Elder Neal A. Maxwell of the Quorum of the Twelve Apostles taught, “There is a difference, therefore, between being ‘anxiously engaged’ and being ‘over-anxious.’”

Educators in the Church Educational System teach gospel doctrines and knowledge of the scriptures and also counsel students about personal issues such as strengthening testimony, learning how to receive personal revelation, working through difficult family or social circumstances, and solving specific issues in their lives. This often creates bonds of trust with students and students will often approach teachers with their intimate spiritual and temporal concerns.

As a Church educator, it is likely you have had these types of close relationships with students. It is likely also that you have experienced many instances when a youth, feeling this special bond and relationship of trust with you, comes to you privately in a spirit of penitent confession. In those moments, your training has taught you well to refer them to their bishop or other local ecclesiastical leader to work through “the pain, remorse, and depression associated with sin.”[1] The bishop has the priesthood keys and spiritual stewardship over your student. However, there is a subset of students for which this standard referral may be inadequate to address the complexity of their concerns; they may need some additional counsel and referrals. This guide aims to help you to identify and properly refer these students so their spiritual and mental health needs may be more effectively addressed.

This article begins with a discussion of perfectionism. It then illustrates how rigid, inflexible self-expectations of perfection can become destructive as individuals get trapped in an obsessive-compulsive cycle. Scrupulosity—or obsessive-compulsive thoughts about moral and religious issues—is then comprehensively defined, described, and illustrated. Since many caught in this obsessive-compulsive cycle do not recognize it as a mental health issue due to the religious content of their concerns, this article also provides tips for discerning scrupulosity from normative spiritual concerns. Lastly, the article recommends steps to take while counseling the scrupulous student.

To illustrate the principles discussed herein, this article uses many personal experiences, thoughts, and insights from those who have struggled with scrupulosity. Please know that each of these have been shared with permission. I am grateful to each of these courageous individuals for sharing their intimate stories so that you might be of greater service to the scrupulous students in your ministry.

Identifying the Scrupulous Student

Adaptive Perfectionism

Perfectionism can be both adaptive and maladaptive.[2] Elder Neal A. Maxwell of the Quorum of the Twelve Apostles taught, “There is a difference, therefore, between being ‘anxiously engaged’ and being ‘over-anxious.’”[3]

The devout disciples that are “anxiously engaged” may be what we call adaptive perfectionists or positive perfectionists. Adaptive perfectionists set high standards for themselves, seeking to reap the positive consequences of success, not out of fear of negative evaluation or failure.[4] So they have high standards for themselves but are not necessarily disturbed when those standards are not met. Failure results in adaptive behavior, such as engaging their problem directly, trying again, readjusting standards, working harder, or simply accepting the situation.[5] Or if they do struggle when they fail to meet those standards,[6] they are able to work through the situation, create flexibility in their thinking, and resiliently move forward. Indeed, researchers have found that working to meet high standards has been associated with higher self-esteem and life satisfaction.[7]

In religious worship, the anxiously engaged are careful about living the gospel in all areas of their lives.[8] They are conscientious about living the gospel in its fullness to the best of their ability. Researchers described this process: “Healthy religious observance . . . is generally typified by . . . moderate and flexible approaches to most areas of religious belief and practice, viewing perfect adherence as more of an ideal than as an imperative that is necessary to avoid subjective guilt or the threat of severe punishment.”[9] As a religious educator, you’ve likely had private or public conversations with many such students and have noticed their strong faith and their ability to come to a healthy, balanced resolution about their difficulties even in the face of disappointment in themselves or their own behavior.

Toxic Perfectionism

The “over-anxious” disciples in your ministry are students that may struggle with maladaptive or toxic perfectionism, or obsessive-compulsive anxiety. This type of negative perfectionism often constitutes a frantic effort to live error-free: “the tendency to believe there is a perfect solution to every problem, that doing something perfectly (i.e., mistake free) is not only possible, but also necessary, and that even minor mistakes will have serious consequences.”[10]

These students are generally very loyal to God and committed to keeping his commandments and trying to perfectly follow him, but when they fail to meet their own unattainably high standards they are overcome by anxiety, panic, and obsessive rumination about their perceived failures. Instead of actively engaging their problems, negative perfectionists tend to avoid them.[11] Negative perfectionism is associated with categorical thinking, the tendency to view the world in black-or-white terms, and intolerance and distrust of others.[12] One researcher explained, “The perfectionist paradigm typically combines unrealistic expectations with an unhealthy preoccupation with faults, weaknesses, mistakes, and sins. . . . Fear of failure is a constant concern. Though it is correlated with conscientiousness, perfectionism goes far beyond diligent effort and ‘demand[s] absolute perfection from the self.’ Perfectionists tend to engage in an unrelenting quest for flawlessness and berate themselves or others for falling short of this impossible standard.”[13] This researcher summarized, “Thus the problem with perfectionism is not high expectations; it is neurotic expectations that are unrealistic and oppressive.”[14]

The overanxious students’ faith is strong, equal to the faith of anxiously engaged students; they are wonderful, dedicated disciples! Yet their toxic perfectionism creates problematic, inflexible thinking that often paralyzes them spiritually as a result of anxiety’s compelling influence. President Boyd K. Packer taught that “our physical body is the instrument of our spirit” and that it houses “delicate physical senses which have to do with spiritual communication.”[15] Anxiety disrupts these “delicate physical senses” because it causes our brains to release chemicals that create physiological responses that compete with the Spirit. It can be difficult to differentiate between what our body feels because of spiritual sensations and what it feels because of its release of various stress hormones.[16]

This compelling, uncomfortable physiological anxiety reaction is what keeps many people stuck in a destructive cycle of anxiety. For example, one individual shared, “I felt trapped with anxiety. I looked to find relief from the anxious feelings that surrounded my fears and doubts. . . . The anxiety mounted because even though I knew deep down inside I really should be okay and acceptable to God, I couldn’t feel it because of the adrenaline that was flowing through my body. Because of this physiological process, I couldn’t fully feel peace and was unable to relax and let the Spirit ‘really’ talk or whisper to me.” Another individual echoed those sentiments: “OCD and scrupulosity will always generate a stressful and anxious response to your mind and body. For the longest time, that is what kept me from being able to see the truth. I would always think that because I was so stressed and anxious about this thought it must be true. I didn’t have the skills to not be anxious about the topic.”

Maladaptive or toxic perfectionism is in large part defined by a feeling of discrepancy, the feeling that one is never good enough. Discrepancy has been associated with guilt and shame.[17] One author explained, “We are not good enough for ourselves because we don’t fit with our own image of perfection. We cannot forgive ourselves for not being what we wish to be, or rather what we believe we should be. We cannot forgive ourselves for not being perfect.”[18]

This perceived discrepancy has a significant impact on the individual’s sense of worth. Researchers have noted, “Maladaptive perfectionists, compared to non-perfectionists, seem to suffer from a misperception of their worthiness, rather than lacking confidence in their academic performance. . . . This suggests that when working with maladaptive perfectionist students, counselors should differentiate between self-esteem (worth) and self-efficacy (ability), and focus attention on the former.[19]

Scrupulosity

In addition, the high anxiety of toxic perfectionism can morph into a more extreme problem, obsessive-compulsive disorder (OCD). One researcher said, “OCD sufferers may initially be seeking to be scrupulous (in a nonpathological sense), but the problem grows until functioning is severely affected. The initial concern was appropriate, the eventual consequences destructive.”[20]

The term “scrupulosity” is literally derived from the Latin word scrupulum (“small stone”), which evokes an image of a sharp stone or small pebble in one’s shoe.[21] Researchers noted a subsequent shift in definition: “a later meaning was a minute apothecaries’ weight, one twenty-fourth of an ounce, so small as to affect only the most sensitive scales. The term in English acquired a moral interpretation of a thought or circumstance so insignificant as to affect only a very delicate conscience.”[22] It entered “the religious vocabulary to describe people with overconcern and hesitation concerning all areas of appetitive behavior and commonly ‘assailed by naughty and blasphemous thoughts.’”[23]

Scrupulosity is a religiously themed subtype of OCD. It is “a psychological disorder primarily characterized by pathological guilt or obsession associated with moral or religious issues that is often accompanied by compulsive moral or religious observance and is highly distressing and maladaptive.”[24] Being religious does not make one prone to scrupulosity; however, “if OCD develops in an individual who is very religious, his or her religiosity is likely to express itself in the OCD.”[25] One researcher summarized that “a cardinal feature of scrupulosity is persistent uncertainty leading to anxiety and fear about whether or not one has committed religious or moral sin.”[26] In scrupulosity, “three types of beliefs pertain to intolerance of uncertainty: (1) beliefs about the necessity for being certain; (2) beliefs that one has a poor capacity to cope with unpredictable change; and (3) beliefs about the difficulty of adequate functioning in inherently ambiguous situations.”[27]

Anxiety is a future-oriented emotion. Yet scrupulosity keeps individuals tormented by past sins, events, details, mistakes, and the like because of the uncertainty felt and the overestimation of threat about how those issues may affect their future salvation.[28] Also, at times it is the case that they suffer with obsessive rumination even when they did nothing wrong, but they worry about the possibility of having committed sin, and they second-guess and doubt their intentions or motives in various situations. They wonder if their motives were 100 percent pure at every moment. The uncertainty that these “non-logical doubts”[29] create is highly anxiety provoking and distressing for the scrupulous individual. One individual explained, “The best way I can describe scrupulosity would be a thought would enter my mind that would trigger a stress reaction that begins the process of worrying if that thought is true. My mind almost starts working at hyperspeed coming up with thoughts that would support the triggering thought being true, even though it is not. Stress and anxiety typically make scrupulosity worse, so I begin entering a downward spiral where I feel like I can't get out.”

These religious obsessive-compulsive symptoms do not represent a generally more severe form of OCD, but they do represent a particularly distressing presentation of OCD.[30] In talking about their experience with scrupulosity, individuals have used words and phrases such as “tortured,” “paralyzed,” “haunted,” “excruciating,” “debilitating,” “suffering so severely,” “completely overwhelmed,” “so deeply painful, embarrassing, and frustrating,” and such. In all my years of work with psychotherapy clients, I have never felt so much pain and agony in my office as I have in working with those suffering with scrupulosity. For example, one individual summarized his panic: “I started to become fixated on perfectionism in the form of making my calling and election made sure and the fear of falling and not being exalted. The duration of eternity and not being exalted terrifies me.”

In public and personal religious worship, conventional religious rituals are done to connect with the divine, maintain tradition, participate in community, and help maintain a sense of peace and meaning in the face of trials and stress.[31] Yet scrupulosity’s tyranny transforms normative conventional religious rituals into compulsive rituals. For example, prayer, scripture study, and church and temple attendance no longer create peace or feelings of connection with the Spirit but are done out of fear of punishment and create feelings of condemnation.[32] One individual commented that his prayers were “repetitive” and that he was “always just begging” for forgiveness all the time.

Summarizing several studies on guilt, one researcher commented, “Scrupulous rituals serve the opposite function of their intended purpose. Scrupulous rituals are driven not only by an obsessive need for certainty, to achieve a state of perfection, and to feel ‘right,’ but also to allay guilt caused by an obsession that violated the literal ‘letter’ of the religious law (i.e., a blasphemous thought). As a result, the ‘spirit’ of the religious law—that one is forgiven for (unintended) transgressions—becomes lost on the sufferer who is not able to experience the intended restorative benefit the ritual was created to provide.”[33]

Indeed, scrupulosity eclipses[34] one’s view of heaven, the nature of God, and the role of the Atonement of Jesus Christ in one’s life and eternal journey. It distorts, corrupts, and obscures beautiful gospel truths. Researchers examined the relationship between the principles of grace and legalism relative to mental health in Brigham Young University students. Grace was defined as a view that God is active in helping us in our lives, while legalism referred to a strict, literal or excessive conformity to a religious code. They found that “the higher the subjects’ legalistic beliefs were, the less they reported experiencing God’s grace and, in turn, the poorer the mental health outcomes. . . . A legalistic view of God may lead to poorer mental health partially because it interrupts the ability to experience grace. Legalistic beliefs and practices appear to diminish a sense that God is aware of their concerns, attends to their needs, and provides for them through divine grace.”[35]

Scrupulosity is legalistic because as religious practice gets narrow and extreme, it becomes focused on marking off checklists to satisfy specific obsessional issues rather than seeking to live according to broader gospel principles. Indeed, researchers have found legalism to be positively correlated with perfectionism, scrupulosity, anxiety, depression, and shame.[36] One individual came to the awareness that the God she had been worshipping was the “wrong God” because in her mind he was a “scary dictator-with-a-checklist type of God.”

The frantic efforts to check gospel to-dos off a list, attempting to live each moment with absolute, dogmatic perfection may give an individual a momentary sense of control while in a swirl of anxiety, but in the end it obfuscates pure doctrine while the obsessive-compulsive anxiety is reinforced. One individual, now recovered from scrupulosity, reflected, “Ironically, in trying so hard to live the gospel through the lens of scrupulosity, I was actually doing the complete opposite, without even realizing it or meaning to. I was completely denying Christ—who he is, what he did, and his role in my life. I couldn’t stop believing that it was by my merits and my perfection, not his, that my salvation was determined. I didn’t believe his Atonement applied to me, and I was trying to save myself.” In other words, “scrupulosity masquerades as a desirable, higher standard of righteousness and personal worthiness—but it’s not! Instead, it actually denies Christ and his gospel. Scrupulosity replaces our loving, merciful Father and his Spirit with punishing, crippling anxiety and guilt, creating a rigid, demanding checklist approach to gospel living. This is because scrupulosity isn’t about faith; it’s about obsessive anxiety.”[37]

Helping the Scrupulous Student

Tips to Assist Those with Scrupulous Fears While Teaching

As you teach, awareness of maladaptive perfectionism and scrupulosity can positively influence how you communicate to your students about sensitive issues. Here are some points to consider as you teach your classes:

1. Avoid casual statements indicating your opinion surrounding confession or other gospel principles that someone with scrupulosity may internalize as fact or doctrine.
2. Avoid turning gospel principles into checklists.
3. Express faith, hope, and confidence that the Atonement of Christ, not our own effort, saves and perfects us!

First, a problematic area of concern for those with scrupulosity is the confession of sin. So, avoiding statements of opinion about how to apply the doctrine of confession or other gospel principles is imperative. Teach the doctrine, share scripture, and read from General Authorities, Church documents, the Church’s Bible Dictionary, and the like. For example, the Bible Dictionary entry for “confession” states: “Confession to a church official (in most cases the bishop) is necessary whenever one’s transgression is of a nature for which the Church might impose loss of membership or other disciplinary action. The bishop cannot and does not forgive sin, but he may judge the matter and waive the penalty that the Church might otherwise impose against the person. The repentant sinner must still make confession and obtain forgiveness of the Lord.”[38]

One individual reported the one thing he remembered from a particular seminary teacher was a statement made in class lecture that if a student was unsure if she or he should confess to the bishop about a potential sin, then that meant they probably should. This statement, although well meaning, is not accurate when compared with the Church’s statement above. For example, this type of opinion stated by a teacher can unwittingly create difficulty for those students with maladaptive perfectionism or OCD scrupulosity who may have the urge to confess every minor questionable thought that comes into their head. The types of thoughts that some with scrupulosity end up confessing to ecclesiastical leaders include such things as “I doubt God,” “I can’t be sure if my motives were pure,” “Was I completely honest?,” “Did I look at that advertisement of a person in a bathing suit a moment too long, turning it into pornography?” Clearly, these types of thoughts are concerning to one with scrupulosity, but they are not “of a nature for which the Church might impose loss of membership or other disciplinary action.” In fact, Church leaders do not impose discipline for thoughts.

Even though this particular individual now understands his own scrupulosity, the doctrine of confession, and the unhelpfulness of the teacher’s statement for someone with scrupulosity (it is actually the opposite of what the scrupulosity sufferer should do), this teacher’s opinion still hangs with him when he has the urge to compulsively confess, causing him anxiety and self-doubt. Therefore, it is best to avoid such statements. In class, if a student is taught the Church’s official position on confession and is still uncertain if a sin needs confession to a bishop (beyond personal confession to the Lord), refer them to their parents who may more accurately be able to hear their concern and, with parental discernment, counsel them appropriately.

Second, avoid turning gospel principles into checklists. Gospel checklists will torment the scrupulous student with hopes that they can be saved if they just follow all the right steps. Elder David A. Bednar of the Quorum of the Twelve Apostles gave a training to seminary and institute teachers in which he stated the importance of being mindful about this issue. Throughout the training he talked about needing to base teaching on gospel principles and stated, “We’ve got to not turn things into checklists and formulas.”[39] This teaching is particularly critical for those with OCD. In a podcast I talked about the potential damage of a list-like approach to gospel living, “because someone with OCD is going to go through and they are going to make sure they have checked off every little thing on that checklist, and then they’re going to wonder why they still feel so horrible.”[40]

Third, express faith, hope, and confidence that the Atonement of Christ, not our own effort, saves and perfects us! Since scrupulosity corrupts an individual’s perception of the nature of God and the Atonement of Christ, it can be helpful for students to have their Church educators share the many hopeful doctrines of eternity. For example, we are taught that God’s nature is one of eternal love. This doctrine can easily be found in teachings of the apostles and prophets and all four standard works. A sampling follows: Elder Jeffrey R. Holland of the Quorum of the Twelve Apostles taught, “The first great truth of all eternity is that God loves us with all of His heart, might, mind, and strength.”[41] In the Old Testament we are taught, “For I know the thoughts that I think toward you, saith the Lord, thoughts of peace, and not of evil, to give you an expected end” (Jeremiah 29:11). In the New Testament we are taught, “But God commendeth his love towards us, in that, while we were yet sinners, Christ died for us” (Romans 5:8). In the Book of Mormon we are taught, “I began to pray unto the Lord that he would have mercy on me, according to the multitude of his tender mercies” (1 Nephi 8:8). And in the Doctrine and Covenants, in a revelation to Joseph Smith in 1830, Jesus Christ taught, “Lift up your hearts and be glad, for I am in your midst, and am your advocate with the Father; and it is his good will to give you the kingdom” (Doctrine and Covenants 29:5). One individual reflected about an experience with a seminary teacher: “I remember my junior year someone asked about the celestial kingdom, and my teacher looked at us and sincerely stated, ‘I think that everyone in this room will make it to the celestial kingdom.’ That really helped and inspired me and boosted my confidence.”

Tips for Recognizing Scrupulosity

The overanxious students are loyal to God. Yet that strength can become their downfall.[42] Students that are chronically concerned about the uncertainty of whether or not they have sinned are not able to lay hold to a healthy, peaceful relationship with spiritual belief and religious worship and often become frustrated with feelings of hopelessness. Just as with bothersome pebbles in one’s shoe, unwanted and intrusive thoughts of doubt or unworthiness return again and again no matter how hard they try to repent or how much others may counsel them or reassure them.

As recognizing scrupulosity can be difficult because of the powerful, compelling physiological impulses created by anxiety that compete with feelings of the Spirit, here are a few tips to help the religious educator.

1. Identify the feelings the student is experiencing. Are they characteristics of anxiety or spiritual promptings?
2. Is the student careful in all areas of gospel living, or do they have a pet obsession or two that exceed what is required by religious doctrine? Are they perhaps focused on insignificant religious rituals (while ignoring other important aspects of their religious beliefs)?[43]
3. If there is a legitimate sin clearly identified that is needing repentance or confession, is the student experiencing godly sorrow or anxiety?
4. Does repentance work for the student?

First, for many, there is difficulty discerning between a spiritual prompting and an anxious, scrupulous obsession. Due to the religious content of the obsessive thoughts, the individual often simply accepts their problem as a religious one without examination. It doesn’t occur to them that anything else could be going on because there isn’t a question in their mind as to what is going on—from their perspective, a thought about worthiness (for example) is the Spirit communicating to them.[44] Yet a common cognitive distortion I have seen in clients with scrupulosity is “I feel unworthy, so I must be unworthy.” For some, it may never occur to them that their problem is an anxiety problem until someone else talks with them about it. In my clinical work as a psychologist, this has been the single largest barrier to successful treatment outcomes that I have encountered with clients. Months into therapy, some clients are still enticed by the idea that their doubts and fears may really just be the Spirit communicating to them about some significant failing in their moral core.

Asking the student to identify their feelings can be helpful in clarifying the driving force in their emotional experience. If the student is worried or agitated; feeling fear, panic, or a sense of crisis (even for minor issues); feeling impulsive (such as feeling like they have to go to talk to their bishop right now or they are going to hell); feeling confusion, debilitating guilt, and despair then they are clearly under anxiety’s influence.[45] The Spirit does not operate through intimidation, fear, and condemnation. Elder Richard G. Scott taught, “Two indicators that a feeling or prompting comes from God are that it produces peace in your heart and a quiet, warm feeling.”[46] We learn such truths from the scriptures: “But the fruit of the Spirit is love, joy, peace, longsuffering, gentleness, goodness, faith, meekness, temperance” (Galatians 5:22–23). These spiritual feelings contribute to an overall sense of “goodness and righteousness and truth” (Ephesians 5:9).[47]

Second, the scrupulous individual will generally have obsessional concerns “regarding a few particular facets of religious practice, which ironically may interfere with other (often more important) aspects of observance.”[48] This is one signal that a student may be suffering from scrupulosity. It is common for the overanxious, scrupulous individual to have specific concerns that their obsessions and anxiety swirl around. One individual with scrupulous fears around honesty reported that he was “paralyzed by this anxiety—that unless I was overkill in honesty, I wasn’t going to make it to the celestial kingdom.” A single student with scrupulous fears around living the law of chastity perfectly may choose not to date, hoping to be able to avoid any thoughts or circumstances that may evoke feeling physically attracted to someone and possibly experiencing some sensation of sexual arousal. The topics specific to their obsessions evoke tremendous anxiety for these individuals, yet, interestingly, it is common that these individuals may be more casual in other areas of gospel living.

Third, godly sorrow is not driven by anxiety. Adaptive guilt is helpful to us in our spiritual journey as it pricks us when we “have truly wronged another or violated a personal [or religious] standard for which rectification is appropriate.”[49] This type of guilt is part of godly sorrow. Alma teaches, “Only let your sins trouble you, with that trouble which shall bring you down unto repentance” (Alma 42:29). Even if a student is guilty of a particular sin that is pricking their conscience, their remorse should lead them to repentance, not to panic and despair.

True repentance allows each of us as sinners to be reconciled with God through the Atonement of Jesus Christ. Nephi states, “Believe in Christ, and . . . be reconciled to God; for we know that it is by grace that we are saved, after all we can do” (2 Nephi 25:23). Yet if a student works through the repentance process in a spirit of godly sorrow and is still unable feel reconciled to God, unable to feel peace or to feel clean and worthy, this is a signal that toxic guilt and toxic anxiety may be driving them. One individual shared his struggle trying to feel clean after working with his bishop to resolve sin: “My problems with scrupulosity developed when I was about seventeen years old. I had to clear things up so that I could get ready for my mission and was confessing things that I needed to. I would go into the bishop’s office and confess sometimes multiple times in a week, not all new sins, but a lot of describing the sins that I had made in more detail. I also saw accidents as something that I needed to confess. I then never got to the spot where I could consider myself clean or worthy. I went on day to day thinking that I was unworthy, and I kept needing to get told by a leader that I was worthy.”

One individual learned how to move past her anxiety: “I’ve come to feel the difference between the Spirit gently whispering to me when I have actually sinned and when a correction is needed versus the relentless anxiety that led me to obsess about every tiny mistake and to try to be absolutely perfect in every detail. I’ve learned how to repent in a productive and cleansing way when I sin instead of the compulsive, repetitive, futile ‘repentance’ I was driven to in the past.”

Fourth, repentance does not work as it should when toxic anxiety is at the core of the student’s concern. Many with scrupulosity have a deep and abiding determination to do whatever is necessary to be worthy and acceptable to their Father in Heaven. They may be concerned about a blatant sin, a possible sin, or their motives and intentions. They may do all the things they have been taught to do in order to repent but they do not feel peace and do not feel clean; repenting does not bring relief. One individual shared this thought: “I didn’t have the judgment at the time to know what was really happening—all I knew is I felt horrible and couldn’t feel better. I didn’t know what to do and I was totally stuck. ‘Repenting’ wasn’t working.”

This is in direct contrast to the true doctrine of repentance that teaches us that as we turn to Christ, he will accept us, cleanse us, and heal us. In the Book of Mormon, Alma was “racked with torment” and “harrowed up by the memory” of his sins (Alma 36:17, 19).[50] Alma’s description of his pain and torment, like others that are guilty of great sin, is similar to the feelings and experiences of those with scrupulosity. Yet Alma was relieved of his torment upon receiving Christ: “O Jesus, thou Son of God, have mercy on me, who am in the gall of bitterness. . . . I was harrowed up by the memory of my sins no more. And oh, what joy, and what marvelous light I did behold” (Alma 36:18–20). He also commented, “I did cry out unto the Lord Jesus Christ for mercy . . . and I did find peace to my soul” (Alma 38:8). In other words, repentance works in the gospel of Jesus Christ for the sinner, but for those struggling with obsessive-compulsive anxiety it doesn’t work so well. Certainly, those with scrupulosity can repent of sin and have that repentance accepted of the Lord, but they do not feel it has been accepted and they are not able to experience the “joy” and “marvelous light” of repentance.

Counseling the Scrupulous Student

These students need you, as religious educators, to understand, even when they do not, that their problem is actually not related to the content of their concern (such as a perceived sin in a particular area). Their problem lies in the process of their concern—obsessive-compulsive anxiety. When you understand that, you will know as they stand at your gate that the best course of action is not simply to refer them to an ecclesiastical leader. A comprehensive approach to the scrupulous student is recommended to meet their spiritual and mental health needs.

Here, I outline four steps to take in counseling the scrupulous student:

1. Counsel the student about the anxious flavor of your interactions with them. Teach them about scrupulosity. Suggest that their problem may not be a spiritual problem but instead may be a mental health issue regarding toxic perfectionism or obsessive-compulsive anxiety.
2. Refer them to their parents for support and to get help accessing resources.
3. Refer them to their bishop to clarify the nature of their concerns, educating them about the bishop’s role. Make contact with the bishop, with the student’s permission, to talk about your impressions of what may be going on with the student.
4. Suggest they make an appointment to be assessed by a mental health professional trained in the treatment of OCD. Explain to them that a bishop and a therapist occupy different roles and that both may be necessary for helping them to overcome their concerns.

Highlight the Role of Anxiety in Current Concerns

As you engage in discussion with the scrupulous student about their concerns, it is likely that you will come to be able to recognize their anxiety. For example, in one study researchers sought perspectives and experiences of ultra-Orthodox Jewish rabbis with scrupulous parishioners. Several rabbis highlighted that they were able to discern the maladaptive nature of scrupulosity by the urgent manner in which the inquiries were made followed by a demand for an immediate answer. One rabbi described, “When I answer such a person, he keeps debating, raising some far-fetched scenarios which perhaps I haven’t considered. He jumps from one subject to another, forcing me to repeat my answers again and again. You can see that the person is trapped in some kind of mechanism.” Another rabbi described the feeling of “not being listened to. . . . I was doing my utmost to answer the questions of such a person, but it felt that he was caught in his own thoughts, repeatedly asking the same questions I just answered, at times with minor changes without even considering my advice.”[51]

When the maladaptive nature of their anxiety becomes apparent to you, first, counsel them about the anxious flavor of your interactions with them. Let them know they sound anxious or stressed. Ask them if their worry is unmanageable. For example, one individual began to understand the impulsive nature of anxiety. He would often have feelings such as “Do this now, or you’re going to go to hell!” Yet in time he learned that the Spirit is not impulsive[52] and that revelation is not that easy.[53] He learned to give himself time: “OK, if you feel this way in two days you can act on it. If not, you know what was going on.” Typically, after a couple of days the anxiety was gone. In treatment, I will often encourage people to put a pause on a confession to an ecclesiastical leader while they are trying to figure out how to discern between their anxiety and promptings of the Spirit. If it is truly a prompting from the Spirit to repent, the need to repent will still be there in a few days or weeks; if it is a prompting from anxiety the concern will disappear once the individual is distracted and has some distance from it.

Then educate the student about scrupulosity. Many people do not know about scrupulosity and don’t understand that religious concerns can even be related to mental health concerns. Suggest to the student that their problem may not be a spiritual problem related to their strength of faith or worthiness, but that it may be a mental health issue regarding toxic perfectionism or obsessive-compulsive anxiety.

The goal here is not to be a therapist and convince the student that they have scrupulosity or to try to diagnose them but just to plant the seed of possibility in their mind for them to ponder. For example, you might say something like “It might just be possible that the issue isn’t that you didn’t repent properly. It sounds like you’re really anxious.” Other individuals such as a therapist can be responsible to more fully explore with the student their experiences and feelings and assess them for a diagnosis.

Invite Parental Involvement

Second, if you suspect that this is an issue for your student, prayerfully consider if you should contact their parents directly or invite the student to address their parents on their own. Many parents will not understand scrupulosity and will need to be educated about the complexity of the issue. You may want to refer them to this or other articles to learn more.

Parents can provide the student access to resources, such as locating therapists, providing insurance coverage, and supplying money for therapy session fees. These are important practical issues that many students don’t understand, requiring their parents’ assistance.

In addition, parents often function as a student’s primary social support. They can offer encouragement and love. They can talk through with the student what they are learning in treatment to facilitate internalizing therapy principles. They can hold the student accountable to follow through with ecclesiastical meetings and/or therapy sessions. They can support the student in completing therapy homework assignments between sessions. One individual shared their experience:

Opening up to my parents allowed them to take crucial steps in helping me recover, the biggest of which was helping me find a great therapist who understood how to help me. My parents have not been able to take away my OCD, but their support, love, and intentions to understand and show empathy have lifted and encouraged me to work through a lot of the therapy process. Also, I received two priesthood blessings from my father that have helped me immensely on the road to recovery. I think about them almost every day. . . . I’m grateful that in my case, it was my dad who could give me those priesthood blessings and that my parents have been people that I can open up to and discuss my feelings. They have been pivotal means of support throughout my ongoing OCD recovery process.

As with this individual, many students rely heavily on their parents for counsel and reassurance. Therefore, as parents learn more about the scrupulosity with which their child suffers (if such a diagnosis for them is warranted), they need to be taught that offering reassurance to their child relative to their scrupulous fears will not ultimately help them break free from the obsessive-compulsive cycle and heal. The natural reaction of a parent is to offer their child reassurance that they are OK spiritually, and in truth, they are. However, offering this type of reassurance or answering questions about whether they are OK spiritually interferes with the main therapy goal of scrupulosity treatment. Treatment seeks to maintain uncertainty for the individual, which is “to break the association between fear and uncertainty about having possibly sinned”[54] and to “learn to manage the uncertainty in a functional way.”[55]

For example, one individual illustrates the importance of his connection with his father, while also showing that his father’s reassurance wasn’t sufficient to help him therapeutically. “Over the course of six weeks, I met with the branch president at the Missionary Training Center and confessed six times. I always remembered more. . . . At one point in the MTC, I emailed my dad, asking if I needed to confess yet another past ‘sin’ that I had thought of. When he told me that I hadn’t done anything wrong, it didn’t bring me relief. Instead, I took it as a sign that Satan was using my family’s mercy to lull me into complacency. I grew convinced that I would have to endure alone. . . . And I confessed again.”[56]

Therefore, you can suggest to the student that it could be helpful to them to ask their parents to offer support and love but not engage with them regarding the content of their scrupulous fears. If the student does seek reassurance from a parent, the parent can be instructed to answer. “I am sorry you are struggling, but that’s a scrupulosity question so I can’t answer that for you.” Or “I know this is painful. I’m sorry. I sure love you! Yet that is an OCD question, so you’ll need to work through your anxiety about it.”

Make a Referral to an Ecclesiastical Leader

Third, if the student clearly has an issue that would be important to confess to an ecclesiastical leader, or if the student remains uncertain if confession to an ecclesiastical leader is warranted and they are uncomfortable speaking to their parents about the issue, refer them to their bishop for working through the repentance process or to clarify the nature of their concerns.

As a judge in Israel, the bishop will know what type of approach to take to the student’s confession or discussion of concern. Sometimes bishops will discern a genuine spiritual issue that they will address and work with the student to resolve. Sometimes bishops will believe the issue is not of significant importance requiring their intervention and they may reassure their parishioner that they are OK from a spiritual standpoint. However, a caution for educators and ecclesiastical leaders: if the student’s concern is of a scrupulous nature, reassurance that they are OK will only comfort them temporarily and then the anxiety will return. One researcher explained, “The scrupulous person . . . tends to be mistrustful of himself and of others—including the many confessors he has ‘tried’—and to cling to one conviction, that of his own sinfulness.”[57]

One individual shared his story, vividly illustrating the futile nature of reassurance from authority figures when a problem is scrupulous in nature:

It began when I remembered something I had done when I was nineteen which launched me into a period of frantic obsession. I became extremely concerned about times I thought I had broken the law. This fear was fueled by the need to “obey, honor, and sustain the law.” Normally mental compulsions of repentance were enough to eventually make me feel better. This time though I could not find any relief for the guilt I felt because in order to truly repent I felt I needed to make things right with legal authorities which terrified me. So I ended up sitting in the discomfort day after day until I called the police and confessed (which I did with them telling me I was legally fine) and until I eventually went and talked to my bishop who reassured me that I had done nothing wrong. I felt peaceful for probably ten or fifteen minutes before I again was unable to cope with the thoughts of going to jail, displeasing God, and never being happy again. At the time I worked in the stake offices every Tuesday for my young single adult stake, and the Tuesday after speaking to my bishop, I went and talked to my stake president, who likewise assured me I was spiritually fine and helped me go over every concern I had in detail. He explained to me in a logical way why they were not legally or morally wrong. This helped temporarily, but ultimately things continued to be miserable. I could not sleep or eat any significant amount during this time and lost ten pounds in a little over a week. I isolated myself in my bedroom and asked for priesthood blessings from someone almost every day. I became suicidal during this time in the sense that I wanted to die, for God to end my life.

Since those with scrupulosity cannot find peace from their anxiety on their own, they often cling to those in authority to reassure them, hoping that it will assuage their anxiety. This individual confessed to three different sources of authority—the police, the bishop, and the stake president—and, painfully, still had his mental health deteriorate, ending up in a suicidal crisis. Since reassurance from an authority, religious or otherwise, will not ultimately bring lasting peace to the scrupulous individual, it is a wise bishop who can discern the over-anxious disciple. In a podcast interview, I was interviewed by host Morgan Jones about the nature of scrupulosity. She shared this personal story:

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 applauding that.

This particular bishop understood the flavor of an overanxious confession. However, since scrupulosity is not known or well understood by many, a bishop or other ecclesiastical leader may not be aware of scrupulosity and may unwittingly allow or even encourage repeated meetings and confessions and reinforce obsessive and compulsive tendencies.[58] In time, the bishop may realize that they are caught with the student in an anxious cycle. This can wear down both the student and the bishop. Therefore, it would be helpful to ask the student for permission to contact their ecclesiastical leader. In that communication, you may be able to share with the Church leader the nature of your discussions with the student and your impression that it may be an issue of overanxiety. You may also share some of what you know about scrupulosity and invite the leader to learn more. This intervention could save the student and the ecclesiastical leader from spending a lot of time, energy, and spiritual pain going around in circles about a scrupulous concern and allow them to consider the best approach to dealing with the anxiety.

Make a Referral to a Mental Health Professional

Fourth, if your student is showing signs of scrupulosity it would be useful to recommend that they seek an assessment or treatment from a psychologist or other trained mental health professional that works specifically with OCD.

It is important to educate the student and parents about the bishop’s role as a Church leader contrasted to the role of a trained mental health professional. Explain to them that a bishop and a therapist occupy different roles and that both may be necessary for helping them to overcome their concerns. Elder Alexander B. Morrison of the Quorum of the Seventy taught, “We must understand, however, without in any way denigrating the unique role of priesthood blessings, that ecclesiastical leaders are spiritual leaders and not mental health professionals. Most of them lack the professional skills and training to deal effectively with deep-seated mental illnesses and are well advised to seek competent professional assistance for those in their charge who are in need of it.”[59] Please suggest to the student and their parents that they make an appointment to be assessed by a mental health professional trained in the treatment of OCD. By the same token, the therapist will not seek to take on the role of the bishop. Even though the content of therapy will involve religious themes, the focus for the mental health professional is on the treatment of anxiety.

It may also be useful to suggest to the scrupulous student that they have their ecclesiastical leader and mental health professional consult with each other (often this occurs by video chat or phone call while the individual is with the therapist). Clinicians working with clients who were members of The Church of Jesus of Christ of Latter-day Saints explained:

Ecclesiastical consultations also serve the valuable purpose of lending credibility or authority to the therapist in the eyes of the client. If the scrupulous person places a high value on doing what is right in the sight of God (often as interpreted by the priesthood leader’s perspective in whom the LDS scrupulous person likely has high confidence), then having the therapist and the priesthood leader on the “same page” regarding treatment lends some borrowed trust and credibility from the priesthood leader to the therapist. Essentially, if the therapist can demonstrate that the bishop and the therapist are in agreement, then client compliance on the part of the LDS scrupulous person increases significantly.[60]

The bishop will play a supportive role. Lending credibility to the therapist and encouraging the client to pursue treatment are important because it will be the trained mental health professional working with the student in therapy sessions that will allow them to change and heal from the obsessive-compulsive cycle. Treatment will not diminish the faith of the scrupulous student, but will, in the end, allow them to reconnect with the divine and find peace and joy in their religious belief and worship—enjoyment that is presently lost to them in the chaotic swirl of obsessive-compulsive anxiety. One individual, after recovering from scrupulosity, noted: “I believe I’m more loyal now [to God] than I’ve ever been, it’s just manifested in the correct and healthy actions and feelings.”

With OCD, the gold standard in psychotherapy treatment involves more than just talk therapy; it is an active therapy process that generally involves cognitive work as well as exposure and response prevention both in the therapy sessions and at home between sessions.[61] Research has found treatment to be effective with scrupulosity.[62] Because the problem is an anxiety problem, not a religious problem, both approaches address learning to tolerate the uncertainty caused by the individual’s own anxiety. One individual reflected on the importance of this principle in his recovery: “Perhaps the most important thing in my recovery was developing a tolerance for uncertainty. I had developed scrupulosity out of a need for control and in order to recover I needed to let go of that control. I had to be willing to believe I was wrong with no logical explanation or understanding of why or how. I would now refer to this as faith, though at the time it felt like sinning to me.”

Cognitive therapy helps individuals identify problematic assumptions and thinking patterns and challenges the truthfulness of those thoughts, which helps to create cognitive flexibility. It addresses such topics as thought control, inflated sense of responsibility, overestimation of threat, intolerance of uncertainty, and the like.[63] One individual, treated with cognitive therapy, said of his life after recovery, “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.”

Exposure therapy provides experiences that allow the individual to confront the thing they fear the most: their own anxiety. One individual reflected, “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.”

As the scrupulous individual faces their anxiety, several things occur. First, they learn they can indeed tolerate anxiety that presently feels unbearable; that although anxiety is uncomfortable, it is not dangerous. Second, they learn that if they don’t use escape or avoidance to shield themselves from their anxiety, it can go away on its own without them doing anything to try to make it go away. Third, as they learn these things, they gain more confidence in their own ability to cope. That confidence then encourages continued healthy thoughts and behaviors that help the student break the compulsive cycle and continue to move forward to health.

One individual shared this about his recovery:

Not only do I feel like I have come out as a whole person, but I also feel like I have discovered and learned valuable lessons about myself, mental health, and the gospel of Jesus Christ as scrupulosity, in my context, was closely connected to my faith. I feel far more compassionate now to those who suffer from mental health challenges and I feel a sense of purpose in trying to help with those who suffer in this way. In addition to a greater level of empathy to those who suffer in mind, 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. My life after therapy has brought me more joy, a clearer understanding between what is the Spirit and what is my anxiety, an improved and closer relationship to God and my wife, and an enhanced level of gratitude for living.

This individual’s mother also reflected on changes she observed in her college-age son since he had concluded therapy: “His whole concept of Heavenly Father changed. Overall—like a huge weight or burden has been lifted. He seems much more relaxed and at peace with the learning and growing process of life—much more able to be himself. He is openly grateful and joyous of the difference this therapy has made in his life, and the tools and understanding he feels like he now has to recognize and navigate situations that would've previously brought anxiety and distress.”

Summary

A religious concern is not always born from religious content, such as a question about a particular doctrinal position within the Church, a misunderstanding of how to apply particular doctrines, or adaptive guilt resulting from sin. As this article has extensively discussed and illustrated, at times religious concern is born from highly toxic, poorly regulated anxiety. This anxiety can hijack a student’s religious belief and worship. Religion then becomes a source of deep suffering rather than providing peace and light. Individuals are highly motivated to resolve their concerns but become trapped in an obsessive-compulsive cycle of unwanted intrusive thoughts about moral and religious doubts and fears, along with enacting compulsions such as reassurance seeking and confession. This obsessive-compulsive cycle limits their ability to resolve their concerns without seeking out professional mental health intervention. Religious educators, as those on the front line with students, have the opportunity to identify these students. Educating the student about toxic anxiety, and referring them to their parents, ecclesiastical leader, and a trained mental health professional, takes a comprehensive approach to treating the debilitating anxiety so they can find the therapeutic relief they so desperately crave—finding joy again in living the gospel of Jesus Christ.

Notes

[1] Alexander B. Morrison, “Myths of Mental Illness,” Ensign, October 2005, 31–35.

[2] Joachim Stoeber and Kathleen Otto, “Positive Conceptions of Perfectionism: Approaches, Evidence, Challenges,” Personality and Social Psychology Review 10 (2006): 295–319.

[3] Neal A. Maxwell, “Notwithstanding My Weakness,” Ensign, November 1976, 12–13.

[4] Brandy A. Fedewa, Lawrence R. Burns, and Alex A. Gomez, “Positive and Negative Perfectionism and the Shame/Guilt Distinction: Adaptive and Maladaptive Characteristics,” Personality and Individual Differences 38, no. 7 (2005): 1609–19.

[5] Fedewa, Burns, and Gomez, “Positive and Negative Perfectionism,” 1609–19.

[6] Michelle D. Craig, “Divine Discontent,” Ensign, October 2018, 53.

[7] G. E. Kawika Allen and Kenneth T. Wang, “Examining Aspects of Religiosity, Perfectionism, Scrupulosity, and Well-Being among LDS Individuals,” Psychology of Religion and Spirituality 6 (2014): 257–64.

[8] David Greenberg and Jonathan D. Huppert, “Scrupulosity: A Unique Subtype of Obsessive-Compulsive Disorder,” Current Psychiatry Reports 12 (2010): 286.

[9] Jonathan S. Abramowitz and Ryan J. Jacoby, “Scrupulosity: A Cognitive-Behavioral Analysis and Implications for Treatment,” Journal of Obsessive-Compulsive and Related Disorders 3 (2014): 140–49.

[10] Obsessive Compulsive Cognitions Working Group, “Cognitive Assessment of Obsessive Compulsive Disorder,” Behaviour Research and Therapy 35 (1997): 678.

[11] Fedewa, Burns, and Gomez, “Positive and Negative Perfectionism,” 1609–19.

[12] Fedewa, Burns, and Gomez, “Positive and Negative Perfectionism,” 1609–19.

[13] Allan D. Rau, “‘Be Ye Therefore Perfect’: Beyond the Perfectionist Paradigm,” Religious Educator 12, no. 3 (2011): 38.

[14] Rau, “‘Be Ye Therefore Perfect,’” 38.

[15] Boyd K. Packer, “Revelation in a Changing World,” Ensign, October 1989.

[16] Debra T. McClendon, “Discerning Your Feelings: Anxiety or the Spirit?” Ensign, April 2019.

[17] Fedewa, Burns, and Gomez, “Positive and Negative Perfectionism,” 1609–19; Kenneth G. Rice and Robert B. Slaney, “Clusters of Perfectionists: Two Studies of Emotional Adjustment and Academic Achievement,” Measurement and Evaluation in Counseling and Development 35, no. 1 (2002):35–48.

[18] Don Miguel Ruiz and Janet Mills, The Four Agreements: A Practical Guide to Personal Freedom (San Rafael, CA: Amber-Allen Publishing, 2010), 18.

[19] Han Na Suh et al., “Comparing Perfectionist Types on Family Environment and Well-Being among Hong Kong Adolescents,” Personality and Individual Differences 70 (2014): 111–16.

[20] Greenberg and Huppert, “Scrupulosity,” 285.

[21] Chris H. Miller and Dawson W. Hedges, “Scrupulosity Disorder: An Overview and Introductory Analysis,” Journal of Anxiety Disorders 22 (2008): 1044.

[22] David Greenberg, Eliezer Witztum, and Jean Pisante, “Scrupulosity: Religious Attitudes and Clinical Presentations,” British Journal of Medical Psychology 60 (1987): 29.

[23] Greenberg and Huppert, “Scrupulosity,” 284.

[24] Miller and Hedges, “Scrupulosity Disorder,” 1042.

[25] Greenberg and. Huppert, “Scrupulosity,” 283.

[26] Jonathan S. Abramowitz et al., “Religious Obsessions and Compulsions in a Non-clinical Sample: The Penn Inventory of Scrupulosity (PIOS),” Behaviour Research and Therapy 40 (2002): 825–38.

[27] Obsessive Compulsive Cognitions Working Group, “Cognitive Assessment of Obsessive Compulsive Disorder,” 678.

[28] Miller and Hedges, “Scrupulosity disorder,” 1046; Obsessive Compulsive Cognitions Working Group, “Cognitive Assessment of Obsessive Compulsive Disorder,” 678.

[29] Mujgan Inozu, Yasemin Kahya, Orcun Yorulmaz, “Neuroticism and Religiosity: The Role of Obsessive Beliefs, Thought-Control Strategies and Guilt in Scrupulosity and Obsessive-Compulsive Symptoms Among Muslim Undergraduates,” Journal of Religion and Health 59 (2020): 1145.

[30] Elizabeth A. Nelson et al., “Scrupulosity in Patients with Obsessive-Compulsive Disorder: Relationship to Clinical and Cognitive Phenomena,” Anxiety Disorders 20 (2006): 1071–86.

[31] Leslie J. Shapiro and S. Evelyn Stewart, “Pathological Guilt: A Persistent Yet Overlooked Treatment Factor in Obsessive-Compulsive Disorder,” Annals of Clinical Psychiatry 23, no. 1 (2011): 68.

[32] Bruce M. Hyman and Cherlene Pedrick, The OCD Workbook, 3rd ed. (Oakland, CA: New Harbinger Publications, 2010), 180.

[33] Shapiro and Stewart, “Pathological Guilt,” 68.

[34] Gary E. Stevenson, “Spiritual Eclipse,” Ensign, October 2017.

[35] Daniel K Judd, W. Justin Dyer, and Justin B. Top, “Grace, Legalism, and Mental Health: Examining Direct and Mediating Relationships,” Psychology of Religion and Spirituality (2018): 7.

[36] Allen, Wang, and Stokes, “Examining Legalism, Scrupulosity, Family Perfectionism, and Psychological Adjustment,” 1.

[37] Debra T. McClendon, “Understanding Scrupulosity (Religious OCD),” Ensign, September 2019.

[38] Bible Dictionary, s.v. “Confession.”

[39] David A. Bednar, “An Evening with a General Authority,” Church of Jesus Christ of Latter-day Saints video, February 7, 2020, 1:16:22.

[40] Debra T. McClendon with Morgan Jones (host), “Scrupulosity—Obsessive-Compulsive Anxiety You May Mistake as Faith Crisis,” All In (podcast), July 1, 2020.

[41] Jeffrey R. Holland, “Tomorrow the Lord Will Do Wonders Among You,” Ensign, April 2016, 127.

[42] Dallin H. Oaks, “Our Strengths Can Become Our Downfall” (BYU devotional address, June 7, 1992), BYU Speeches.

[43] Kyle N. Weir et al., “Scrupulosity: Practical Treatment Considerations Drawn from Clinical and Ecclesiastical Experiences with Latter-day Saint Persons Struggling with Religiously-oriented Obsessive Compulsive Disorders,” Issues in Religion and Psychotherapy 36, no. 1 (2014): 59.

[44] Weir et al., “Scrupulosity,” 59.

[45] Debra T. McClendon, “Discerning Your Feelings: Anxiety or the Spirit?,” Ensign, April 2019.

[46] Richard G. Scott, “How to Obtain Revelation and Inspiration for Your Personal Life,” Ensign, April 2012, 47.

[47] For characteristics of scrupulosity contrasted with tenets of pure religion, see “Understanding Scrupulosity (Religious OCD), chart, Ensign, September 2019.

[48] Abramowitz and Jacoby, “Scrupulosity,” 140–49.

[49] Shapiro and Stewart, “Pathological Guilt,” 68.

[50] It is helpful to note for someone with scrupulosity that Alma’s sins were not minor sins that tend to occur in the course of daily living as an imperfect mortal. In addition, they were not just inadvertent, possible sins, or moments when Alma may have questioned whether his motives were 100 percent pure. Alma’s sins were blatant, purposeful sins (see Alma 36:12–22; Alma 38:7). In fact, he and his friends were called “the very vilest of sinners” (Mosiah 28:4). Even still, “the Lord saw fit in his infinite mercy to spare them” (Mosiah 28:4).

[51] Benny Horwitz et al., “A Qualitative Analysis of Contemporary Ultra-Orthodox Rabbinical Perspectives on Scrupulosity,” Mental Health, Religion & Culture 22, no. 1 (2019): 88.

[52] McClendon, “Discerning Your Feeling,” Ensign, April 2019.

[53] Richard G. Scott, “To Acquire Spiritual Guidance,” Ensign, October 2009.

[54] Jonathan Abramowitz, “Treatment of Scrupulous Obsessions and Compulsions Using Exposure and Response Prevention: A Case Report,” Cognitive and Behavioral Practice 8, no. 1 (2001): 81.

[55] Abramowitz, “Treatment of Scrupulous Obsessions and Compulsions,” 81.

[56] Derek Baker, “My Battle with Religious OCD,” Ensign, September 2019.

[57] G. Mora, “The Scrupulosity Syndrome,” International Journal of Clinical Psychology 5 (1969): 166.

[58] Horwitz et al., “Contemporary Ultra-orthodox Rabbinical Perspectives,” 94.

[59] Morrison, “Myths of Mental Illness,” 31–35.

[60] Weir et al., “Scrupulosity,” 63.

[61] Abramowitz and Jacoby, “Scrupulosity,” 145–46.

[62] Jonathan S. Abramowitz, “Treatment of Scrupulous Obsessions and Compulsions Using Exposure and Response Prevention: A Case Report,” Cognitive and Behavioral Practice 8 (2001): 79–85; Farzad Farhood et al., “Effectiveness of Cognitive Behavioral Therapy Based on Exposure and Response Prevention on Patients with Contamination Obsessive Compulsive Disorder and Scrupulosity,” Journal of Shahid Sadoughi University of Medical Sciences 27, no. 11 (2020): 2099–11.

[63] Obsessive Compulsive Cognitions Working Group, “Cognitive Assessment of Obsessive Compulsive Disorder,” 677–81.