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:

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.

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