"Let He Who Is Without Sin "

-OCD and Religion-

by Fred Penzel, Ph.D.

If you had to sum up most of OCD in two words, they would be "pathological doubt." OCD can cast doubt on almost any aspect of a person's life and can force them to question almost anything they are, or anything they do. OCD is also extremely insidious and can infiltrate anything that matters to you. I have heard many of my patients state that "OCD seems to know how to pick on whatever will bother me the most."

One particular area that is of great importance and sensitivity to many people is their religion and matters of religious practice. It is something that they would like to feel is the most certain in their lives. As you could guess, this turns out to be a prime target for obsessive thoughts. Religious obsessions can take on any of the following forms:

• That the person has sinned or broken a religious law, or displeased their god in some way, either in the past or present, and may therefore go to hell or receive some other punishment
• That prayers have been omitted or recited incorrectly
• Repetitive blasphemous thoughts
• Thoughts about impulsively saying blasphemous words or committing blasphemous acts while attending religious services
• That the person has lost touch with God or their beliefs in some way
• Thoughts of being "unworthy" of salvation in some way
• Intrusive sexual thoughts about God, saints, religious figures, etc.
• That the person, through negligence has broken religious laws concerning speech, dress, food preparation, modesty, etc.
• Intrusive "bad" thoughts or images that occur during prayer, meditation, or other observances that "contaminate" and ruin or cancel out the value of these activities
• Believing that one's religious practice must be 100% perfect, or else it is worthless or worse
• Thoughts of being possessed

Naturally, the stronger a sufferer's beliefs, or the more orthodox their sect, the more distressful and upsetting these symptoms can be. There are many who, no doubt, suffer in silence, feeling too embarrassed or worried that they will be thought crazy or branded as religious outcasts. When people do seek help, they often turn first to their religious leaders. If they are fortunate, this person will have at least some understanding of problems of this type. If not, their revelations may be met with skepticism, criticism, or passed off as "nothing to worry about." In the worst cases, individuals are treated harshly, and told that they really are sinful and that their religious practice needs to be improved. They may even be instructed to do penance in some way, only worsening the belief that they have truly done something wrong. Even where a religious leader is sympathetic, consistent compulsive questioning and phone calling for reassurance by a sufferer can wear them down to the point where they become angry or impatient. After all, they are only human, and OCD, in truth, probably could try the patience of a saint.

If obsessions are intrusive, unpleasant thoughts, compulsions are the mental and physical activities that people with OCD come up with as a way of dealing with them. Since doubt is what drives most OCD, the answer, as OC sufferers see it, is to do, know, and control everything in a compulsively perfect way. When everything is perfect, there is no room for doubt. Compulsions start out as solutions, but inevitably become a large part of the problem themselves. On the surface, they may have some resemblance to religious practices, but are often exaggerated and extreme behaviors that are out of control. Some typical compulsions that are used in response to religious obsessions might include:

• Saying prayers, or carrying out religious acts repetitively until they are done 'perfectly (a process that can sometimes last for hours)
• Saying prayers or crossing oneself a special magical number of times
• Constantly asking for God's forgiveness, or telling God that you didn't mean what you said or did
•  Rereading passages from holy books over and over to make sure nothing was misunderstood or missed
• Repeatedly asking religious leaders or authorities the same questions on religious practice to be sure of understanding the answer, or to get reassurance about specific acts or words being sinful
• Doublechecking different religious acts or observances to be sure they were done correctly
• Repeatedly reviewing past thoughts or actions to determine if they were sinful or not
• Protecting religious symbols, ornaments, books, or pictures from "contamination"
• Constantly reviewing one's own words or phrases for double meanings that might have been irreligious or blasphemous
• Trying to imagine special "good" religious images or thoughts to cancel out "bad" and irreligious images or thoughts
• When any activity was performed with a blasphemous thought in mind, having to redo it with a "good" thought
• Excessive confessing of religious misdeeds or sinful behaviors to obtain forgiveness or reassurance
• Having to carry out religious dietary, dress, or appearance codes perfectly

This list by no means exhausts the possibilities. They are almost endless.

Treatment for religiously oriented OCD is in most ways, similar to that of any other form of the disorder behavioral therapy in the form of Exposure and Response Prevention (E&RP) and possibly medication. The general principles of behavioral treatment for OCD involve gradually confronting obsessions while resisting the doing of compulsions. In this way, the sufferer slowly builds up tolerance to the thoughts and their anxiety as they retrain themselves to not respond compulsively. Those with OCD typically make things worse for themselves by trying to follow their instincts in avoiding or trying to escape the things that make them anxious. In their zeal to eliminate all possibilities of doubt and risk, they do not stay with what they fear long enough to learn the truth. Unlike other forms of OCD, the facing of religious obsessions has some particular problems that must be carefully addressed. These issues would include the following:

1. Religion involves intangible matters of faith that cannot be seen, touched, or discussed from a scientific or logical point of view, in the way many other OCD problems cannot be seen, touched, or discussed from a scientific or logical pint of view in the way many oer OCD problems can.
2. In order to confront blasphemous thoughts and images, sufferers need to carry out behavioral homework assignments that superficially also look irreligious, but really aren't. Sufferers may be asked to agree with their unacceptable thoughts, or say or do things that bring on their anxieties, as they resist doing compulsions. Religious leaders who are consulted but don't understand may not be willing to give their approval for such an approach. Fortunately, there is a growing body of these people who can make the distinction between a psychiatric illness and sinfulness.
3. The consequences of being sinful or blasphemous may not be immediate, but could occur after a person's death far in the future
4. Behavioral homework may not involve simply doing things the way that ordinary people do (using the stove normally, driving without double checking, etc.), as when facing other types of OC fears, but may require the person to overcompensate somewhat in the opposite direction so that they can eventually find the middle ground

Getting people to engage in E&RP for their religious obsessions can be tricky, owing to some of the above issues. Matters of faith can get involved here in ways that make the planning and doing of homework a delicate maneuver. 

In order to be able to get a perspective on these issues, so that treatment may proceed, there are a number of understandings that must be established between patient and therapist. The most important one is that religious obsessions really have nothing to do with true religion as it is understood. They are biochemical aberrations, and therefore not a person's own real thoughts. They are, as a patient of mine once said, "synthetic thoughts." While the problem may superficially appear to be a religious one, it could really be about anything that OCD chooses to pick on. As said earlier, OCD has an uncanny way of picking on things that will bother a person the most. When a person is in the midst of OCD, it can be quite difficult to be objective and to see that these are not one's own real thoughts. A phrase many of my patients use is, "But it seems so real."

When a person is asked to confront their thoughts and actually confront their fears by allowing that they are true, it can sometimes be difficult for them to see that they are not doing this to mock, belittle, or speak badly of their own beliefs, but are instead engaging in treatment. There are usually three points I like to make to patients before beginning therapy. These are:

1. That if God or one's particular deity sees and knows everything, then they would have to know that the person is doing these exercises as treatment, and not to be irreligious. They would understand that the person is simply trying to break out of OCD in order to become closer to their God and more appropriate in their observance.
2. That what they have been doing up until this time is not correct and appropriate religious observance, but is compulsive and outside the norm, and cannot continue if they wish to be appropriately observant according to the dictates of their faith.
3. That they are being asked to do some things that on the surface may look religiously inappropriate in order to get them over their anxieties, so that they can return to what is considered appropriate religious practice. What they have been doing up until this time in terms of compulsions would also have to be considered religiously inappropriate. Unless they build some kind of tolerance to the thoughts and anxieties, they will remain prisoners of their OCD. 

Recovering from OCD means taking risks, and this means letting go, not just in the sense of letting go of compulsions, but also in terms of letting go of that need for certainty in the face of obsessive doubt. Doing certain types of behavioral homework assignments for OCD may sometimes make a person feel as if they are jeopardizing their immortal soul, but there are times when in order to prevail over the illness, they have to take a leap of faith. There is a very good saying that is used by the members of Alcoholics Anonymous "Let go, let God." My own interpretation of this for our purposes, is that if you have faith and truly believe, you sometimes have to put yourself into God's hands and trust that you will be guided in the right direction. 

It is also important for patients to understand that they will not have to go on doing these types of assignments indefinitely - only until they reach the point of recovery. 

Can everyone get past their obsessive religious fears in order to take what look like risks in the service of recovering? The answer is that not everyone can. Although I have seen quite a number of people recover from this particular type of OCD, not everyone is ready or able to recover at a given time, nor may they have the insight to see what is really happening. Some people find their thoughts extremely believable, due to the magnitude of their biochemical problem. Their fear of damnation or punishment at a particular time may override their desire to reach a recovery. However, if an OCD sufferer can accept and understand the true nature of treatment, they stand a better chance of improving. They need to accept that the subject matter of the thoughts involves the very aspects of their lives about which they want to be the most certain. Faith has helped many individuals overcome great obstacles in life, and when correctly channeled, it can also help to overcome OCD.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000). You can learn more about it at www.ocdbook.com