Monthly Archives: October 2014

Help for Jewish Scrupulosity Problems

Posted on by
Reply

I got the chance to sit down with Dr. Jedidiah Siev and talk about OCD with scrupulosity. I asked him about seeking treatment and individual experiences of OCD with a focus on Jews with scrupulosity. You can listen to our conversation and read the complete transcript below. You can find out more about Dr. Siev on his website.

– Lee Baer, Ph.D. 

Play audio here:

IMG_0864

Lee Baer, Ph.D. (LB): When we’re talking about scrupulosity, most of the papers have been on Orthodox Jews. Do you think that reformed Jews or conservative Jews would develop scrupulosity?

Jed Siev, Ph.D. (JS): My personal experience has not been with non-orthodox Jewish people with scrupulosity about their Judaism.  For a while I thought that meant that the other folks don’t have it. Sometimes you’ll have someone who develops scrupulosity about their religion as they were raised. Maybe someone who’s lapsed or shifted away from being Orthodox might have it. One of my colleagues said that he regularly sees people who identify as reformed and have scrupulosity. So they certainly must exist even if they don’t come to me.

LB: If somebody realizes they have OCD, they have scrupulosity – what would you suggest in terms of consulting or a group of psychologists or psychiatrists?

JS: In both cases it’s just really important to interact with people who are knowledgeable. So a psychologist who’s knowledgeable about OCD and scrupulosity but also open being at least educated about some of the specific religious requirements or boundaries. I’d say the same thing about clergy, clergy are for the most part very open to collaboration with a therapist but they could accidentally, inadvertently reinforce the problem. For example, if they don’t understand OCD and ERP they can make suggestions that can reinforce it. If someone continues to obsess, a religious clergy member who has been trained to avoid sin might give advice that in the case of OCD coopting the religion is actually in service to OCD. Like, “keep praying, keep confessing, or undo it in some sort of way.” You have to have someone who’s willing to have a discussion and become educated if they’re not already just about the basics of OCD, OCD treatment, and the rational of that. It’s really helpful if you can communicate them as the patient or the therapist that your goal isn’t to undermine religion. On the contrary, religion is usually influenced badly by OCD and your goal is to help them lead a more fulfilling life in service of their goals and values by removing OCD from religion.

LB: Probably many people who find out they have OCD with scrupulosity won’t be seeing a therapist because they don’t have access to one, or they can’t afford it, or they’re afraid to go, or live an area with no one who treats them. Would you recommend that they go to a clergy person that they trust as a first step?

JS: Certainly there’s nothing wrong with consulting a clergy person. It depends where they are in their awareness of their problem. Some people at first are not sure where the boundary is. A lot of people say to me, “I don’t know the line is between what I’m required to do religiously and when it becomes OCD.” Clarifying that kind of thing can certainly helpful. It’s hard to say a blanket statement because I don’t know who the clergy person is and what their level of knowledge is. If you’re still trying to understand whether you have OCD to an extent that your religious observance has been coopted by the OCD or if it’s quantified religious observance. That would be a good place to start.

LB: If a clergyperson says “God has exclusions for someone who’s sick, sort of a blanket.” Is that helpful?

JS: That can be tricky because if someone is using any kind of excuse to explain or pardon why it’s okay for them to do what they’re doing, that’s undermining the exposure. If you’re already trying to do ERP or engaging in exposures to tolerate uncertainty and someone says “well, you can go and eat that even though normally it might not be ok because you’re sick and therefore you have dispensation.” So I worry about that being avoidance and reassurance. Now you’re not taking any risk because you’ve got some sort of special dispensation and you’re no longer doing something that requires you to tolerate appropriate levels of risk and uncertainty.

LB: So what can a clergyperson then say that would help other than: God understand that you have this problem and he’s not going to punish you for that. Isn’t that reassurance?

JS: I distinguish between just setting down what the guidelines are and seeking excessive reassurance or acting in a way that’s not similar to everyone else. For example, if just about everyone else in the religion is not praying for an hour at a time or they’re not engaging in the same kind of rituals as you are, you need to learn to tolerate the same amount of risks. But, if nobody else would eat this, I don’t see how it’s helpful to say “well, you’re sick therefor you have an excuse to eat this.” It’s not an exposure anymore, it’s just permission. If it would be as simple as the clergyman saying this is permissible and just laying out accurately what the normative standards are for, say, eating kosher – if that would be enough to provide reassurance, the patient wouldn’t be there in the first place.

LB: How about concrete examples. Somebody who worries during fast that they swallow their saliva and that’s breaking the fast. What would you tell them in that situation?

JS: I think it’s helpful to clarify what the religious requirements are at first and I wouldn’t consider that to be a problem of reassurance. I think it would be ok to ask somebody whether one is prohibited from swallowing during the fast. If the answer that it’s permissible to swallow, then that helps guide you to make the decision that this fear is not a bonafide, legitimate religious fear, it’s a fear that stems from OCD. Then I would ask them to handle it the way you handle all your OCD obsessions which probably means by taking that risk, by turning into it instead of away from it, and doing ERP

LB: So in that case, that’s just correcting misinformation?

JS: Well, what I imagine would happen to people with that obsession is that they’ve heard it since the time they were kids and they know that’s officially the rule. But there’s all the what-ifs. What if I’m salivating a lot, what if it comes out of my mouth and I suck it back in – all the obsessional what-ifs.

LB: I think it would be helpful to talk about some specific cases you’ve seen. Doubt is a major thing.  If somebody can’t be certain that the food they’re eating didn’t come in contact with a non-kosher plate and they try and think back and remember that. Then it’s this doubt and uncertainty. Can a clergyperson help there?

JS: I’ll give you an example of one of the first people I worked with. She did in fact have contamination issues related to keeping kosher. In Jewish law, you can’t mix milk and meat products. She would avoid cooking meat products the same day she had handled milk…maybe there would be residual bits of the milk. The first thing we did was work our way up from things that are clearly permissible in Jewish law but still caused her some anxiety. For example, touching dairy and meat pots that are all clean and cold – not even heated up. There’s no reason at all in Jewish law that one couldn’t do that but it still caused her some amount of anxiety. It’s actually the case that there’s no reason at all why even if you have a little residual milk on your hands that you couldn’t then touch meat, but we’ll leave that on the side.

LB: Would every rabbi agree with what you just said?

JS: Yes. Then, what we would ultimately build up to is doing things that were still permissible by whatever Jewish rabbinic authority she accepted. I find it useful to have the patient have a say in that so you’re not picking and choosing leniencies. So she had her rabbinic authority, and we consulted with her rabbinic authority. He understood, and was certainly open to us explaining, what the rational was for treatment and what we were trying to do. What he was able to do was find the limits of how far we could go without technically violating law – even in ways that people typically wouldn’t do their kitchen. For example, it would be very unusual for people at the same time to be cooking dairy and meat on the same stove. It would be unusual for you, if you kept kosher, to handle cheese and then immediately handle meat, maybe just wiping you handle on a towel once without washing your hands. That wouldn’t happen commonly, and it might make people with OCD a little uncomfortable because, why are you doing it? But there’s actually nothing technically prohibited about it. So he helped us find things that would be really pushing the limit even beyond what people might normally do, but not beyond what was permissible. So everything we did was technically permissible.

LB: Let’s say that someone can’t be certain that they didn’t do something accidentally – violate some rule.

JS: Which they never can.

LB: If they say to a rabbi, what will happen if without my knowing it I violated a law? What would the rabbi say?

JS: It’s hard for me to know what everybody would say, it might depend on exactly which law. I think it would probably depend quite a bit on the degree of carelessness leading to violation of law.  I’m not a religious scholar, but there’s a difference between being wildly careless. That would be the same thing with contamination – it would be different if you just started using needles without making sure they were clean needles and you ended up contracting a disease.  That would be an inappropriate risk to take, it would be careless, it would be high risk behavior, and not being able to be sure that it wouldn’t happen.

LB: So if someone worries, or doubts, how can I be certain that the rabbi that was supposed to certify that this chicken or cow was killed properly, that they didn’t make a mistake. Would the clergyperson tell them that God would hold it against them, if those things happened without their intent or knowledge?

JS: No. Certainly not.

LB: Other than dietary problems, which are mainly the ones I’ve seen, where people actually stop eating. What else have you seen? Have there been problems with cleanliness or women menstruating or things like that?

JS: Certainly. Ritual purity, family purity laws as well as other kinds of ritual purity. Prayers, people will obsess about not having sufficient concentration during certain prayers or repeating those prayers. I worked with a young man who was concerned about bowing during prayers in front of something like a railing because the railing might be shaped like a cross, there’s a vertical part and a horizontal part. That same young man also had obsessions in doing his religious studying. He had obsessions about accidentally making vows which he would then violate, and that would be a serious problem. For example, in typical Talmudic study, the study is structured around legal hypotheticals. So one studying with a partner might say something like “I say to you that I owe you a hundred dollars…” and then you talk out the case. He would have all kinds of obsessions that he was accepting upon himself as a vow that he didn’t owe the money and wouldn’t actually give it, so a lot of concerns about vows. He had concerns about violating the Sabbath as well and would engage in all sorts of avoidance and checking rituals to try to avoid doing that.

LB: Using electricity and things like that?

JS: He was worried about carrying things in places he couldn’t carry. He would check his shoes and his pockets for any drops of lint that might be in there accidentally.

LB: Say someone is not actively involved in a congregation and they have these questions. Where should they go to get clarification on rules?

JS: Do you mean questions about whether or not they’re permitted to do something?

LB: Let’s say they’re afraid to go to a synagogue because they’re worried they’re violating law. So they are praying at home and now they’re worrying that their hearts not in it or they’re not concentrating enough – where you would you suggest they go to get advice?

JS: It sounds like some sort of joint assessment from a knowledgeable and acceptable to them clergyperson about whether or not they’re exceeding the standards as well as from someone who knows enough about OCD to decide whether or not these are symptoms of obsessions and compulsions.

LB: Wouldn’t clergy from different denominations give different advice?

JS: I think clergy from all denominations might see it themselves differently, but I think they’d be able to recognize – if you have a reformed rabbi, they would not have very much difficulty recognizing whether someone’s behavior was compulsive vs. an Orthodox normal way of behaving. What’s most important is that the person not end up shopping around so much and get the sense that they’re either shopping for leniencies or stringencies. What I suggest is that they pick someone who is a respectable religious authority to them, whatever they personally believe, so that persons answer can be taken as religious advice.

LB: Are there cases where people said: “if I had explained it differently…” I saw someone who didn’t take this rabbi’s advice, went to Jerusalem didn’t take that rabbi’s advice, was trying to see the head rabbi on Brooklyn – was on the list for years – and probably would have doubted his advice too. How would you advise that person?

JS: That’s the same as with any OCD, there’s always doubts that will creep up afterwards: maybe I didn’t explain it well, they didn’t understand it well, I wasn’t so clear, they weren’t paying attention, If I only would have told them this extra piece of information they would have known it. That’s the case with people who are worried about whether they’re going to harm somebody and are recognizing the hidden threat inside them. So that’s always going to be the case, and the person has to decide. I would ask them to be the partner in the decision making process, if they were my patient. They have to decide what their standard is for being able to assume something is ok. This comes up panic patients, they go to the doctor and the doctor has cleared them and said it’s panic. But we all know doctors make mistakes sometimes. How many times do you need to get worked up again before you’re going to decide that although doctors sometimes make mistakes, the appropriate decision, at this point, is to accept it as if it’s fact. That’s the same kind of decision making process that they have to make when it’s a religious issue.

LB: The last area is for family members. Advice for family members, assuming there is not therapist, how would a family member work with something like this?

JS: The family member has to understand that they’re not a therapist. There’s a different kind of dynamic between family members and therapists and a patient. There are different kinds of battles and the patient doesn’t relate to you in the same way. You also have to understand as the family member, what may seem like a “just get over it” kind of thing to you, because you recognize that it’s excessive, is not experienced that way for the other person. You’re kind of suggesting they run a marathon when they hate running because you like running, and you’re going to run a marathon. I would say that there’s a little bit of a do no harm kind of approach that I’d suggest which is – are you really going to talk them into it by yelling at them one more time or just by trying to convince them that the rabbi said it’s ok as if they don’t remember that.

[subscribe2]

Help For Catholic Scrupulosity Problems

Posted on by
Reply

Image_MinichielloI had the pleasure of speaking with Dr. William E. Minichiello, a psychologist at Mass General Hospital, about OCD with Catholic scrupulosity. You can listen to our conversation and read the complete transcript below. Here are the links to the resources he mentioned:

Scrupulous Anonymous

The Paulist Center Boston

Paulist Fathers

– Lee Baer, Ph.D.

Play audio here:

 

You said that you recently saw a woman who was raised Catholic who came to you with scrupulosity concerns about having committed a sin. Do you want to start, without identifying her, by saying what her fear was and then what you told her about what sin is and isn’t?

That was an elderly woman who was referred to me with scrupulosity. She had a lot of doubt about sins, confessions that really weren’t sins. What I explained to her was that in order for something to be seriously sinful, first of all, the matter of what she was concerned about had to be serious matter. That was one thing. The second thing was that she had to know that it was serious. Then the third thing was that she had to have full consent of her will to do that which is serious. Clarifying that for her was very important because she was confessing things that really weren’t sins – they were faults. She never had what we call sufficient reflection. In other words, she never reflected on the fact that she wanted to do that which was seriously sinful. In other words, something that would separate her from God. She never had that reflection. Most importantly, she never had full consent of her will to do that which was seriously sinful, which she knew to be seriously sinful. She was confessing a lot of sins which, as I said, weren’t sins. Certainly nothing that would separate her from the love of God. That was extremely helpful to her, once she got that clear. Her trips to confession became normal rather than what they were. She would go to confession frequently and whenever she went to the liturgy she wouldn’t take part in the most important part, the reception of the Eucharist. That was important to clarify that for her.

Would you say the majority of Catholic priests would agree with the three points that you laid out to her?

I would say the majority of priests should. If they in fact do, I don’t know. The majority of them should be familiar with the principles I laid out. Certainly those who reflected on the teachings of the second Vatican council would be aware of those. I would say they were taught them, whether they carry them out in practice I don’t know, but they should be aware of them.

If someone who’s Catholic has excessive praying or doubts about whether they committed a sin, where would you recommend that they go first for advice in their community?

What they should do to start out with is to find out what they can about an organization called Scrupulous Anonymous, which lays out those principles pretty clearly in its publications. Start there and then go to a parish that’s a progressive parish – where there’s a high probability that the priests would be progressive in their outlook and progressive in their moral teachings. I think that would probably be the best approach.

Let’s say that they’ve been going to a church with their family for years and they haven’t spoken to the priest there yet. Do you think that should be their first step?

If they have a feeling based on having gone to Mass there and based on what they’ve heard in the sermons, they can make a judgment that this is a person with a progressive approach or a black and white approach. If it’s a black and white approach I would suggest that they not and suggest that they go to a place like the Paulist Fathers Chapel in Boston. In most major cities the Paulists have a chapel where they celebrate the liturgy, hear confessions, give lectures, etc. Based on what their assessment is of their local parish from what they’ve heard when they’ve gone there and what they’ve talked to other people in the parish about, if they have a feeling that the priests there are progressive in the spirit of the Second Vatican Council, go there. If not, seek out a place like a Paulist center – if they’re near a large city.

How often have you run into or spoken to priests who you would consider black and white in their thinking and might make the persons scrupulosity worse, or not recognize it as scrupulosity?

It’s certainly less so than it used to be, before the Second Vatican Council. I don’t know if it’s the majority, but a fair number of priests are knowledgeable about scrupulosity and how to handle scrupulous patients.

What’s your impression of the current Pope? If you were to sit down and speak to him about patients you’ve seen who are Catholic who have OCD, do you think he would generally agree with the points that you mentioned? From what you know of his writings and speeches. 

Based on what I’ve seen, he’s terrific. His approach is exactly what’s been needed for so long. He emphasizes the love and mercy of God rather than the aspect of sin and punishment and damnation. His approach is fabulous, and I just hope it continues. He’s emphasizing the right things – he’s emphasizing compassion, love, and forgiveness.

Do you think he would recognize when someone has a problem with doubt, he would separate it being a spiritual problem from being an OCD problem?

I think so. I think his approach is excellent. If every priest in the world adopted his approach I think that would be a major step forward in helping people with religious scrupulosity.

The major ritual or compulsion we see is obsessive praying, or not feeling like the person said the prayer with the right frame of mind. Maybe you could talk about what you’ve seen and what you advise people to do about prayers that can take hours, or they worry all day about whether they’ve prayed correctly.

The important thing there is for people to realize that God knows what’s in their heart and that it’s not necessary for them to repeat prayers. What is prayer – it’s talking to God. You wouldn’t talk to your closest friend and keep repeating the same thing – it would be meaningless. With God, it’s even less necessary to repeat anything because God knows what’s in our heart. The scrupulous person needs to keep that foremost in his or her mind when they pray. They just need to talk to God as if they would talk to their best friend and not continue to go over and over the same thing.

What have you advised patients as far as knowing when to stop or knowing when a prayer is enough?

What I would advise them to do is to start off with what I just said: focus on the fact that God knows what’s in their heart and try and go against what their OCD is telling them to do, which is to repeat what they just said. The goal would be to try and do what someone who doesn’t have OCD with scrupulosity would do, they would say their prayer once and not repeat it. Someone who’s scrupulous, that’s going to be a little difficult, so you try and get them to reduce the number of times they repeat based on how many times they are repeating.  You set a goal, and get them to reduce it each day or each week until they get to the point where they’re like someone who doesn’t have OCD and they just say their prayers once.

How does a person without OCD know when is enough and what’s average length to spend in prayer?

What people who don’t have OCD do, they say their prayer once because they understand and accept that God knows what’s in their heart and it’s not necessary for them to repeat again what’s in their heart. They’ve already done it and God knows what it is. Move on, say it once and that’s it.

Let’s say they can stop repeating but they feel that they have to mention everyone in their family, or is sick, or every friend in their prayer. So even if they don’t repeat it can take hours and hours for them to mention everyone. What advice would you give them?

I’d give them similar advice. So maybe mention everybody once and then after that when they pray they can just say “all those people who I had previously mentioned to you, God. These are the people for whom I’m offering this prayer.” And not go through the list of a hundred people. If they’ve done it once, then they can just make that reference. “God I’ve already told you the people for whom I offer this prayer.”

One of the problems that mental health professionals have in treating people with scrupulosity of whatever religion is they’re not as trained or knowledgeable about the scriptures or the particular religion. Are there New Testament quotes or verses that particularly bother people?

I think there are New Testament verses that would help people not to get into those kinds of things. Some of the verses from John’s gospel about God having loved us, those are important verses to help people. The best approach is getting people to just accept that God loves them and that God knows what’s in their heart. They don’t have to repeat prayers, they don’t have to be afraid that God is waiting for them to make a mistake and that he’s going to hammer them. Try to get them to understand some of the parables that Jesus taught and pointing out how forgiving God is, how accepting God is of our frailties and our sins. The parable of the Prodigal Son, going over that and getting them to understand that in the parable, the father had a big party to celebrate the return of his son, who had gone down to the city and blown his inheritance on riotous and sinful living. When the son had lost everything and wanted to return to his father’s house, the father didn’t make him jump through any hoops. He ordered a big party and sent his other son out to kill the fattened calf and rejoice – the son who he thought was lost had returned.

That’s an example of someone who with intent did something wrong.

People who have OCD, they don’t intend to do those kinds of things. They have all this overwhelming doubt that they did. Doubt doesn’t count. Where there’s doubt there’s no sin.

The last thing I wanted to talk to you about is something that you’ve emphasized talking to me and I don’t think I’ve heard from anybody else. It’s just this idea that the view of the Catholic God as a punishing God seems to have changed a lot since after the Second Vatican Council. I think you’ve said that psychiatrists see a lot less OCD with scrupulosity than they used to. Could you just talk about that change and when it happened and why it happened?

I think that’s one of the encouraging things with Pope Francis. He’s much different than the last two popes who focused on sin and punishment rather than on love and forgiveness. Prior to the Second Vatican Council (1962-1965), that’s what the focus was on and since the Council, the focus has been on love and compassion and not on sin and punishment.

For younger people who weren’t around in the 60’s, what changed in the teaching?

It was a change in focus. The focus went from the negative aspects of religion to the positive aspects of religion. The emphasis shifted away from sin and its consequences and punishment to positive things like compassion, focus on the social gospel; feeding the sick, comforting the grieving, helping the homeless, administering to the poor and the needy. These are the works of mercy as spelled out in the 25th chapter of Mathew’s Gospel. Jesus talks about the last judgment. There’s nothing in there about sexual sins or anything like that. “I was hungry and you gave me to eat, I was naked and you clothed me, I was a stranger and you welcomed me.”, etc. The passage goes on: “When did we see you this way?” and Jesus says: “As long as you did these things for the least of my brothers, you did them for me.” That was the change and emphasis away from sin to ministering to the least of the brothers. The emphasis changed.

That was around the early-mid 60’s?

That was when the council started in 1962 and ended in 1965. Under the next Pope, Paul VI, there was implementation of that. With John Paul II, here was a retrenchment, an effort to get back to the way things were before the Second Vatican Council. I think that has ended now with Pope Francis who is much more like John XXIII who called the Second Vatican Council to reform the church.

Do you think a lot of the differences in advice that a scrupulous Catholic might get would depend on when their priest attended seminary?

I think that’s part of it. But not exactly. You have a lot of young priests who were devotees of Pope John Paul II who are part of that retrenchment. It’s really about how priests responded to the Second Vatican Council and how they’ve tried to implement it at their parish. In different Catholic parishes you’ll see a big difference depending on how the clergy in that parish have responded to the Second Vatican Council.

You mentioned that people should look at Scrupulous Anonymous…

One of the things that they can find there are the 10 commandments of the scrupulous. I think those are extremely helpful. Not to confess doubtful sins when they confess their sins in the Sacrament of Reconciliation, not to repeat sins that have previously been confessed, not to repeat their penance, not to be afraid of looking at a crucifix or a statue because a bad thought enters into their mind. A lot of excellent things are in those 10 commandments.

And their organization is run by knowledgeable, reputable priests and scholars?

It is run by the Congregation of the Redemptorists whose founder, Saint Alphonsus Liguori, also suffered from scrupulosity himself. They’re very reputable and they’ve been at the forefront of helping people with scrupulosity.

The last thing you mentioned was that people can contact the Paulists in their area?

The Paulists are highly educated. They run a lot of the Newman Clubs in the major universities in the United States. In all the major cities in the United States – Boston, New York, Chicago, San Antonio – they have what they call the Paulist Center. It’s like a parish for people who are alienated from their own parish. They have daily Mass, Sunday Mass, confessions, a series of lectures and outreach to carry out the social gospel in the city. To help the poor and so on.

What about people who live in South America or Canada or Europe? Are there Paulist Centers there?

I know there are in certain countries, in Europe and Canada, I don’t know what they have in South America. I know they’re found in some of the European countries.

Any last advice to give to a Catholic who suffers from scrupulosity?

The advice would be that they need to understand that they have a treatable condition and it’s not something that they should continue to suffer with. It’s not something that God wants them to suffer with. God wants them to achieve peace and hope. That’s what Jesus’s message was all about, to bring God’s love and God’s peace and God’s healing and God’s forgiveness to them. There is help out there if they can find the right place to go and the right people to give it to them.