How Do I Care for those Burdened by Religious Scrupulosity?

When Jesus admonished religious teachers and leaders of his time with, "You give a tenth of your spices—mint, dill and cumin. But you have neglected the more important matters of the law—justice, mercy and faithfulness" (Matthew 23:23, NIV), he was naming the un-wholeness of scrupulosity. Scrupulosity is a sub-type of obsessive-compulsive disorder (OCD) that involves moral and religious anxieties and rigidity. Characteristics associated with scrupulosity include perfectionism, self-doubts, discomfort with uncertainty, persistent and tormenting thoughts interpreted as "immoral" or sacrilegious, poor insight, and depression (Besharat & Kamali, 2016; Siev et al., 2021). For example, a scrupulous person likely will feel anxiety about not having enough faith or not being saved, or not being pure or pious enough. Classic symptoms include repeatedly performing religious rituals with worry that they might be done incorrectly, fearing God will punish him or her and looking for reassurance from a religious leader. For practicing religious persons, whether nurse or patient, the question of when religiosity becomes unhealthful gives pause. It also invites self-examination and recognition of desire for wholeness—opportunity. The following therapeutic responses to scrupulosity are offered for nurses who are not prepared as mental healthcare providers. Make a referral to a mental health professional with expertise in OCD. Treatments for religious scrupulosity include exposure and response prevention, cognitive behavioral therapy, and acceptance and commitment therapy (Siev, 2022). Note how spiritual giants (e.g., Ignatius of Loyola, Martin Luther, John Bunyan) would have been in modern times diagnosed with scrupulosity. Indeed, many do experience spiritual doubts and fears at times, and framing scrupulosity as "part of the human condition" could ease a patient's anxiety. With this acceptance, a patient may be better able to reflect on his or her religious anxieties and do the inner work of seeking wholeness. Unconditional acceptance of the patient is key. Do not assume that the sufferer is aware that these fears are irrational; their anxieties feel real, urgent, and legitimate. The parts of the brain that warn of danger are always on high alert with OCD. Thus, avoid contradicting or arguing with a patient about moral or religious anxieties. Also, avoid trying to "fix" or correct his or her doubts. Support reflection and examination of religious anxieties. Nonjudgmental listening is essential if a scrupulous person begins to talk. Although most nurses are not qualified to conduct therapy for the OCD patient, they can listen deeply. Also suggest open questions for the patient to journal or think about further (e.g., What doubts or fears about God or salvation might exist? How did parents, teachers, religion, and society teach these anxieties? How helpful are their beliefs? What beliefs would be helpful and ease their anxiety? How do they experience love—in God, in the universe?) Encourage patients to taste, see, hear, smell, or feel the lovingkindness of God to allow them to be just and merciful toward themselves. This does not mean, however, advocating for more religious scrupulosity (e.g., "Pray more and longer"). Rather, it may mean exploring non-religious ways of experiencing God's love (e.g., mindful nature walks, saying best Self [God] affirmations while looking in a mirror). Modeling self-compassion and showing unconditional positive regard toward a patient also implicitly teaches he or she is God's beloved. With successful treatment, patients may be able to see the irrationality of their thoughts and apprehensions. Mindful that the most frequently given commandment in the Bible is "fear not," care for your patient with a spirit of calm, trust, and compassion (Isaiah 41:10). Focus on wholeness and ease within yourself while offering assurance. Thus, perhaps, both you and the patient can experience more love-infused living—(w)holiness.