Part 3

Scrupulosity Treatment

In part 3, chapters 9 through 14, I present a comprehensive exploration of scrupulosity treatment, including treatment considerations, self-help treatment, and treatment outcome.

Chapter 9, “Treatment Considerations,” looks at various aspects of scrupulosity treatment. This a high-level discussion that sets the stage for the more detailed treatment chapters that follow. I first address motivation to engage in therapy for those that may be hesitant to do so. I then give overviews of medication use and psychotherapy in treating OCD. I also compare and contrast the short- and long-term effectiveness of medications and psychotherapy. Most of the chapter outlines unique difficulties in scrupulosity treatment that anyone considering intervention should avoid. Lastly, I discuss the role of uncertainty.

Chapters 10 through 13 present a self-help treatment approach to help you apply treatment principles in a practical way. Chapter 10, “Self-Help Treatment: Building a Solid Emotional Foundation,” is all about mindfulness, including distress tolerance and self-care. Almost without exception, when people first meet with me, they report having very little in the way of adaptive soothing and coping that works for them. If you’re going to learn to tolerate the distress of high levels of anxiety in therapeutic treatment, then you need internal emotional-stabilization resources to be able to work through the process. I discuss mindfulness, which encompasses self-soothing, meditation, basic distress tolerance skills, and positive sentiment activities. I conclude with a brief introduction to acceptance and commitment therapy (ACT).

In chapter 11, “Self-Help Treatment: Cognitive Work,” I cover the cognitive model and define common cognitive distortions. I introduce you to six exercises you can do to address your anxiety: doing a cost-benefit analysis, challenging distortions, examining definitions, completing a thought chart and a responsibility pie chart, and transferring responsibility to God.

Chapter 12, “Self-Help Treatment: Exposure,” introduces you to some basic principles of the exposure model and to exposure and response prevention therapy. I also discuss two theories about how exposure works to reduce anxiety: habituation and the inhibitory learning model of extinction. Both theories are incorporated into the treatments herein. I also address the principles you need to follow to do exposure properly. Lastly, I explore the different types of exposure therapy.

In chapter 13, “Self-Help Treatment: Specific Exposure Exercises,” I teach you about specific exposure exercises that you can do on your own or in your work with a therapist. I first discuss how to prepare for exposure by examining your willingness to do exposure. Then I teach you how to construct a hierarchy of fears to guide your choice of content to use for the exposures and discuss other exposure principles to consider. I then look at specific exposure exercises, teach you how to put together an imaginal exposure narrative, and describe how to conduct an imaginal exposure. Lastly, I comment briefly on how to integrate the many therapeutic elements I’ve described in the treatment chapters.

I conclude the treatment chapters with chapter 14, “Treatment Outcome.” It addresses what is likely a critical question on your mind: “Is there hope that I can improve and find joy in my religious devotion?” In this chapter I explore psychotherapy treatment outcome for those struggling with OCD and particularly scrupulosity. I share three clients’ observations about how therapy has helped them, as well as their detailed stories with data from their recovery. I also share an outcome of a “crash course” in therapy and long-term stories of healing to give you a glimpse into your future possibilities—a life at peace with your religious beliefs.

Chapter 9

Treatment Considerations

This chapter is split into two general parts. Part 1 presents an overview of available treatment options. Part 2 more fully explores treatment considerations for engaging in psychotherapy treatment for scrupulosity OCD.

Part 1: Overview of Treatment Options

Medications for OCD

Medications for anxiety lower physiological arousal. You may feel less anxious as you take medication or feel able to recover more quickly from anxiety triggers when they come. These medications also help to decrease obsessions and the urges to perform compulsions. Some might say they “take the edge off,” help the brain “relax,” or make the thoughts “less sticky.”

Medications that are used primarily in the treatment of OCD are called first-line treatments. Reviews have indicated that the selective serotonin reuptake inhibitors (SSRIs), which act on serotonin, are the most effective medication for the treatment of OCD.[1] The SSRIs are a newer class of antidepressants, but they are not new drugs. These drugs, often used in treating depression, are also effective in treating OCD and are FDA approved to treat adults with OCD in the United States. Some of these include names you’ve probably heard: sertraline (Zoloft), fluoxetine (Prozac), fluvoxamine (Luvox), and paroxetine (Paxil). Zoloft, Prozac, and Luvox have also been approved to work in children as well. The SSRIs are generally well tolerated and have a favorable safety profile.

Other medications used as first-line treatments for OCD include venlafaxine (Effexor) and duloxetine (Cymbalta), which are serotonin-norepinephrine reuptake inhibitors, and clomipramine (Anafranil), a serotonin reuptake inhibitor that is a tricyclic antidepressant that acts on both serotonin and norepinephrine. Clomipramine may have greater efficacy over the SSRIs; however, poor tolerability and even potential lethality in overdose make it a less practical first choice.[2]

There are other medications that are used off-label to treat OCD. When a medication is used to treat a disorder or an age group not specifically listed on its prescribing label as an FDA-approved use, then that’s considered an off-label use. Paxil is not FDA approved to treat OCD in children, but it is commonly used for that purpose. Other drugs used off-label for treating OCD include the SSRIs citalopram (Celexa) and escitalopram (Lexapro).

Nearly all SSRIs have randomized clinical trials and FDA indications that support their use for OCD. There is no evidence suggesting that one SSRI is superior to another, so SSRI choice may simply be an issue of preference.[3] So how does preference come into play in choosing which medication(s) to try? As therapists cannot generally write prescriptions, you will need to visit with a medical provider about medications. Ideally, you would work with a psychiatrist (a medical doctor with specialized training in mental illness and medications). However, in many circumstances psychiatrists are in high demand and have long waitlists. If needed, a general medical practitioner can also prescribe these types of medications. Your provider may have a preference about which medication you should try due to how the medication has performed with previous obsessive-compulsive patients. That is likely a good place to start. Oftentimes it’s trial and error, as you won’t know how a medication works for you until you try it. If one medication begins causing you problems (i.e., side effects) or it is not helping you (please note that it takes as long as four to six weeks to reach therapeutic dose), then it is a good idea to discuss the possibility of changing medications with your doctor.

Research reviewing treatment studies that examined medication impacts on sexual and sexual/religious obsessions found that people had a poorer response to the medication in two studies (relative to other types of OCD obsessions). In other studies, those who responded to the medication and those that did not were not significantly different in terms of percentage of individuals with sexual and religious obsessions.[4] So one cannot easily predict from the research whether medication will be of service to you in your battle against scrupulosity. You will just need to try it for yourself, if you choose to do so.

Psychotherapy for OCD

Life experiences and behavior therapy have measurable effects on brain structure and function.[5] So taking a medication is not the only way you can change your brain function when you have a disorder such as OCD. In truth, we are changing our brain every day with learning and experience.

The general goals of scrupulosity psychotherapy treatment are to (1) weaken distorted and dysfunctional beliefs that are not consistent with a person’s religion and religious identity, (2) increase a person’s ability to tolerate uncertainty, and (3) reduce a person’s reliance on avoidance, compulsions, and other safety-seeking behaviors that prevent changes in belief and improved tolerance of uncertainty.[6] This approach helps people with scrupulosity to engage in their religious practice in a healthy, flexible, and faithful way.

Therapy is successful, in large measure, because of its focus on eliminating safety-seeking behaviors while managing the physiological arousal of anxiety. As you’ll recall from our earlier discussion, “safety behaviors are coping behaviors used to reduce anxiety and fear when the user feels threatened.”[7] So therapy is helpful because we ban the use of safety behaviors, exposing the person to the feared anxiety rather than seeking to shield or protect them from it. Through that process, people learn to tolerate anxiety, and in time the anxiety tends to diminish. One woman commented on her therapy process:

I found that once I made the decision to fight back against my obsessive-compulsive disorder and really put energy into doing so, things got better pretty quickly. I had heard this would be true and was pleased to see it happening in my own life. That, after all, is the basic principle behind behavior therapy: you make purposeful changes in your behavior that counter what the mental illness demands and progress occurs. As I did it, I took back ground from the OCD. My self-esteem and confidence increased. I began to improve. . . . I was changing, I was becoming who I used to be.[8]

Psychotherapy treatments are often administered in an outpatient individualized format, with either in-office, face-to-face meetings or via secure HIPAA-compliant video chat or telehealth services. Typically, outpatient psychotherapy meets for forty-five to sixty minutes at a time, once or twice a week.

Psychotherapy treatment for OCD can also be administered via group therapy. Group therapy is a format in which a mental health professional leads a group, activating principles of group dynamics to achieve a therapeutic purpose. In a group therapy session you learn treatment skills, but the therapist also works to harness the collective power of group dynamics and interactions with other group members to help participants learn additional insights, gain a sense of universality (“Wow, I’m not the only one!”), and the like. In addition, group therapy offers the practicality of treating several people at the same time, which also reduces the financial expense to you as the client. Generally, research has found group therapy to be as effective as individual treatment.[9] For OCD specifically, research has shown mixed results.[10]

Medication Use Compared to Psychotherapy

Medications have been compared to psychotherapy in research studies to evaluate which therapeutic approach may be more effective. In the short term, medications and therapy provide similar outcome results, although the medications may provide undesirable side effects that do not occur as a result of therapy. The selective serotonin reuptake inhibitors (SSRIs) are generally well tolerated yet are not without side effects; people will often discontinue medication because of problematic side effects such as sexual dysfunction. We don’t generally conceptualize therapy as having side effects, but if we looked at potential cons, one might say that therapy in the short term is more time-intensive and more expensive that using medication. Other “side effects” would likely be positive, including improved communication, emotional intelligence, confidence, resilience, and empathy—in addition to learning to manage your anxiety.

In the long term, however, the research does show that psychotherapy far outperforms medication. Cognitive behavioral therapy (CBT) outperforms medication for anxiety disorders. A metanalysis is a study in which researchers take many research studies that address the same topics and summarize the treatment results. One metanalysis examining sixty-seven studies[11] found that for OCD, cognitive behavioral therapy focusing on exposure and response prevention therapy (ERP) was “clearly more efficacious” than medication use. They had a differential effect size (which represents the clinical significance of the findings) of g = 0.64. In the social sciences this represents a moderate effect size, which is impressive. This means that many people will benefit from that therapeutic intervention. Cognitive behavioral therapy that focuses on exposure and response prevention (i.e., CBT/ERP without medication) is “recommended as the first-line treatment if you are willing to do the work that is required and are not severely depressed.”[12]

Some people struggle with therapy-resistant anxiety; they may be working diligently in therapy but not making progress or have other co-occurring mental illnesses that are making progress difficult. In that case it can be beneficial to combine treatments, using both medication and therapy.[13] The combination of medication and psychotherapy can be helpful because medication can blunt agitation to help the person more fully benefit from the therapy.

Additionally, if you are taking psychotropic medication for your OCD and are continuing to have problems or have a desire to get off your medication, cognitive behavioral therapy is the recommended treatment. On the other hand, if you have unsuccessfully tried cognitive behavioral therapy and are not willing to try it again, the recommended treatment is medication.[14]

Treatment Considerations when Medication and Outpatient Psychotherapy Don’t Work

Other psychotherapeutic treatment options[15]

Sometimes even receiving excellent treatment via both psychotherapy and medication may not be enough to meet your therapeutic needs. This may be particularly true if you have other co-occurring mental health conditions. There are other, more intensive treatment options available if you find you or your loved one in need of a higher level of care. There are both adult and child programs available.

First, many clinics that treat OCD offer what is called an intensive outpatient program (IOP). In an IOP, you live in your home but attend (either in person or virtually) approximately three hours of therapy per day, five days per week. Within these therapeutic hours the program may offer you a varying number of hours of individual personalized treatment with a therapist, group psychoeducational meetings teaching OCD treatment skills, and time with a psych technician or clinical assistant who assists and supports you in enacting the exposures in your treatment plan. The program may also assign additional therapeutic homework to do in your own time. These programs are by definition intense and require a great deal of emotional and financial commitment. However, it can be a very helpful option for those who need it.

If an IOP is not adequate, day programs are often provided that offer group and individual therapies at a mental health treatment center. Day programs typically run from nine in the morning to five in the evening, five days per week. These programs are also offered at mental health hospitals, and in these settings the treatment is called partial hospitalization.

There are also residential treatment options in which one lives voluntarily in an unlocked mental health treatment center or hospital. This is residential care for severe, treatment-resistant OCD. These programs offer an in-depth, longer-term level of care with a consistent treatment environment. Program stays may vary in length due to program differences and your therapeutic needs; they may last from thirty to ninety days.

Lastly in terms of invasiveness and cost is inpatient treatment. This is the highest level of care provided in a locked mental health unit of a behavioral hospital. Stay can be voluntary or involuntary. This level of care is appropriate for those who are unable to care for themselves or are a danger to themselves (i.e., imminently suicidal) or to others. The goal of inpatient care is to stabilize the client and then transition him or her to a lower level of care.

Biological treatments approaches for OCD[16]

When you have treatment-resistant OCD that does not respond well to medication and other psychotherapeutic approaches, be aware that there are other biological treatments that are available (with varying effectiveness). Generally, you want to try the least invasive treatments first and not escalate to more invasive treatments unless you do not respond to the first ones. Because these treatments are beyond the scope of this book, I offer brief introductions and encourage you to learn more online, if desired.

Transcranial magnetic stimulation (TMS) is a noninvasive, FDA-approved treatment for OCD in which short pulses of magnetic energy coming from a cap worn on the head stimulate nerve cells in the left dorsolateral prefrontal cortex, an area of the brain responsible for mood regulation. These magnetic fields create small electrical currents that activate cells that are thought to release neurotransmitters like serotonin, norepinephrine, and dopamine.[17]

Deep Brain Stimulation (DBS) is an invasive but reversible FDA-approved treatment in which an electrode is inserted into the brain in the nucleus accumbens located in the basal ganglia. A neurostimulator unit is implanted into the chest wall. This procedure has been shown to cause the brain to release dopamine.

Psychosurgery is less commonly recommended since these newer techniques, discussed above, have been developed. In bilateral anterior internal capsulotomy, surgeons create bilateral lesions in the brain guided by a three-dimensional image of an MRI scan taken before the procedure. In dorsal anterior cingulotomy, surgeons sever the anterior cingulate cortex and the cingulum bundle.

Experimental treatments (no FDA approval). Transcranial direct current stimulation (tDCS)[18] is a noninvasive, painless, yet experimental treatment. It uses direct electrical currents to stimulate parts of the brain by passing a constant low-intensity current through two electrodes that are attached to the scalp. It is said to modulate neuronal activity.

Ketamine is a potent N-methyl-D-aspartate receptor antagonist and glutamate modulator that is FDA approved for anesthetic use, but not FDA approved for treatment of psychiatric disorders. The use of ketamine in the treatment of OCD is administered via infusions by some outpatient clinics. It is said to be fast acting, so one can know quickly if the treatment will be helpful. Yet ketamine use for OCD is experimental. Research provides inconsistent results.[19]

Gamma knife is an experimental procedure that allows doctors to destroy targeted brain tissue without surgically opening the brain. The most recent version of this procedure is called gamma ventral capsulotomy because it is limited to the bottom (ventral) half of the brain called the anterior capsule. One gamma ray on its own is not dangerous to brain tissue. In gamma knife procedures, doctors use intersecting gamma rays to create an energy level high enough to destroy tissue.[20]

Part 2: Psychotherapy for Scrupulosity

If You’re Hesitant to Start Psychotherapy Treatment

You may feel hesitant to pursue psychotherapy treatment for scrupulosity. Maybe you don’t think you need it. Maybe it seems like too much work. Maybe you fear treatment will cause you to think about your fears even more. Or maybe you worry that to seek treatment for scrupulosity might mean that your faith will be weakened or you will become lukewarm in your religious devotion. In a moment of discouragement, overwhelmed with his anxiety, one client, a married man in his early twenties, expressed, “I’m so scared that this treatment is going to destroy my testimony.” Yet treatment focuses on treating the anxiety process, not on trying to get you to abandon your religious beliefs. This same person, at the end of his treatment process, later explained, “I have been receiving treatment for two years now, and my testimony is stronger than ever. I think I worried that somewhere along in my treatment I would come across something to convince me the church isn’t true. What happened was the opposite. Not only was my testimony strengthened, but the experiences and skills I have gained in therapy have become an integral part in helping me strengthen my spiritual foundation.” Or maybe you just don't think treatment will work for you. One client also expressed this sentiment:

I assumed therapy wouldn’t work for me and I thought it would be a waste of money. I accepted the idea I was “never meant to be happy” and would never get better. I honestly thought I was a lost cause. Yet, speaking with my therapist and learning the skills to combat scrupulosity OCD, I’ve seen a significant difference in my life—and my family and friends have said the same. Even though I’m still early in my recovery, I can confidently say I see progress and the noise of OCD is not as loud as it was before. I still have days that I struggle, which is expected, but through therapy and doing the work, I have hope again and greater confidence for my future.

If such concerns make you hesitant to engage in therapy, you may want to further consider that you’re exhausted and distressed from obsessing about your fears already. Since you’re fully occupied obsessing about them anyway, wouldn’t it be better to learn to think about them in a therapeutic way?

If you just can’t bring yourself to pursue treatment for your own sake, then perhaps you can consider doing it for your loved ones. They will be blessed as you move toward mental health and all of you can enjoy freedom from the suffering of scrupulosity. Consider this person’s counsel as you read the remaining chapters:

To those who may feel unsure about going to therapy, taking medication, or even a mental health diagnosis: you will never know if you do not try. If my experience with OCD has taught me anything, it has taught me that beauty is found in the ambiguous and uncertain “gray areas” of life. We have no way of knowing beforehand the results of mental health treatment. Thus to me, going to therapy and taking my medication were acts of faith. Faith is a principle of action and power. As we act in faith, power and knowledge flow into our lives. It has been so for me. So, if you’re worried about starting your journey with mental health, take courage, invest in faith, and try.

General Psychotherapy Approaches to Scrupulosity Treatment

As I talk about the importance of psychotherapy treatment for scrupulosity, please be aware that I am not just talking about receiving talk therapy in which you may be getting counseling from a general practitioner from a common-sense perspective. Even if the mental health professional is a particularly thoughtful, wise, or perceptive experienced mental health professional, this type of psychotherapy will not improve your OCD and may even make it worse. “Modern views of treating OCD with psychoanalysis [or other talk therapy] is that the treatment provides the opportunity for more obsessing without any symptom resolution.”[21] One client stated after seeing a variety of therapists over some years that “there was a lot of talking going on, but not a lot of fixing.” In OCD there is a lot of fixing to do! Exposure and response prevention (ERP) is a very active behavioral treatment. You’ll talk, true, but you’ll also act—both inside and outside the therapy session. If you’re struggling with scrupulosity, make sure you seek treatment from someone competent to treat OCD using evidence-based (research-based) practice.[22]

As mentioned, the main treatment for OCD is cognitive behavioral treatment (CBT) that focuses on exposure and response prevention (ERP), with ERP being the first-line treatment for OCD.[23] Additionally, some treatment providers may utilize acceptance and commitment therapy. In cognitive work, you learn to recognize the difference between OCD and a more reality-based thought process. For many people, the cognitive work provides great foundational skills to help work through these issues. Research has shown that behavior therapy that includes ERP may have some advantages over the cognitive work alone in the treatment of OCD.[24] While exposure is the gold standard, the cognitive work is a valuable adjunct. One client said: “Now that I have the skills I do, I feel a new power in my life that I never quite had before. I am much more aware of how my brain works and I can detect when scrupulosity and OCD are speaking, and because of this ability, I can dismiss those thoughts for thoughts of actual truth. As soon as I can dispute obsessive thoughts, anxiety and stress soon begin to die down and I can reorganize my thinking pattern to be more healthy.”

Nuanced Scrupulosity Treatment Issues to Consider

Now, let’s ask the question: Is scrupulosity harder to treat than other forms of OCD? The simple yet painful answer is: Yes, it is. In the bulk of research studies, people with scrupulosity (including unacceptable or taboo thoughts) tend to have a poorer prognosis and are more likely to be resistant to treatment than those with other forms of OCD.[25] Other studies produce mixed results.[26] Many of my clients struggle with scrupulosity and other forms of OCD. In my experience, the scrupulous piece to their OCD is clearly harder to treat than their other obsessive-compulsive concerns. One client simply stated, “I can function with OCD, but if I can’t function, it is my scrupulosity.”

As you consider treatment possibilities and what you can do to work on healing your scrupulosity, here are nine issues gleaned from academic research that may make scrupulosity a more difficult treatment process. This in-depth discussion is not to discourage you from seeking to treat your scrupulosity. To the contrary, carefully considering how these difficulties may play out in your personal circumstance and treatment efforts may help you avoid them and improve your treatment process.

First, a significant reason the treatment process for scrupulosity may be difficult lies in identifying and accepting the nature of the problem. The person, family members, and therapist may all misinterpret the problems as religious, preventing the person from getting into therapy in the first place or undermining the therapy process. One research study among an orthodox Jewish population examined attitudes toward scrupulosity OCD and nonreligious OCD by having community members read vignettes about both forms of OCD. They found that although both were identified correctly as mental illness, the attitudes toward those with symptoms of scrupulosity were biased toward a social-religious explanation of the symptoms (over a medical/psychological model). For example, study participants were less likely to endorse OCD symptoms to a “chemical imbalance in the brain” and more likely to attribute symptoms to “the way he was raised” and “being too religious.” They also had more stigma against the person as well as bias against help-seeking behaviors.[27]

Those suffering from scrupulosity may be in excruciating pain but may incorrectly view their symptoms as the domain of religion and not psychiatry.[28] That is because scrupulosity’s toxic levels of anxiety compete with feelings of the Spirit. They often end up believing this to be a spiritual problem because the anxiety so strongly compels them to be concerned about their spiritual welfare. This is the single largest barrier to treatment that I have encountered with my clients. Sometimes, even months into treatment, clients are still doubtfully asking themselves, “Is this really OCD? Is it really scrupulosity?” They feel so confused because they just feel like it is their own moral failing. The more they focus on the religious content piece, the more they stay trapped when it is the anxiety that is promoting and perpetuating this obsessive-compulsive cycle, not the content of the religious concern.

Scrupulosity can also be more difficult to treat if family members discount it. The family members may also view the symptoms as the domain of religion and not psychiatry, which can undermine scrupulosity treatment even if you are in it! For example, one client knew she was struggling painfully with scrupulosity, and she was committed to her therapy; however, a loved one in her family would try to get her to analyze her faith in an effort to find the “seed of doubt” belying her religious faith. The more he wanted to explore what he saw as her faith problems, the more distressed she became. So she learned to respond, “Remember that this is OCD. This is not religion. Talk to me about OCD. Don’t talk to me about faith right now. I can’t handle the conversations about faith. Please don’t ask me to share my testimony right now.” This loved one would repeatedly ask her to spiritually engage, or to share her testimony. She worked on responding from a psychological OCD perspective (process), rather than trying to give a spiritual answer (content). For example, if you had a similar situation, you might be able to respond, “My OCD just makes everything so confusing. I need to learn to manage my anxiety. It’s an anxiety problem. I probably need to be more consistent and doing the things I’m learning in therapy.”

Therapists may also contribute to the difficulty of treatment if they incorrectly identify scrupulous symptoms as religious behavior instead of being psychiatric in nature, thus overlooking it in their treatment.[29] If the person or family members have missed it but end up presenting for another reason to a therapist (who is not trained in OCD), it may also be possible the therapist may miss it. Scrupulosity is not well known or well understood, even among many treatment providers. It may be very easy for a therapist not trained in OCD to believe the person suffering with scrupulosity to simply be a very devout religious person, misinterpreting some of his or her concerns as religious in nature rather than psychiatric.

Second, the treatment process for scrupulosity may be more difficult than other forms of OCD if the person does not see the therapist as having authority in the domain of religious observance.[30] For example, for ultraorthodox Jews, a psychotherapist “cannot give religious guidance, and has no authority within the ultra-orthodox community, and is only afforded a role with the rabbi’s acquiescence.”[31]

In addition, I previously described a scrupulous person’s reliance on authority for confession. Please remember that your therapist is not an ecclesiastical leader but will continue to respect the role of your religious leader. Your therapist is not seeking to forgive sin or absolve you of your mistakes, but is trying to help you learn to live your religion joyfully and peacefully by helping you learn how to manage your anxiety.

Third, scrupulosity treatment may be more difficult than treating other forms of OCD because the person may be less trusting of exposure-based treatments for fear of disrespecting his or her faith.[32] Germs are easier for clients to combat than sins.[33] Figure 9.1 shows the therapy progress of a newly married woman in her twenties with a mixed presentation of OCD, suffering from germ and contamination issues as well as scrupulosity.

Figure 9.1. Client example of Outcome Questionnaire-45.2 charts

These charts[34] are generated from scores from an outcome measure (Outcome Questionnaire-45.2)[35] that clients complete each time I meet with them for a therapy session so I can track symptom distress and treatment progress. The clinical cutoff line (the dotted line) is at a score of 63. So anything below that is in the average range. This cutoff line represents distress that’s high enough to warrant targeted clinical treatment. The score is recorded at the y-axis with the session number on the x-axis.

As you look at these charts, you can see that in session 1, she came in with an initial score of 106. That is a high score representing very high distress. Now, you can see that she improves in her distress at a fairly good pace through session 10 (106 down to 72). But then you see her therapeutic progress slow and her scores start to deteriorate. Her initial progress in therapy was due to her improvement in dealing with germs and contamination. She was very motivated and successful at germ exposures. She would push herself between sessions to do exposures that we hadn’t assigned. We may have assigned one exposure, but she would come back to session reporting, “Oh, and I also pushed myself and did this and this and this . . .” She was making awesome progress.

However, the scrupulosity exposures were so much more terrifying for her. For example, she would not resist her compulsive repentance prayers, and her reassurance-seeking behavior was intense. Ultimately, she did not make the therapeutic progress that she and I would like to have seen. Our goal was to get her below that clinical cutoff of 63 and get her distress and symptom levels into that normal range; we were unsuccessful (she moved out of state, so we were unable to complete treatment since that was before the now-common trend of interjurisdictional video-chat telehealth sessions).

In other words, clients fear that doing an exposure exercise may be too risky, even sinning. Exposure walks them straight into uncertainty. They wonder, “Am I doing something wrong?” It’s terrifying to them to think that they may be doing something wrong, especially if they were to be guilty of doing that wrong act on purpose. Please know, a therapist properly trained in treating scrupulosity would never presume to ask you to do an exposure that would be considered sinful from the perspective of your religious tradition. If you are a client with another form of OCD, any therapist trained to treat OCD should be competent to help you. However, if you suffer with scrupulosity, it is critically important to choose a therapist that understands the tenets of your religious faith and respects them. Elder Jeffrey R. Holland taught, “If things continue to be debilitating, seek the advice of reputable people with certified training, professional skills and good values. Be honest with them about your history and your struggles. Prayerfully and responsibly consider the counsel they give and the solutions they prescribe. If you had appendicitis, God would expect you to seek a priesthood blessing and get the best medical care available. So too with emotional disorders. Our Father in heaven expects us to use all of the marvelous gifts he has provided in this glorious dispensation.”[36]

With that said, however, exposure does trigger anxiety, so although any given exposure assignment will not be sinful, it may likely feel sinful to you as a client suffering with scrupulosity. One client wrote about these types of fears in one of his therapeutic exercises: “My desire to fight scrupulosity is just an effort to rationalize sin and sinful behavior. This exposure and the ones you are going to do are attempts to conceal past sins or to rationalize them or to rationalize current ones. . . . Maybe you do have anxiety, but you’re taking it too far and are trying to avoid talking to the bishop simply because it scares you to open up about your sins.”

Another client who has now recovered from scrupulosity offered this comment on this fear of sinning: “One of the most important aspects to my recovery was formal psychotherapy (exposure therapy) and alongside that coming to the realization that I was not sinning by doing so. The second point was important so that I could wholeheartedly do my exposures; otherwise I would have not gotten the results I was able to get.” The same client, some years later, wrote this: “I also have acquired a healthier perspective on personal progression and what God expects of me. I used to be hyperfocused on perfecting myself, but I now feel a greater trust in God’s ability to do that for me. I am more comfortable with my weaknesses and can see how God’s grace is sufficient.”

OCD treatment exercises do provoke anxiety—on purpose. If they did not, they would not be effective in combating this insidious disorder. As such, mental health professionals ask their clients to do some exposures that feel terrifying to them. Some clients will take the leap of courage and fully immerse themselves in their therapist’s treatment plan and gain the treatment benefits, while some will struggle to fully embrace treatment and continue to struggle painfully. This client had learned to understand that exposure was not synonymous with sinning. He has been able to enjoy the spiritual benefits that come from recovery because he engaged in exposure therapy. He has a greater trust in God’s ability to perfect and save him. In the end that is what each person with scrupulosity wants most desperately—to have spiritual peace.

Fourth, treating scrupulosity is harder to treat than other forms of OCD because the person may be less willing to risk feared outcomes than physical consequences.[37] In germ and contamination OCD, the feared consequences of touching germs may be illness or a trip to the emergency room for themselves or others. In scrupulosity, sufferers fear disappointing God, losing their eternal salvation, losing their family forever, and failing their purpose and mission on earth. So it’s very scary for them to think about doing an exposure wondering if that exposure is putting their worthiness, purity, or eternal welfare in jeopardy. One person talked about this fear when he recorded his feelings about an exposure treatment: “My life will fall apart. I will not become who I want to be, achieve my dreams, or reach my full potential, and I will be doomed for eternity to never enter the celestial kingdom.”

This is terrifying. In germ or contamination OCD, people can touch something they deem “dirty” (exposure), resist washing their hands (response prevention), and then see in a few days that they didn’t get sick after all. With that unexpected outcome, they can start to reappraise their threat assessment and realize that maybe things are not as threatening as they seemed. But with those struggling with scrupulosity, it can be a lot more difficult to get them to buy into the exposures if the feared outcome is eternal damnation.

Unfortunately, I have seen people continue to struggle more than is necessary; when they don’t do their exposures wholeheartedly, they just don’t tend to improve. The failure to commit to their exposure exercises simply prolongs their agony as the obsessive-compulsive cycle is perpetuated.

Exposure and response prevention (ERP) treatment for this group may be more challenging to implement, as well. Compulsions in scrupulosity tend to be primarily mental. Ritual prevention includes suppression of mental compulsions, which is more difficult than resisting physical compulsions. Treatment includes more imaginal exposures. The most extreme fears, such as the fear of “going to hell,” are difficult to address with traditional in vivo ERP exercises. Reassurance-seeking behaviors may be easily overlooked and not properly addressed as compulsive rituals. And, as I have already discussed, moral and religious consequences may not lend themselves easily to the experience of disconfirming evidence.[38] For example, we cannot escort a person across the veil of death to meet God and to feel of his love and mercy in order to disconfirm their scrupulous fear that God will punish them and condemn them for their sins and misdeeds despite their change of heart and repentance.

Sixth, treatment for scrupulosity may be more difficult because the anxiety attacks one’s deepest values, which causes deep discouragements and self-doubt about who the person is at the core as an eternal being. Those suffering with scrupulosity are some of the most faithful, loyal followers of God that I have ever met. Indeed, “OCD fears are not latent desires to be an apostate,”[39] and “OCD is not some hidden wish fulfillment,”[40] although clients almost unanimously believe that to be true. The presence of scrupulous fears are not evidence of their truth. The fear is “OCD’s method of turning the patient’s own core values against himself or herself.”[41] If you struggle with scrupulosity, do not let OCD’s fears discourage and paralyze you into the passivity of failing to pursue treatment.

Seventh, others in the religious community, including ecclesiastical leaders, may in advertently reinforce a person’s OCD by giving reassurance or expressing admiration [42] (i.e., admiring or praising him or her as a “spiritual giant” for being so conscientious about religious principles). It is not uncommon for those with scrupulosity to be praised for their thoughtfulness as they confess something most people wouldn’t even think twice about; they may be highly regarded as being spiritually sensitive. Yet the praise reinforces the problem. This is somewhat analogous to the positive reinforcement received by people who are losing weight due to an eating disorder. They are thinking in distorted ways and exhibiting maladaptive patterns. And yet as they lose weight people praise them, letting them know how great they look. Unfortunately, that only encourages the disordered behavior further. So those in the faith community need to be careful not to reinforce scrupulous attitudes and behaviors. A podcast host shared this personal story during a discussion about scrupulosity:

I’ve realized that this is something that I think I likely struggled with when I was younger, and up until a couple years ago when I literally left the temple and immediately called my bishop thinking, “I need to confess something.” And I went in to the bishop and he basically just said, “This is not something that you should be here for.” . . . And it was so helpful to me. I think sometimes the reaction is like, “Oh, you’re just such a good person. So it’s so good of you that you would think that you would need to come and confess that.” And for the first time, somebody said to me, “You really shouldn’t be here for this,” rather than like applauding that.[43]

Eighth, treating scrupulosity may be more difficult because religious authorities tend to discourage moral or religious risk-taking and reinforce the idea that one should distance himself or herself from potential moral violations or sins.[44] Knowing what you have learned about safety behaviors in previous chapters, you can see how counsel such as “better safe than sorry” may only serve to reinforce the scrupulosity cycle.

Ninth, although ERP is a first-line treatment for OCD, “its implementation for religious patients with scrupulosity necessitates nuanced modifications.”[45] For example, scrupulous obsessional fears “often relate to repugnant ideas and ‘unknowable’ or long-term negative consequences (e.g., ‘I will go to hell when I die’), which cannot easily (if at all) be violated or disconfirmed with ERP. Thus, treatment of such symptoms must focus on violating expectations related to uncertainty.”[46] This will pose a serious challenge to mental health clinicians that have less experience treating OCD with ERP. As a client, your best outcome will likely be achieved working with a mental health professional that is well trained not only in ERP treatments for OCD but also in how to make the nuanced modifications necessary to treat scrupulosity effectively.

The Role of Uncertainty in Psychotherapy for Scrupulosity OCD

The reassurance-seeking behaviors I have discussed throughout the book are typically done with the goal of reducing uncertainty. Uncertainty is a “lack of sureness about someone or something.”[47] Intolerance of uncertainty, a deep-seated fear of the unknown, is a broad concept that generalizes across anxiety disorders.[48] “The oldest and strongest emotion of mankind is fear, and the oldest and strongest kind of fear is fear of the unknown.”[49] In scrupulosity OCD there is pervasive doubt and fear, as well as intolerance of uncertainty about the moral or religious status of oneself or one’s behavior[50] (such as “Maybe I’ve sinned”). One client created a formula to describe the role of uncertainty in his OCD process: “Uncertainty + Important (something that truly matters to me) = Breeding ground for OCD.”

If uncertainty is such a big part of the OCD struggle, why do we want to maintain uncertainty in scrupulosity treatment? One of the goals of the formal psychotherapy process is to create cognitive flexibility, or the ability to see a broad range of options, switch tasks, challenge distortions (thoughts that are not accurate or are errored in some way), and tolerate unpredictability. In scrupulosity OCD, religious practice severely lacks flexibility and tends to become very narrow, rigid, and trivial as you focus on minute details. Creating cognitive flexibility in the therapy process is done through cognitive work as well as through exposure experiments. The exposure work is the gold standard for treatment. It’s going to help you get a handle on learning to tolerate your own anxiety, and by so doing will actually diminish that anxiety. Embracing uncertainty will need to become a way of life in the therapy and post-therapy processes to maintain therapeutic gain and ward off relapse.

The role of uncertainty (for the one suffering with scrupulosity)

The role of uncertainty is paramount in your treatment progress. You will need to gather up the courage to challenge your fear of uncertainty. One client described that pivotal moment:

Recovery started when things came to a head one Sunday afternoon when I was feeling completely overwhelmed by my obsessions to be completely honest. I knew “cognitively” that I was going way beyond the mark, and yet, even though I knew from my head that I was “OK enough” with God and that I was going beyond the mark, I couldn’t shake the anxiety that I wasn’t OK with God. That is when it struck me that if this was how heaven was supposed to feel like, then I wanted nothing to do with it! And again, cognitively, I knew that the high level of anxious feelings I had wasn’t how it felt in heaven and that God wasn’t the author of those feelings. Regardless, I still couldn’t shake it. So, I had to turn myself completely over to God and say, “Alright, I can’t do this anymore the way I am trying to do it. I may not make it to the Celestial Kingdom and that’s OK, because I can’t handle the level of stress and feelings of anxiety that I am living with right now to get there.” That was the starting point of me receiving relief and learning to manage things by not demanding immediate perfection of myself and allowing the true Gospel of Christ’s Atonement to save me even though I might not live completely honestly. The moment I backed off was the moment I started gaining power.

Once he metaphorically gave up—gave up the toxic perfectionism that was tormenting him and embraced uncertainty—that is when his healing began. This willingness and openness to embrace the uncertainty and accept the anxiety that comes with not knowing is a critical piece in turning toward your own healing. You don’t have to want to face your greatest fears, you just have to be willing to do so. If anything else you have tried to overcome your scrupulosity would have worked, wouldn’t it have worked by now?

The role of uncertainty (for others)

If someone is uncertain about having sinned, it is natural for that person to want counsel from from a trusted person in order to gain certainty—and it is natural for that confidant to want to offer comfort and assurance. If you are the recipient of a scrupulous individual’s reassurance-seeking, you may feel that offering such reassurance is the compassionate and helpful thing to do. Giving reassurance to most people would be completely appropriate because they are able to accept it as a soothing, stabilizing influence in settling their discomfort about their situation. However, for those with scrupulosity, the reassurance does not work because the toxic anxiety quickly provokes another “what if” question or counterargument. The situation is paradoxical—giving reassurance to comfort their distress is not the compassionate thing to do! Rather, the compassionate thing to do is to help them maintain a sense of uncertainty, giving them an experience with their anxiety and thus helping them learn to “break the association between fear and uncertainty about having possibly sinned.”[51]

Whether you may be a family member or friend, ecclesiastical leader, or even mental health professional of someone suffering with scrupulosity, please keep in mind that “answering questions about risk would interfere with the goal of maintaining uncertainty.”[52] You want to encourage them to stop asking any questions related to their OCD concerns (such as “Was this okay?”) and to instead choose to accept the doubt and to practice being able to say something to the effect of “I don’t really know.”

So how do you respond according to your compassionate feelings in a way that will actually be compassionate for the scrupulous sufferer? Focus on process, not content. Simply labeling the anxiety process as you see it is generally not helpful—for example, “That’s OCD” or “That’s a scrupulosity question.” However, you can be explanatory: “I can’t answer that for you. Answering that question won’t help you and will actually undermine your treatment.” A softer approach would be the most ideal and compassionate—for example, “I’m sorry your anxiety is making things so hard for you. What can you do to work through the process?” Or “I’m sorry you’re so concerned. What have you learned in therapy that you can do to work through the anxiety?” Another example: “I know you really want reassurance from me. What could you do instead?” Then—and this is important—don’t engage in the content of what they’ve asked about.

One couple shared their experience with compulsive confessions, emphasizing the importance of reinforcing uncertainty rather than giving reassurance:[53]

Wife: Can I just add that feels so counter intuitive to hear a confession as a wife, and I’m sure as a leader, and you can see that, oh my gosh, this is not something you need to be confessing, and so you want to comfort and give them all the certainty in the world that “Of course you don’t need to confess, and of course that wasn’t dishonest or impure,” or whatever it is. You want to just gift them that certainty again. I had to stop doing that—even though it feels so wrong to say, “Maybe you did lie.” I’m thinking in my head, Oh my gosh, he did not lie. I’ve been here through this whole process and that was not cheating. That’s what I want to say. But I had to learn that I was literally making it worse by reassuring him that it was okay and that he was honest; and I just have to know when something sounds like a confession, to just say like, “Yeah, maybe.”

[Husband]: Aubrey became one of my major outlets—it’s not always confessing to your church leader, although in this context, it often is. But it’s like you have an impure thought, and I need to confess that to my wife, to make sure she says we’re still okay, or whatever it is. So, I unintentionally ended up putting that burden on her. And like she said, this is absolutely no fault of hers; her natural response is to comfort and validate that confession, and while it momentarily lets that pressure off, in the long term it just reinforces that cycle. So, I think it’s very difficult—and has been very difficult for her—to change her behavior and sort of let me struggle with it and accept the uncertainty. But in the long term that’s really the only thing that can end up working.

You won’t respond perfectly each time, but as you continue to practice you’ll find a way to express all the love and compassion you desire without reinforcing the person’s toxic anxiety. You will need to be willing to displease him or her in the moment by saying in essence, “I’m here with you, but I’m not going to go there with you. Let’s remind you that this is anxiety and that you have therapeutic tools.” If the person continues to pressure you for reassurance, you may (subtly) remove yourself from the situation, such as by leaving the room or ending the phone call or responding with an exposure-type statement reinforcing uncertainty about the person’s core fear (e.g., “Maybe you weren’t honest. It’s hard to tell.”).[54]

Notes

[1] Dougherty, D. D., Brennan, B. P., Stewart, S. E., et al. (2018). Neuroscientifically informed formulation and treatment planning for patients with obsessive-compulsive disorder: A review. JAMA Psychiatry, 75(10), 1081–1087. https://doi.org/10.1001/jamapsychiatry.2018.0930

[2] Denys D. (2006). Pharmacotherapy of obsessive-compulsive disorder and obsessive-compulsive spectrum disorders. Psychiatric Clinics of North America, 29(2), 553–xi; and Ackerman, D. L., & Greenland, S. (2002). Multivariate meta-analysis of controlled drug studies for obsessive-compulsive disorder, Journal of Clinical Psychopharmacology, 22(3), 309–317. https://doi.org/10.1097/00004714-200206000-00012

[3] Soomro, G. M., Altman, D., Rajagopal, S., Oakley-Browne, M. (2008). Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder(OCD). The Cochrane data base of systematic reviews, 2008(1). https://doi.org/10.1002/14651858.CD001765.pub3.

[4] Starcevic, V., & Brakoulias, V. (2008). Symptom subtypes of obsessive-compulsive disorder: Are they relevant for treatment? Australian and New Zealand Journal of Psychiatry, 42(8), 651–661. https://doi.org/10.1080/00048670802203442

[5] Clark, S. A., Allard, T., Jenkins, W. M., Merzenich, M. M. (1988). Receptive fields in the body-surface map in adult cortex defined by temporally correlated inputs.Nature,332,444–445. https://doi.org/10.1038/332444a0; and Pittenger, C., & Duman, R. S. (2008). Stress, depression, and neuroplasticity: A convergence of mechanisms. Neuropsychopharmacology, 33(1), 88–109.

[6] Abramowitz, J. S., & Hellberg, S. N. (2020). Scrupulosity. In E. A. Storch, D. McKay, & J. S. Abramowitz (Eds.), Advanced casebook of obsessive-compulsive and related disorders: Conceptualizations and treatment (pp. 71–87). Academic Press/Elsevier, 76. https://doi.org/10.1016/B978-0-12-816563-8.00005-X

[7] Safety behaviors (anxiety). (n.d.). In Wikipedia. https://en.wikipedia.org/wiki/Safety_behaviors_(anxiety)

[8] Ferguson, K. (2017). The OCD Mormon: Finding healing and hope in the midst of anxiety. Cedar Fort, 102–103; emphasis added.

[9] Fuhriman, A., Burlingame, G. M. (2000). Group therapy. In A. Kazdin (Ed.), Encyclopedia of psychology (Vol.4). Oxford University Press, 31–35.

[10] Fals-Stewart, W., Marks, A. P., & Schafer, J. (1993). A comparison of behavioral group therapy and individual behavior therapy in treating obsessive-compulsive disorder. Journal of Nervous and Mental Disease, 181(3), 189–193. https://doi.org/10.1097/00005053-199303000-00007; and Bulut, S. & Subasi, M. (2020). Group therapy in adults with obsessive-compulsive disorder: A review. Open Journal of Medical Psychology, 9(4), 150–159. https://doi.org/10.4236/ojmp.2020.94012

[11] Cuijpers, P., Sijbrandij, M., Koole, S. L., etal.(2013). The efficacy of psychotherapy and pharmacotherapy intreating depressive and anxiety disorders: A meta-analysis of direct comparisons. World Psychiatry, 12(2),137–148. https://doi.org/10.1002/wps.20038

[12] Abramowitz, J. S. (2018). Getting Over OCD: A 10-step workbook for taking back your life, (2nd ed.). The Guilford Press, 31.

[13] Abramowitz, 2018. Getting Over OCD, 31.

[14] Abramowitz, J. S. (2018). Getting over OCD, 32.

[15] International OCD Foundation. (n.d.). How is OCD treated? https://iocdf.org/about-ocd/ocd-treatment

[16] For a more thorough discussion, see Shapiro, L. J. (2020). Obsessive compulsive disorder: Elements, history, treatments, and research. Praeger, 181–184.

[17] UNC School of Medicine Psychiatry. (n.d.). How does TMS work? https://www.med.unc.edu/psych/patient-care/interventional-psychiatry/tms/how-tms-works

[18] Johns Hopkins Medicine. (n.d.). Brain stimulation services. https://www.hopkinsmedicine.org/psychiatry/specialty_areas/brain_stimulation/tdcs.html

[19] Bandeira, I. D., Lins-Silva, D. H., Cavenaghi, V. B., et al. (2022). Ketamine in the treatment of obsessive-compulsive disorder: A systematic review. Harvard Review of Psychiatry, 30(2), 135–145.

[20] International OCD Foundation. (n.d.). Gamma knife treatment for OCD. https://iocdf.org/about-ocd/ocd-treatment/gamma-knife

[21] Shapiro, L. J. (2020). Obsessive compulsive disorder, 91.

[22] McClendon, D. T., & Burlingame, G. M. (2011). Has the magic of therapy disappeared? Integrating evidence-based practice into therapist awareness and development. In R. H. Klein, H. S. Bernard, & V. L. Schermer (Eds.), On becoming a psychotherapist: The personal and professional journey (pp. 190–211). Oxford University Press.

[23] Olatunji, B. O., Davis, M. L., Powers, M. B., Smits, J. A. J. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research, 47(1),33–41. https://doi.org/10.1016/j.jpsychires.2012.08.020

[24] Olatunji, B. O., Rosenfield, D., Tart, C. D., et al. (2013). Behavioral versus cognitive treatment of obsessive-compulsive disorder: An examination of outcome and mediators of change. Journal of Consulting and Clinical Psychology, 81(3), 415–428. https://doi.org/10.1037/a0031865

[25] Williams, M. T., Farris, S. G., Turkheimer, E. N., et al. (2014). The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder. Journal of Anxiety Disorders, 28(6), 553–558. https://doi.org/10.1016/j.janxdis.2014.06.001. Huppert, J. D., & Siev, J. (2010). Treating scrupulosity in religious individuals using cognitive-behavioral therapy. Cognitive and Behavioral Practice, 17(4), 382.

[26] Starcevic, V., & Brakoulias, V. (2008). Symptom subtypes of obsessive-compulsive disorder: Are they relevant for treatment? Australian & New Zealand Journal of Psychiatry, 42(8), 651–661. https://doi.org/10.1080/00048670802203442

[27] Pirutinsky, S., Rosmarin, D. H., & Pargament, K. I. (2009). Community attitudes towards culture-influenced mental illness: Scrupulosity vs. nonreligious OCD among orthodox Jews. Journal of Community Psychology, 37(8), 953.

[28] Huppert et al., 2010. Treating scrupulosity in religious individuals, 382.

[29] Williams et al., 2014. The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder, 553–558.

[30] Huppert et al., 2010. Treating scrupulosity in religious individuals, 382.

[31] Greenberg, D., & Shefler, G. (2008). Ultra-orthodox rabbinic responses to religious obsessive-compulsive disorder. Israel Journal of Psychiatry and Related Sciences, 45(3), 183.

[32] Williams et al., 2014. The impact of symptom dimensions on outcome for exposure and ritual prevention therapy in obsessive-compulsive disorder, 553–558.

[33] Shapiro, L. J. (2015). Understanding OCD: Skills to control the conscience and outsmart obsessive compulsive disorder. Praeger, 119.

[34] Lambert, M. J., Gregersen, A. T., & Burlingame, G. M. (2004). The Outcome Questionnaire-45. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment: Instruments for adults (pp. 191–234). Lawrence Erlbaum Associates Publishers.

[35] Lambert et al., 2004. Outcome Questionnaire-45, 191–234.

[36] Holland, J. R. (2013, November). Like a broken vessel. Ensign, 41. https://www.churchofjesuschrist.org/study/general-conference/2013/10/like-a-broken-vessel

[37] Huppert et al., 2010. Treating scrupulosity in religious individuals, 382.

[38] Williams et al., 2014. The impact of symptom dimensions on outcome for exposure and ritual prevention therapy, 553–558. Williams, M. T., Mugno, B., Franklin, M., & Faber, S. (2013). Symptom dimensions in obsessive-compulsive disorder: Phenomenology and treatment outcomes with exposure and ritual prevention. Psychopathology, 46(6), 365–76. https://doi.org/10.1159/000348582

[39] Huppert et al., 2010. Treating scrupulosity in religious individuals, 385.

[40] Schwartz, J. M., & Beyette, B. (1996). Brain lock: Free yourself from obsessive-compulsive behavior. HarperPerennial, 43.

[41] Huppert et al., 2010. Treating scrupulosity in religious individuals, 385.

[42] Huppert et al., 2010. Treating scrupulosity in religious individuals, 382.

[43] Jones, M. (Host). (2020, July 1). Debra Theobald McClendon: Scrupulosity—Obsessive-compulsive anxiety you may mistake as faith crisis (No.87) [Audio podcast episode]. In All In. LDS Living. https://www.ldsliving.com/all-in/debra-theobald-mcclendon-scrupulosity-obsessive-compulsive-anxiety-you-may-mistake-as-faith-crisis

[44] Huppert et al., 2010. Treating scrupulosity in religious individuals, 382.

[45] Huppert et al., 2010. Treating scrupulosity in religious individuals, 382; emphasis added.

[46] Buchholz, J. L., Abramowitz, J. S., Blakey, S. M., et al. (2019). Sudden gains: How important are they during exposure and response prevention for obsessive-compulsive disorder? Behavior Therapy, 50(3), 678.

[47] Merriam-Webster. (n.d.) Uncertainty. In Merriam-Webster.com dictionary. https://www.merriam-webster.com/dictionary/uncertainty.

[48] Carleton, R. N. (2012). The intolerance of uncertainty construct in the context of anxiety disorders: Theoretical and practical perspectives. Expert Review of Neurotherapeutics, 12(8), 937–947.

[49] Joshi, S. T., Schultz, D. E. (2001). An H. P. Lovecraft encyclopedia. Greenwood Press, 255.

[50] Summers, J. S., Sinnott-Armstrong, W. (2014). Scrupulous agents. Philosophical Psychology, 28(7), 947–966. https://doi.org/10.1080/09515089.2014.949005

[51] Abramowitz, J. S. (2001). Treatment of scrupulous obsessions and compulsions using exposure and response prevention: A case report. Cognitive and Behavioral Practice, 8(1), 81. https://doi.org/10.1016/S1077-7229(01)80046-8

[52] Abramowitz, J. S. (2001). Treatment of scrupulous obsessions and compulsions using exposure and response prevention, 81.

[53] Ostler, R. (Host). Episode 199: Tim and Aubrey Chaves, active LDS, faith crisis, scrupulosity [Audio podcast episode]. In Listen, Learn, & Love Hosted by Richard Ostler. Apple Podcasts. https://podcasts.apple.com/us/podcast/episode-199-tim-and-aubrey-chaves-active-lds-faith-crisis

[54] Gillihan, S. J., Williams, M. T., Malcoun, E., et al. (2012). Common pitfalls in exposure and response prevention (EX/RP) for OCD. Journal of Obsessive-Compulsive and Related Disorders, 1(4), 251–257. https://doi.org/10.1016/j.jocrd.2012.05.002