxiety disorder (GAD) and major depressive disorder (MDD). Beverly has been experiencing “excessive anxiety and worry occurring more days than not for at least six months” (American Psychological Association, 2013, p. 222). However, because her anxiety is related exclusively to her religious beliefs, she does not meet the criteria for GAD (American Psychological Association, 2013). The symptoms associated with MDD are guilt, feelings of worthlessness, and difficulty concentrating, but she does not meet the full MDD criteria, and her symptoms are better explained by OCD (American Psychological Association, 2013).
Evidence-Based Theoretical Approach
A form of Cognitive Behavioral Therapy, specifically Exposure and Response Prevention (EX/RP), is considered the evidence-based first line of defense for individuals struggling with OCD with the scrupulosity subtype. The CBT-informed development of EX/RP is based on the idea that individuals with OCD maintain their anxious baseline and obsessions by repeatedly engaging in rituals that relieve the anxious distress. For Beverly, this can be seen in her compulsion to pray and repent when she is anxious about her thoughts or actions possibly being sinful. EX/RP sees the patient “engage in sustained exposure to feared stimuli that trigger obsessions without ritualizing” (Huppert & Siev, 2010, p.1). With this, the individual learns that distress decreases without performing compulsions and that the feared consequences do not occur, challenging their preconceptions about disastrous outcomes (Huppert & Siev., 2010).
However, because of the nature of scrupulosity OCD, sometimes, when we are talking about the fear of consequences, “we are talking about the afterlife, which cannot be directly tested,” so it is important that “the patient must have faith in what [the therapist] and other religious advisers say before the patient is willing to do exposure therapy” (Baer, 2002, p. 109). We also do not ever want to ask clients to engage in behavior they deem sinful, as this might make them worse (Baer, 2002). When working through this with a client, a helpful question may be, “‘Do you truly believe that God is going to punish you for having your thoughts?’” (Baer, 2002, p. 109). For Beverly, it seems that she does see her thoughts as an act of sin, which means part of her therapy process is to rework her theology with the help of her campus pastor, who understands OCD (Baer, 2002).
There is also growing evidence that Acceptance and Commitment Therapy (ACT) offers beneficial perspectives while practicing EX/RP, and our clinical practice uses an integrative approach pulling from both a cognitive and values-based framework. The ACT approach to exposure emphasizes learning “to interact with feared stimuli in new and more functional ways so that the client can move in the direction of values - the things that are important and meaningful in life - which are currently disrupted” (Twohig et al., 2014, p. 1). While traditional EX/RP focuses solely on symptom relief, ACT also urges the client to pursue values-based living regardless of the intrusion of anxiety and safety behaviors (Twohig et al., 2014). In the case of scrupulosity, we believe considering values is imperative. We often ask ourselves as clinicians, “Which aspect of the obsession is the OCD talking, and which aspect is religious observance?” We do not want to encourage clients to disengage with their religion if it is important to them; we only want to encourage them to participate more healthily.
Role of Therapist
Creating a safe and welcoming clinical practice is essential. The therapist must establish a warm, trusting relationship with the client to achieve this. We believe this relationship should be collaborative, meaning the client and therapist discuss symptom reduction goals and interventions together. The therapeutic alliance has improved the likelihood of favorable outcomes across various psychotherapies and disorders; therefore, we believe in building this trust as quickly as possible (Horvath & Luborsky, 1993).
While we want to build and maintain a good relationship with Beverly, OCD research has shown that specific techniques predict better outcomes than common factors such as therapeutic relationships and expectations (Strauss et al., 2018). A study by Wheaton (2016) and colleagues found that the ratings of the quality of therapeutic alliances did not affect the overall outcome of treatment in EX/RP, but the “degree to which patients and therapists allied on the tasks of therapy did predict outcomes, suggesting that this particular aspect of the therapeutic alliance matters most to EX/RP” (p. 2). The study also indicated that task agreement correlated with improved EX/RP adherence. As stated previously, we will be focused on Beverly’s values in our work together, which will aid in task agreement for future exposures.
Because of the importance of faith in Beverly’s life, our practice must carefully consider her culture in our treatment plan. Baer et al. (2002) stress that collaboration with religious leaders may help alleviate client trepidation in seeking mental healthcare. We scheduled bi-weekly meetings with Beverly’s pastor, where we updated him on Beverly’s progress, and he shared helpful information regarding her behavior at church and on campus. Beverly approved of this release of information between both parties.
Goals and Interventions
As previously stated, our clinical practice utilizes an integrated approach of CBT and ACT. The interventions we used for Beverly primarily align with the ACT framework; however, we also incorporated adjunctive CBT-informed EX/RP. Research shows that ACT interventions produce clinically significant reductions in compulsions (Twohig et al., 2006, p 4). The primary objective of ACT is to help clients work towards greater psychological flexibility, defined as one’s ability to be in the present moment while simultaneously observing one’s inner experiences and engaging in actions that move one towards a more value-driven life (Twohig et al., 2014). There are six core processes of change within ACT, which all help the individual gain greater psychological flexibility. The six core processes are acceptance, cognitive defusion, awareness of the present moment, self as context, values, and committed action (Twohig et al., 2014).
In the early stages of Beverly’s treatment, we agreed on three treatment goals to focus on for the next three months. We decided to incorporate two research-informed ACT goals and one goal using CBT. To inform the ACT goals, we first spent time with Beverly clarifying her values, which can also be viewed as our initial intervention. Within ACT, values are defined as “ongoing actions.” These ongoing actions embody how an individual wants to behave towards themselves and others on an ongoing basis - i.e., what and who matters most to them (Harris, 2019).
Values differ from goals because they do not have an “end date” and are not time-bound. Instead, values are a choice to live a certain way each day; they are not the “shoulds” of life but indicate how an individual wants to live in the here and now (Harris, 2019). We provided an ACT values card deck to help Beverly clarify her top five values (Niculescu, 2021). During this session, we asked her to sort the cards into three categories: “most important,” “important,” and “not currently important.” Then, we discarded all the piles except the “most important.” From here, we slowly asked Beverly to pick her top 10 and her top 5 values.
Beverly’s five freely chosen values were faithfulness, family, creativity, inner peace, and community. Considering these values, Beverly came up with two goals she would like to focus on:
The client will increase values-driven behaviors from zero times per week to at least one time per week by attending a spiritual artist group at Wheaton (connecting the client to values of creativity, community, and faithfulness).
The client will monitor and track compulsions from zero times per week to seven days per week in a spreadsheet, noting impairment frequency and intensity. These include prayers, confessions, avoidance behaviors, and accusations of sin (connecting the client to the value of inner peace).
By clarifying the value of inner peace, Beverly began to buy into the therapeutic process. She recognized that her religious OCD makes it challenging to experience a balanced, fulfilling life. The tracking of compulsions helped us to identify what to focus on in our future exposures together while also acting as a psychoeducational piece for Beverly. Seeing her compulsion frequency listed on the page helped her to recognize just how frequently her daily activities are interrupted by her OCD. Maintaining her spreadsheet could identify further triggers and track progress once we embed exposures in later sessions.
Our weekly sessions also monitored her commitment to attending Wheaton’s artist group. Together, we processed how the group fulfilled her pursuit of a values-based life. Beverly reported that talking to new people about her faith made her happy and that she enjoyed creating art again for the first time in many years. In our session following her second spiritual art group, Beverly got through our session for the first time without crying and reported excitement for the future. She also expressed eagerness to create more committed actions surrounding her values.
Following the ACT framework, the second intervention we used with Beverly was cognitive defusion, another one of ACT's six core processes. Cognitive defusion separates them from their anxious thoughts and feelings by understanding them as just thoughts rather than truth (Stoddard & Niloofar, 2014, p. 8). Cognitive defusion must be a fundamental part of Beverly’s treatment because she entered therapy incredibly fused to her thoughts, evidenced by the great distress she was experiencing from them. Beverly’s “obsessions are caused by catastrophic misinterpretations of the significance of [her] intrusive thoughts (images, impulses)” (Twohig et al., 2006, p. 4). It is because of the fusion of her thoughts that she acts to alleviate distress through obsessions and compulsions.
For Beverly to begin exposure therapy, she first needs to undergo cognitive defusion so she does not equate her thoughts to sin. If she does not experience defusion, she would likely view exposures as sinful and, therefore, choose not to engage. This goal of ACT is “to help the client create a new relationship with their obsessive thoughts and anxious feelings: one in which obsessions can be experienced at face value as just another thought and anxiety is simply an emotion to be felt” (Twohig et al., 2006, p. 4).
There are many specific exercises to help individuals experience cognitive defusion. One example is deliteralization, where the therapist asks the client to repeat the obsession over and over until the obsession sounds like a noise devoid of meaning (Twohig et al., 2006, p. 4). When practicing deliteralization, the client is asked to repeat a word or sentence. For Beverly, we asked her to repeat the words sin, Satan, evil, hell, sex, and the devil. We asked her to repeat one sentence: “I’m going to go to hell.” This caused her anxiety initially, but after repeating a single word or sentence for two minutes straight, it started to help lessen the power of the thought (Twohig et al., 2006). She worked on deliteralization each week in session, slowly adding more words to her repertoire. Though Beverly initially felt the need to “repent” to God or her pastor after these exposures, she was forced to sit with discomfort in the safety of our office. When she realized nothing bad happened to her from uttering the scary words, she began to acknowledge that her anxiety was giving the word more meaning than it held.
After building rapport through our work in ACT, we aligned on one final goal based on CBT EX/RP:
3. The client is to increase exposure to triggering stimuli from zero to twice daily for three months.
A necessary component of this process was psychoeducation concerning the nature of OCD and anxiety treatment using EX/RP. According to Abramowitz et al. (2002), the patient's acceptance of the rationale behind the treatment and incorporation of religious elements for client comfort is requisite for success. For example, rather than explaining the evolutionary and biological aspects of anxiety to Beverly, we spent time discussing why God would create anxiety and the ways that anxiety may serve her at times.
We decided to use an imaginal exposure with Beverly as our final intervention, as in vivo exposures can often cause undue distress to patients experiencing scrupulosity (Huppert & Siev, 2010). Huppert & Siev (2010) recommend that the script should depict realistic behavior in the client’s life, as “making the scenario unrealistically extreme from the outset (like intentionally dropping the host during communion), may interfere with the ability of the patient to engage in the scenario, prevent activation of the pathological fear, and thereby dampen the effect of the exposure” (p. 387). With this in mind, we scripted a scenario for Beverly where she goes on a dinner date with a young man her age. During the date, the two discuss secular activities such as painting, going to the movies, and going to pop music concerts. After dinner, the two walk back to her car, and he reaches out to hold her hand. Before parting, the young man kisses her on the cheek. While reading the script to Beverly, we had her close her eyes. We invited her to alert us when compulsions interfered with her ability to be present, and we paused and discussed when this occurred. Over time, the client relaxed to secular triggers and began to pause less frequently, indicating more ease with dating and secular discussions.
Over our three months together, Beverly’s Y-BOC score decreased from 33 to 19, moving her into the “moderate” category of symptom severity. Her PIOS score decreased from 74 to 50, and she also exhibited a decrease in scrupulous symptoms. We plan to continue working with Beverly using our integrative mix of treatment to improve her functioning further and allow her to embrace a fulfilling, values-based life.
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