Religious OCD Among Orthodox Jews

Dr. Moses Appel (Edited by Matthew Shields)

What happens when devotion turns into obsession? When prayer becomes plagued by intrusive thoughts? This post aims to unravel the complexities of a common subtype of Obsessive Compulsive Disorder (OCD), called "religious OCD," also known as scrupulosity. We'll examine its unique impact, especially within the Orthodox Jewish community, offering insights into practical solutions and treatment approaches. While I’ve tailored the examples and advice with Orthodox Jews in mind, those of other faiths may also find guidance here. If you're unfamiliar with the broader context of OCD, my blog post "Inside the Loop: Understanding and Overcoming OCD" provides a helpful foundation before we delve into this manifestation.

         So, what is religious OCD? What makes it unique to other subtypes of OCD?

         As a brief introduction, remember that OCD is a cycle where something in the environment or in one’s mind triggers an Obsession (an intrusive thought urge or image) which causes a person distress, prompting them to perform Compulsions (behaviors and/or mental acts) to relive the distress. These compulsions provide relief, but only very temporarily. Therefore, as one gives in to their compulsions, the distress caused by their OCD triggers increases over time, trapping them into constantly repeating this vicious cycle if they don’t properly treat the disorder. This usually leads to significant distress, often accompanied by functional impairment in important areas of one’s life. This is what makes it a Disorder.

         Religious OCD or “scrupulosity” is a form of OCD where the obsessions and compulsions center around religious beliefs and rituals. It’s critical to know that religion does not cause OCD; rather, those who have OCD and happen to be religious will often experience their OCD as scrupulosity. OCD likes to attach to the values and norms people find dearest, so it makes sense that for believers, it triggers them via their religious practice and/or faith. On that note, out of a general population of people with OCD, around 26% of them have religious OCD (Pinto et al., 2007), with much higher numbers in strict religious cultures.

         Unfortunately, physicians in general have misidentified scrupulosity a whopping 38% of the time, and even more concerning, mental health professionals have missed the diagnosis a staggering 29% of the time (Glazer et al., 2015)! As we will see, Religious OCD manifests round the clock; if unchecked, OCD can pervert every type of religious practice. Changing these rates starts with awareness of the disorder, and I can’t think of a better place to start than with the examples of religious OCD I often encounter in my practice.

1) Prayer: There are many ways that religious OCD can influence prayer. One example is people who constantly repeat prayers for fear they said the words incorrectly, either pronunciation-wise or because they might not have had the “right” level of intent. Another typical case is over-obsessing about keeping “inappropriate” thoughts out of one’s mind while praying. Likewise, we know that praying when one needs to use the restroom is forbidden. Still, when someone is in-and-out of the restroom many times during a single prayer service out of fear of transgression, that’s no longer following Halacha, but rather OCD’s instructions.

2) Pesach cleaning: Before Pesach (Passover) each year, observant Jews clean their homes to ensure that there aren’t  unaccounted for bread-like products. Unfortunately, some people take this commandment way too far, spring-cleaning in ways much more extreme than Halacha instructs. It’s important to talk to a trusted and knowledgeable Rabbi to understand what level of cleaning is appropriate before the holiday, and at what point it becomes OCD, and not Judaism.

3) Examining the “four species” for Sukkot: The Rabbinic tradition delves into the type of blemishes and characteristics that make each element of the four species ineligible for use. However, like with all these examples, the level of specification we take must stem from Halacha, not from scrupulosity. 

4) Milk and Meat: According to the established laws, Jews are not allowed to eat, cook, or gain benefit from mixed milk and meat. But what about avoiding placing a Tupperware of meatballs next to a milk bottle on the refrigerator shelf? Or, using hand-sanitizer several times between touching cheese and stirring the chicken soup? Indeed, these actions, and ones like it, are inappropriately extreme.

5) Ritualistic Handwashing: Like with many Jewish practices, there are a lot of rules when it comes to ritual handwashing. For example, before eating bread, we are instructed to pour water from a cup over each hand a certain number of times, with different authorities disagreeing on the parameters of this law; dispute and complexity is part of the system of Halacha. Ritualistic handwashing becomes problematic, in an OCD-sense, when people, terrified that they did it incorrectly, wash each of their hands many times to ensure that they followed the law “correctly.” 

6) Mikvah (spiritual bath): Both men and women go to a mikvah to spiritually cleanse themselves, although the level of obligation in this practice is much higher for women than men. The laws surrounding mikvah are numerous and complex. Therefore, I think this is a good area to start talking about the difference between cultural norms and scrupulosity regarding Halachik observance. I will address this more later in this article.

To someone outside of the Orthodox community, the way many Orthodox Jews prepare for and use the mikvah may seem excessive, even if their level of care in using the mikvah is determined solely by halachik responsibility and not from OCD. Consequently, it’s vital that we measure scrupulosity vis-à-vis mikvah practices by looking at the current practice one does and then comparing it to societal norms and practices, rather than from the “eye test.” If you are doing well beyond what the law instructs of you, and way more than your community peers are doing, it's likely OCD. On the other hand, if you’re devoting a lot of time and energy into mikvah practices (or any other halachik practice, for that matter), but your practice is source-based and falls in-line with communal standards, OCD most likely isn’t at play. We measure what’s excessive by comparing ourselves to internal, communal standards, not by contrasting with the general public.

7)    Faith Questioning: It is normal to experience doubts about our religious beliefs. The problem for people with OCD is that the questioning about what they “genuinely believe” stems from a place of OCD related anxiety, and not true doubt. They experience questioning ‘How do I know for sure?’ as all-consuming and never-ending. If you generally feel like you believe, but you get triggered by “what if” and “well, how do I know for sure” doubts that you wish you could get out of your head, OCD might be something to investigate.

These are just some of the examples of how OCD can interfere with traditional practice. It’s worth mentioning that it’s much easier to read certain behaviors as problematic as outside observers. For people with OCD, the line between OCD-driven behaviors and standard religious practice is hard to find. Though, for those without OCD, the line is quite clear.

There’s a fascinating paper published in 2010 by Romsarin, Pirutinsky & Siev that hypothesized that because of their careful adherence to religious law, Orthodox Jews would be less likely than their non-Orthodox counterparts to recognize scrupulosity and suggest treatment for people exhibiting religious OCD behaviors. Their idea was that observant folks would be more likely to overlook OCD behaviors than non-observant folks because they would see the behaviors as aspirational. However, the study’s results demonstrated that the opposite was true! Orthodox participants more often recognized scrupulosity/religious OCD behaviors and recommended psychological treatment than did their non-Orthodox counterparts. Why was this the case? The implication found from these results is that Orthodox observers have a greater, more nuanced understanding of Orthodox behavior than non-Orthodox observers, so they could spell out what is standard practice from what is OCD.

Still, the question of following Halacha and engaging in religious OCD is a complex one because of the existence of halachikally approved stringencies. Even for those within the Orthodox community, what looks like an extreme case of OCD for one subset of people is a day-to-day practice for another. There are a few ways to delineate stringencies rooted in a strict understanding of the law instead of ones from OCD. Here are a few ways I’ve learned to address how to differentiate scrupulosity from standard religious practice to help people with religious OCD. 

1) The first question to ask is whether the practice is clearly excessive as compared to what someone’s peers (within their subsect of Judaism) are doing; if you know what most people in a community practice, and it’s evident at first glance that someone is going way overboard, that’s a hint that it might be OCD.

2) Additionally, be on the lookout to see if the practice is fueled by doubts, like ‘WHAT Ifs’ and ‘MAYBEs.’ For example, ‘What if I didn’t pray with complete concentration?” is a very different thought than ‘Interesting, I realize that during this last prayer, I was thinking of a conversation I had with a friend earlier, which tells me my concentration was off for a bit.’

3) Moreover, as mentioned a few times in this blog post, behavior that stems from distress rather than devotion has a higher chance of being OCD. Someone might be very careful in how they clean their home before Pesach, but if they act that way because they connect with the law and spring-cleaning with a high level of detail helps them appreciate the holiday, there's nothing to suggest OCD is active.

4) Not only should acting from distress instead of devotion be a red flag that might indicate OCD but also engaging in behaviors that are actually so stringent they are themselves prohibited by Jewish law can tell you a lot. Going back to the prayer example above, if someone’s uttering God’s name repeatedly while making a blessing (something forbidden by Halacha) because they worry they didn’t have the right kavanah (intention) originally, OCD alerts should be going off.

5) Likewise, if someone’s so hyper focused on one area of ritual practice or religious thought that it comes at the expense of following other norms that their community has adopted, that’s problematic. For instance, if someone is so worried about lacking full concentration in prayer that they stop going to shul (synagogue) and instead pray in their home, this is an indication that their behavior is driven by OCD and not religion. Similarly, if one struggles with a single area of practice at the expense of others, for example, if someone spends so much time in prayer that they don’t have time for Torah study, this is another indication that their behavior is driven by OCD.

6) Another test to determine if someone’s behavior is driven by religion versus OCD is to ask them if they would be able to change their practice if their Rabbi–someone who has more knowledge than them– told them to spend less energy on this law. If someone’s not able to let go of the way they’re doing something, even when their Rabbi instructs them to do so, that indicates that OCD might be at play. 

7)  Last, if someone demands excessive reassurance to ensure they're practicing correctly, such as calling the Rabbi at all hours of the day and night, that's another great way of distinguishing OCD behaviors from normative practice.

Treatment for Religious OCD/Scrupulosity:

Exposure and Response Prevention (E/RP): E/RP is a way to break the OCD cycle by first stopping compulsive behaviors (Response Prevention) and then intentionally triggering the obsessions and refraining from compulsions. Over time, when people are successful in this therapeutic technique, the distress created by their obsessions weakens considerably, thus breaking the OCD cycle. To delve deeper into E/RP, check out my article “Inside the Loop: Understanding and Overcoming OCD.”

For someone who struggles with scrupulosity over having the proper intention while praying, maybe the move is for them to go to a synagogue where people pray very loudly and pray there. For someone who obsesses over mixing meat and dairy, maybe situate the meat and dairy pots next to each other in the fridge. These are hypothetical examples, and each case is different. This complexity is why having the patient, Rabbi, and therapist collaborate is so important. We don’t want people acting against their values but rather working on their OCD.

Obstacles/ Solutions in Treating Scrupulosity:

1) One common challenge when treating scrupulosity is the inability to differentiate OCD symptoms from everyday religious practice. See my earlier discussion about differentiating between normative practice and OCD.  

2) Another obstacle for people with OCD is that they tend to have relatively poor insight about their religious OCD. A great way of addressing this is to relay to them how their OCD behavior interferes with their religious practice. Additionally, exploring together with them why they have a hard time following their rabbi’s instructions might provide insight into their behaviors as stemming from OCD and not religion.

3) A challenge for therapists and patients alike is that typically, neither one of them is a halachic expert. This can make drawing proper boundaries difficult. The solution here is for all parties– therapist, rabbi, and patient–  proactively meet and discuss a religiously sanctioned plan. It is the case sometimes that our religious figures might be new to the concept of OCD, so to make sure everyone is on the same page, the psychologist must explain how OCD functions to the rabbi.

4) Even after the rabbi, patient, and therapist agree to a plan, it’s not uncommon for the patient to still excessively seek reassurance from the rabbi, often in inappropriate ways. Here, it's critical to implement boundaries for when reaching out is okay.

5) Likewise, if someone harasses their rabbi as a way of gaining reassurance, have the rabbi stick to pre-negotiated responses that the patient agreed to ahead of time. An example here might be that if a person can't stop themselves from asking the rabbi if they're righteous, the rabbi can respond, "We discussed this already and I can't answer this for you." Another approach is to have the patient accept personal responsibility for any sins that they might have committed. Often, when people with scrupulosity go reassurance-seeking with their religious mentors, they do it as a way of exonerating themselves of guilt by appealing to authority. Therefore, have them tell themselves that no matter what, if they sin, they are responsible for the repercussions of that.

6) On a similar note, people often misuse the rabbi’s approval of therapy/exposures as a reassurance-seeking behavior. Here’s what I mean by this. Sometimes, people use the rabbi’s endorsement of a therapeutic practice (such as a specific exposure) to clear their conscience of any wrongdoing while engaging in the exposure, which obviously defeats the entire purpose of the exposure. In other words, they are only willing to challenge themselves “because the rabbi said there wasn’t an issue.” For this challenge, I recommend that the therapist not inform the patient the details of the therapist’s consultation with the rabbi. Make sure that as a therapist, the rabbi’s instructions are followed properly, but keep the rabbi’s instructions vague to the patient.

Summary:

In this post, I applied the general OCD framework to scrupulosity and then explored religious OCD’s particularities. I discussed skills people can take to differentiate religious OCD from standard religious practices and other hurdles. I clarified that religion doesn’t cause OCD, but rather that religious practice is a breeding ground for the disorder for those who already have OCD. Finally, I focused on how mental health professionals and religious leaders should coordinate to give patients the best care possible.

As we can now hopefully see, religious OCD is a complicated endeavor, often fraught with what feels like contradictory values at-play. We should never forget that the Torah instructs us not to practice obsessively. In Tehillim (Proverbs 3:17), we’re told that “Her (Torah) ways are pleasant, and all her paths are ‘shalom’ (peace).” OCD distress is certainly unpleasant and unpeaceful. Likewise, in the Gemara (Talmud; Berachos 25b), our sages teach that “the Torah was not given to Heavenly angels.” Instead, God gave the Torah to human beings. People sometimes act imperfectly, and that’s ok.

To finish this blog post, I’d like to relate a story. I once heard a lovely story where a child was waiting for his grandfather to arrive at the train-station, and when the grandfather finally came off and walked off the train car, he asked the child to retrieve his luggage from the back of the car. As the kid struggled to carry the luggage, the grandfather called out from afar “That’s not my luggage!” When the kid got closer, he asked his grandfather how he knew from such a distance that it was the wrong luggage.

Wisely, the grandfather told him that the luggage he packed was very light, so when he saw that the child was burdened by carrying the luggage, he immediately knew it wasn’t his bag. I love this as a metaphor for religion. If religion has become an overpowering burden, then it’s time to reflect whether one is truly engaging with their religion, or if they are instead steeped in an insidious disorder, called OCD.

Disclaimer: All characters and scenarios in this post are entirely fictional. This content is intended for informational purposes only and is not a substitute for professional therapy or treatment from a licensed mental health provider. To contact Dr. Appel, please email office@ADOPsychologyCenter.com.