Mild to severe

"Obsessive compulsive disorder is often associated with uncertainty about the values ​​that are important to that person". About obsessive-compulsive disorder and excessive religious strictness * The article was published on January 11, 2011. And it was brought up again due to all the cases of excluding women and harassing them in the so-called name of religion

Naftali Israeli Galileo

Sara is a 36-year-old ultra-Orthodox mother of eight children, who sought mental health treatment because of anxiety about kosher practices. 1 From the day of her wedding at the age of 20, she had disturbing thoughts that repeated again and again that she did not keep kosher enough, and might mix milk and meat. To get rid of these thoughts, she developed over the years many rituals (rituals), such as washing hands, cleaning and praying. She also sometimes avoided cooking, forcing her husband to do it for her. These thoughts and avoidances greatly disturbed her in her work at home and in her work as a teacher. After coming to cognitive-behavioral therapy (CBT - Cognitive Behavioral Therapy) she was diagnosed as suffering from obsessive-compulsive disorder (OCD - Obsessive Compulsive Disorder).

Prof. Yonatan Huppert, researcher and cognitive-behavioral therapist from the Hebrew University of Jerusalem, has been trying in recent years to characterize a certain type of OCD that is common in religious communities in Israel and the world - religious over-strictness. Before immigrating to Israel in 2007, Prof. Hafert worked at the University of Pennsylvania with senior researchers of anxiety disorders in the world.

Prof. Hafert, what is OCD?
"OCD, obsessive-compulsive disorder, is an anxiety disorder. It is characterized by disturbing thoughts (obsessions), which appear unwillingly and without control and are therefore experienced as intrusive thoughts. Actually these can be thoughts, images or physical urges (like an urge to hurt), and in response to them people do all kinds of rituals that we call compulsions. The purpose of the compulsions is to deal with the thoughts and reduce the anxiety. Most of the time the thoughts, images and impulses are ego-dystonic ('foreign to the self', meaning that are in conflict with the needs and goals of the self. N.Y.), meaning the sufferer does not really want to express the thought or does not believe that the thought is realistic. For example, a person can have an urge to hurt his beloved wife, without really wanting to do so. These thoughts cause great anxiety and cause great suffering and dysfunction in a person suffering from OCD."

Obsessive compulsive disorder and religion: The historical context

The first descriptions in history of OCD-like behavior all have religious content. The Mishnah mentions excessive concern about cleaning the house before Passover, and the Talmud describes people who repeat their prayers for fear that they did not concentrate enough on them. Similar descriptions are found in Christian writings from the 15th century, in which Satan is described as someone who "plants" false thoughts in people and forces them to perform various rituals.

In the Middle Ages, the terms obsessions and compulsions were used in a religious context, so they referred, for example, to inappropriate speech that was forced upon the person (for example, the urge to curse loudly in church). In 1658, a doctor named Flecknoe used the term scrupulosity: the origin of the term is in the field of weight, and it means the smallest weight, which affects only the most delicate scales. The term was used by Fleckno to describe excessive worry and general indecisiveness. In the religious context, the term was used to describe people with excessive worry and hesitation regarding the observance of religious customs such as those who experienced intrusive "dirty" thoughts.

The Enlightenment movement diverted scientific and artistic pursuits from religion to secular life, and so did the pursuit of OCD. In 1935, for example, in a famous lecture by Sir Aubrey Lewis (Lewis) on obsessional diseases, five central preoccupations were defined: dirt, order, aggression, sex and religion. That is, religion has turned from the form and content of OCD into another one of the areas of the disorder. The term religious over-strictness is used today mainly to describe religious symptoms of OCD.

Prof. Hafert, is religious over-strictness a disorder in itself?
"It is very likely that religious over-strictness is not a disorder in itself, but is a subtype of OCD. There are actually several types of OCD. The most familiar types are things like fear of contamination that leads to washing hands, and fear of fires that leads to tests of gas faucets, stoves, and the like. In some studies it was found that the frequency of the fear of thoughts related to religion is in the third or fourth place after these two types, fears of harm or thoughts about sex. That is, the religious thoughts are one category among several categories related to OCD. Their prevalence is relatively high, and it is higher in religious populations."
Fusion, thought and action: Religious over-strictness

The degree of practicing religious strictness among OCD sufferers varies greatly between populations. According to the individual and his research partner Prof. David Greenberg, who works at the Herzog Hospital in Jerusalem, the incidence of this phenomenon ranges from 0% to 93%. In a review of studies conducted in the last decades, it seems that the degree of religious strictness does not cause OCD, but is mainly related to the degree to which religion is an important part of a person's life and the community to which the person belongs. In other words, the more central religion is in a person's life (such as in the lives of ultra-orthodox in Israel), the more "religious" the symptoms of OCD will be.

In recent years, Prof. Hapert has studied ultra-orthodox in Israel and the United States and found that there is no connection between the level of belief or religiosity and the severity of OCD. This is also found in other studies. As of today, there is no scientific research that indicates that religious education causes the appearance of OCD.

Compared to the secular world, the religious world requires extra differentiation and strictness. How can it be explained that this has no effect on the development of OCD?
"I conducted four studies on religion and OCD, and only in one of them did I find a correlation between religion and compulsiveness. But the correlation in this study was very low and explained only 4% of the variance. In the rest of the studies no correlation was found, meaning that the degree of religiosity or secularism is not related at all to the frequency of OCD occurrence, but is related to its quality. How is this possible? In my opinion, it is important to refer to a person's behavior according to the society in which he lives. Each company has its own rules. It is true that the ultra-orthodox have more and more detailed laws, but when you grow up in such a society it goes without saying. It seems that the tendency to OCD is universal, and religion only 'colors' the symptoms so that they are expressed in religious strictness. To be honest, there are no good studies that have examined the prevalence of OCD in ultra-orthodox society compared to secular society in Israel."

People with OCD have a tendency to treat thoughts as equivalent to actions. This tendency is called thought-action fusion in the professional literature. It includes a basic human belief that thinking about something will increase the likelihood that it will happen. For example, that the mere thought of harming someone increases the chance of actually harming them.

Some researchers believe that merging thought and action is more closely related to religious strictness, in such a way that the person who suffers from over-religious strictness experiences thoughts about causing harm, about sex, or about sin as a moral failure, as if he were involved in actually performing such acts.

The idea that thoughts may be equivalent to actions appears in several sources in Western religions, but mostly in Christianity. For example, in Matthew (5, 28-27) there is an explicit warning that anyone who looks at a woman with lust has already burned in his heart. However, current research shows that exposure to such beliefs in a religious society is not a risk factor for the onset of OCD.

And what about merging thought and action? There are religious sources that talk about it explicitly, especially in Christianity.
"My student, Yedidia Siev, tested Christians and Jews in the United States for the level of religious belief, the level of belief in merging thoughts and actions, and the level of OCD symptoms. He found that the Christians believed more in merging thoughts and actions than the Jews, but in both groups the level of religious belief was not related to the level of OCD.

"Among the Christians, there was a strong and distinct connection between fusion and religiosity (as can be expected from the Christian writings), but there was no connection between fusion and the level of symptoms, and with Jews the opposite - there was no connection between religiosity and fusion (because this is not a common belief in Judaism), but there was High correlation between those who believe in fusion and the level of OCD symptoms. That is, the conclusion is not that religion preaches strictness, but the opposite: religion gives believers an answer to their doubts, and apparently those who cannot bear doubt develop OCD. But the difficulty of bearing doubt is a universal characteristic of those suffering from OCD, and not a unique characteristic of religious strictness."

Psychodynamic therapists will give a completely different interpretation to the symptoms of OCD. For example, they will interpret the intrusive thoughts as unconscious impulses of the person. The religious person represses these impulses more strongly than usual, and therefore they return, and with great force.
"This is a possible explanation, but it does not agree with what is found in the studies. As mentioned, in the research I have conducted in recent years I have not found that there are more obsessive-compulsive symptoms in religious people. More than that, over-strictness does not appear because the patient has something against religion, but on the contrary, because he believes in religion. OCD appears in people who care more about keeping the mitzvot. If we were talking about fear of contracting AIDS, then most people would agree that the fact that I think about it anymore does not mean that I want to contract AIDS.

"Despite these things, I agree that both in the culture and in the psychodynamic atmosphere there is a tendency to interpret pathological religious strictness as an opposition to religion, that is, as something that appears because of a doubt that a person has about religion. These ideas were born in Freud, who thought that religion was an obsession, a kind of protection from neurotic aspects. From there was born the reference to OCD as protection from impulses that are contrary to the religious imperative. These ideas are wrong.”

In your experience, what are the typical symptoms of people with obsessive-compulsive disorder?
"OCD is generally related to uncertainty regarding the values ​​that are important to that person. Religious values ​​are very important to the ultra-Orthodox, so religious over-strictness is relatively common among them. From a study conducted by my colleague David Greenberg, it seems that ultra-Orthodox are less busy in areas that are more prominent among secularists, such as gas tests or fear of AIDS. However, as I mentioned earlier on the subject of religious over-strictness, there is intercultural variation, so it is important to distinguish between different religions and cultures. Protestant Christians usually have a fear of cursing Jesus or praying to Satan. Catholics may have a fear of not confessing fully to the priest. Among Muslims, matters of purity are common, and also a fear that they will not pray to the correct figure of the supreme power. Secular Jews may fear that a disaster will happen if they do not kiss the mezuzah or do not observe kosher. This is a special religious strictness, which appears in non-religious people."

"The focus of my research is with religious and ultra-Orthodox Jews. I am developing a questionnaire that will describe religious over-strictness in these populations, and it seems at the moment that there are more or less six areas that describe the fears of such people: the first, prayer - maybe they didn't say the words clearly enough or with enough intention, or they were impure during the blessing or prayer; The second, kosher - usually a fear of mixing meat and milk, and among Jews in the United States also a fear of accidentally buying prey; The third, fear of various principles such as theft, honoring father and mother, a false oath or a false vow, and sometimes keeping the Sabbath; And the fourth, disturbing thoughts are forbidden. In addition to the general characteristics, there is also a difference between women and men, and two additional areas, Thursday and Friday, are related to this difference. The fifth area belongs to men, who are more concerned with fears about putting on tefillin. Haredi men are also busy with academic matters - fear that they did not study well enough, or did not understand well enough what they were studying. The sixth and last area belongs to women, who have more fears related to purity and nida."

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Treatment: doubts and successes

According to Prof. Hafert, the treatment of this disorder requires a unique approach to a variety of issues, and especially sensitivity to religious issues. In terms of assessment, it is important to note that the disorder can also appear in non-religious, secular or atheists. Studies in Israel have found secular people who presented clear religious symptoms such as fear of hell or fear of violating the law of kosher (even though the person does not openly believe in it).

In terms of the therapeutic position, the therapist has to balance between treating the symptoms as signs of a disorder and respecting the patient's beliefs and values. It is important to clarify that the goal of the treatment is not to make a person stop believing or give up his religious practices, but rather the goal is to live his religious life more fully and in accordance with the patient's wishes.

Religious patients with obsessive-compulsive disorder are usually ambivalent about treatment. They ask themselves questions like: "Maybe the thoughts and behavior are necessary to avoid sin? What if I stop the rituals and then believe less?" The individual believes that in the therapist's response to these questions it is important to remember that most religions do not demand perfectionism from the believers. Believers are expected to do their best, but they are not expected to never make mistakes. It is important to show the patient that there are other important values ​​in religion besides the value of perfection, which they believe in, and that the symptoms harm these values. What the patient needs to accept is not the sin itself, but the chance to sin. That is, he must accept the idea that it is impossible to reduce the chance of sinning to zero without increasing the chance of other sins or to stop functioning completely. Therefore the goal of treatment should be acceptance of a certain risk of sin.

The use of clergy can be of great help in treatment, and sometimes it is even necessary. In addition to this, many religious people feel that they cannot treat religious over-strictness on their own, and would be happy to cooperate with the therapist. It is advisable to speak openly with the clergyman, of course after obtaining consent from the patient, and discuss it together.

Sara, the ultra-Orthodox woman mentioned at the beginning of the article, expressed fears that she would come into contact with non-kosher food and thus her family would sin, and anyone who would eat the food she cooked: she would not only sin herself but would spread the sin in her community and end up in hell. Sarah's therapist understood these fears and explained to her the rationale of the treatment, which is mainly exposure to the disturbing thoughts and prevention of rituals related to them. For example, the therapist explained that Sara would have to take more risks regarding kosher laws. As expected, Sarah's anxiety intensified. At this point, the therapist asked to contact Sarah's rabbi, and with the consent of the two, the therapist drew up a gradual list of exposures (in the professional language - hierarchy, N.Y.) according to the degree of Sarah's anxiety about them.

For example, one of the first things planned was for Sarah to touch a closed package of cheese before she cleans a pot of meat (anxiety level of 20 out of 100), and one of the last things - for Sarah to touch an open package of cheese and then a closed package of meat (anxiety level of 100 out of 100). During the exposures Sarah learned to confront her anxiety, and to think things like "I'm going to take the risk of mixing milk and meat. There is a chance that I will turn the food into prey and thereby serve prey to my family and community and that I will burn in hell. But I want to live in peace and joy, and serve my family and my God without OCD. That's why I'll take the risk."

After 17 sessions, Sarah reported a significant improvement, which was also reflected in the intensity and frequency of the symptoms. After a year, Sarah told in a follow-up meeting that her son accidentally spilled a bag of milk on a piece of meat, and even though she felt very anxious, she was able to clean the meat and cook it, according to the Halacha and contrary to the voices of the OCD who allowed her not to do this.

1. The name is obviously fake, and other details have also been blurred. This case is mentioned in the article by Siev published this year (2010) in the journal Cognitive and Behavioral Practice.

Naftali Israeli is a psychologist working in the student counseling services of the Hebrew University in Jerusalem. Graduated from the Department of Physics at the Hebrew University and holds an M.A. in clinical-educational psychology of the child from the University of Haifa.

The full article was published in Galileo magazine, December 2010
for further reading

Jonathan D. Huppert & Jedidiah Siev, "Treating Scrupulosity in Religious Individuals Using Cognitive-Behavioral Therapy, Cognitive and Behavioral Practice" (2010),
doi:10.1016/j.cbpra.2009.07.003

Greenberg D & Huppert JD, "Scrupulosity: a unique subtype of obsessive-compulsive disorder", Curr Psychiatry Rep. 2010 Aug; 12(4): 282-9