The form of OCD we may misdiagnose as faith crisis


Editor’s note: This article was originally published on LDSLiving.com in August 2020.

As members of The Church of Jesus Christ of Latter-day Saints, confession is absolutely an aspect of our religion. We are a church that believes in repentance, and confession is one of the steps of repentance. However, do we understand the purposes of confession and a priesthood representative’s role in the repentance process?

On this week’s episode of the All In podcast, Debra Theobald McClendon, PhD, discusses in-depth the topic of scrupulosity, a form of obsessive-compulsive disorder (OCD) that affects people’s religious experience, which she previously addressed in the September 2019 digital-only edition of the Ensign.

We often think of OCD in terms of those who perform a “ritual,” like repeatedly washing one’s hands to find relief from anxiety. If someone suffers from scrupulosity, “the person judges personal behavior as immoral that one’s faith community would see as blameless,” according to The Doubting Disease

“We, as members of The Church of Jesus Christ of Latter-day Saints, are taught that the gospel is good news, and that religious rituals—such as attending church, participating in the community, attending the temple, partaking of the sacrament—these are things that are done to maintain religious tradition, to experience peace in the face of our trials, and to get social support from our community members,” Dr. McClendon explains. “But in OCD/scrupulosity, it transforms someone's typical religious experience, and these [kinds] of rituals become compulsive rituals that completely destroy their ability to gain any peace or contentment or even joy from the gospel. It destroys faith, and it is so horribly painful for people that they just get into this hopelessness that often is hard to come out of if they don't seek professional help.”

So how, as members of the Church, can we be more sensitive to scrupulosity and those who suffer from it? In the excerpt below, Dr. McClendon explains how we can better respond to scrupulosity and how it is treated.

Read an excerpt from the podcast below or click here to listen to the whole episode. You can also read a full transcript of the podcast here.

The following excerpt has been edited for clarity.

Morgan Jones: I think sometimes the reaction [to confession] is like, "Oh, you're just such a good person. . . . it's so good of you that you would think that you would need to come and confess that." ...So, I think it'll be so interesting as we talk today to hear more about the right way to approach this. Do you have any initial thoughts on that, though?

Dr. Debra McClendon: Yes. Well, just as you're talking about confession, the Ensign article I wrote that's in the digital content section for September of 2019 on understanding scrupulosity has a discussion about whether you should be going to your bishop or a therapist, and how to discern the difference. One of the things I clarify there is simply a quote from the LDS Bible Dictionary. We are taught doctrinally that we're only required to confess to an ecclesiastical leader for certain issues. So here's what the Bible Dictionary says, if I can share this with you: "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."

That is such a critical piece that so many of my clients and so many people struggling with scrupulosity have lost. The bishop becomes an authority figure that gives them a false sense of security—"If I go to this authority and they tell me I'm okay, then my anxiety will go away." The problem is, it doesn't work that way. In fact, I have a story from an individual—his scrupulous concerns revolved around whether he'd broken the law. He went to the legal authorities at the police station and confessed, and he still struggled even though they said, "You're fine." So, then he went to his bishop and confessed, and the bishop's like, "You're fine." And he says, "I felt better for like a minute." So then he went to a stake president, and the stake president goes through, step-by-step, every reason logically why he's fine. Still, after all of those authority figures, he ended up in a suicidal crisis. It becomes very enticing to say, "If I go to this authority figure, they're going to tell me I'm okay." Because they're tricked by the anxiety, thinking it's a spiritual prompting. If it is a spiritual prompting, and you go through the things you need to repent, including a confession to an ecclesiastical leader if necessary, you will feel better. If it is driven by toxic anxiety, you will not feel better, because it's an anxiety issue. It's not a moral issue or a spiritual sensitivity issue. So that's a really important point that I'm glad you've asked me to talk about.

Morgan Jones: Yeah. I think one thing, too, in my experience, it's like sometimes there is a temporary feeling of feeling better, but then that comes right back, and like you said earlier, it comes back stronger.

Dr. Debra McClendon: Exactly. And as it comes back stronger, Morgan, it's important to note, because you've reinforced the anxiety, you will have not only those stronger, increased symptoms of anxiety, you're going to have more worry, and then you're going to lose confidence in your ability to cope with your own life. So, OCD shuts people down because they've lost the confidence that they can cope. Treatment reverses that process by doing things to expose ourselves to those anxieties and, paradoxically, it actually increases our sense of empowerment. It increases our sense of confidence. That's a really important point. So when we talk about what kind of treatments are most effective, the answer is exposure therapy. I don't know if you're familiar with that, but I'd like to talk about that just for a second if that would be okay.

Morgan Jones: Please.

Dr. Debra McClendon: A lot of therapy today goes through cognitive work, where you look at identifying thought patterns that you have and finding where you have some thinking errors or some distortions, and you basically clean up your thoughts. You pull out the things that are distorted, and you're then able to look at the situation from a more reality-based perspective. I do some of that work with my clients with OCD, but the first and foremost treatment is exposure therapy. And literally, what does exposure mean? If you're out in the sun and you have too much exposure, you've gotten too much sun. Exposure therapy is when we take the very thing you fear the most, and we give you—on purpose—experiences with that thing that you fear. The natural instinct is to avoid. It's to escape. It's to run away. So with scrupulosity, how do you escape, avoid, or run away? You go kneel down and repent for three hours to Heavenly Father, you go to your bishop every week for six months, you're trying to get away from the anxiety as much as you can. Instead, we bring the anxiety closer, we look at the fear, and we actually will repeat the fear again and again and again for 45 minutes, an hour, an hour and a half. Then we will do that on repeated experiences.

What we are basically doing is, we are giving your brain the opportunity to make sense of all this—that's in layman's terms. Another word you can use is habituate. We are habituating your mind. And if you hear in that word the word "habit," habituation means that it's becoming a habit for you to have that thought, and then it stops triggering anxiety as you do that. A thought such as, "I've offended God," may cause someone to be exceedingly anxious, but as they repeatedly expose themselves to that, "I may have offended God, I may have offended God," their brain it able to wrap around it and go, "Okay, I may have offended God, all right, I get it." And it just doesn't provoke or trigger the kind of anxiety that it was before, so that they can now move on. Our brains are designed to think thoughts. That's what they do. It's estimated that we have 50,000 to 70,000 thoughts a day, and what happens in OCD, anxiety attacks the very thing you value the most. So if you think about having a thought on the freeway such as, "there's a blue truck," or, "that's a tacky billboard," or, "that's a noisy diesel truck"—you have the thought, and the moment you've had the thought, you've already let it go and you're on to something else. Because your brain knows, and you know, it's just not important.

But if all of a sudden you have a thought, as a highly religious person, that says, "I've offended God, I'm going to go to hell"—all of a sudden, that thought feels more threatening. So instead of just letting it go, you start trying to wrap around that thought, things to insulate you, protect you, and bring the anxiety down from that thought. It's too threatening to say, "I may have offended God,” because as a religious person, “I love God, I want to please God, I value very much His influence in my life and His church in my life," right? So it becomes very threatening to have a miscellaneous thought that you may have offended God.

Because we have 50,000 to 70,000 thoughts a day, we have a lot of thoughts that we particularly don't care for. They may be unpleasant or intrusive or unwanted, but they're naturally occurring. In OCD, we misinterpret the threat associated with these naturally occurring, religious, intrusive thoughts. That's an important point.
Everybody has thoughts of doubt, or thoughts of committing a sin, like, "Oh, I could be snippy or rude to this person," or, "I could do this." These are naturally occurring, but the misinterpretation of threat causes the increase in distress, and then it creates these frantic futile efforts to remove the intrusion and reduce the obsessional distress and, paradoxically, it increases the frequency of the thoughts.

Exposure therapy is hard, obviously, to face the thing you fear the most. It's probably best, especially with a severe case of scrupulosity, to try to do this with a mental health professional who can guide you through this, but this is the therapy that is most shown to be effective for OCD.

Now with scrupulosity, there's one other piece to the treatment, in addition to cognitive work and exposure, that I often do, and other therapists have reported doing as well. We just talked about confession, right? We clarified the role of a bishop in confession, that not every thought we have, even a sinful thought, needs to be confessed to a bishop. Something I also do with my LDS clients at times is doctrinal clarification. That actually can be very helpful. Now most of my clients with scrupulosity, because they love God so much and they care so much about being good sons and daughters of God, if I asked them to give a sacrament meeting talk, or a talk even in a stake conference on any of these related issues, such as forgiveness or repentance or whatever, they could give me a perfect doctrinal talk. So doctrinal clarification can be helpful if someone is misinterpreting a doctrine, but just reading conference talks [and] listening to conference talks will not be enough if you're just clarifying doctrine, because, if you remember, the OCD, the central issue, is not a doctrinal misunderstanding—it's an anxiety issue. So, these people know the doctrine about forgiveness, they know the doctrine about Atonement, they know the doctrine of repentance, and yet the anxiety is so painful. It still trips them up, and they get tricked.

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