It can be argued that many forms of OCD come down to a fear that lack of vigilance could lead to a loss of identity. One with Harm OCD may worry that failure to catch that one impulse could lead to spontaneous discovery that he/she is a violent or harmful person. One with sexual orientation obsessions may be excessively concerned that this one thought or sensation left up to uncertainty could reveal the discovery of gay denial. Choosing to take the risk of accepting you might have touched your shoe but just aren’t going to pull out the hand sanitizer this time could be the slip that reveals you to be an irresponsible or unhygienic person. Nowhere is this identity over-protection clearer than in the case of moral scrupulosity.

In this blog series, I’ll be exploring the form of OCD that manifests most specifically as excessive concern about right and wrong and the false dichotomy of the good person/bad person in OCD. This first entry in the series will focus on defining and recognizing moral scrupulosity in OCD.  It’s important to understand that what I am calling “Moral Scrupulosity OCD” here is not a different kind of disorder, just a name to describe a manifestation of OCD for the sake of simplicity. The term “scrupulosity” is often used to describe religious obsessions, which typically manifest as getting too caught up in the details of one’s religious tenets and whether or not they are being perfectly followed. Moral scrupulosity is, thus, obsessive concern with whether or not one is being good or bad, independently from religious expectations. In other words, the concern is with the “quality” of one’s humanity in the context of the culture in which he or she lives. The values and ethics of that culture are the rules that OCD dictates must be followed perfectly. More to the point, this perfection must be constantly proven beyond the shadow of all doubt. Even as I write this, I can sense the itch of my own morality nuisance demanding that I truly capture the suffering of those with moral scrupulosity OCD. I won’t.

Common manifestations of Moral Scrupulosity OCD

Here are some common manifestations of moral scrupulosity I have seen in clinical practice:

  • Excessive concern with being 100% honest
  • Excessive concern with the idea of being “good” or of not being “bad” (a so-called “good” person wouldn’t think or do xyz)
  • Excessive concern with getting in trouble or breaking rules
  • Excessive concern that a past act was immoral
    • may include awareness of an actual moral misstep but with obsessive need to know exactly how much
    • may include concern that others would reject you if they knew about it
    • may include concern that a thought about an immoral act could be a memory of an immoral act that likely did not even occur (see my blog on False Memory OCD)
  • Excessive concern that adultery or some disloyal act could have or did possibly take place
  • Excessive concern that one has caused someone else to be immoral

Moral scrupulosity likes to borrow from other common OCD manifestations. Though the YBOCS has it listed under the subcategory of religious obsessions, moral scrupulosity actually creeps in to nearly every kind of OCD. Here are some examples:

  • Contamination
    • It would be morally wrong to touch this with dirty hands
  • Checking
    • It would be morally wrong to risk the door being unlocked, the stove being on, etc.
  • Harm
    • It would be morally wrong to be careless in a way that could lead to harm
  • Sexual orientation obsessions
    • It would be morally wrong to deceive others about my attractions and let them continue to believe I am of one orientation when I could be another
  • Pedophilia-related obsessions
    • It would be morally long to have any intrusive thought about a child
  • Relationship obsessions
    • It would be morally wrong to let my partner stay in a relationship with someone who has my thoughts
  • Religious scrupulosity
    • It would be morally wrong to be philosophically flexible or choose my own interpretation of religious doctrine on moral issues

Compulsions in Moral Scrupulosity OCD

Compulsions, that is, behaviors that OCD sufferers engage in to feel more certain that their fears are untrue, can also cover a wide spectrum of human behavior in moral scrupulosity. Consider that for each individual, what makes them believe themselves to be moral is mediated by their own personal worldview. Often I find that people are engaging in compulsions that look like they serve one function, but really serve another, and this problem of failing to recognize why a compulsion is being done can get in the way of treat the OCD. For example, it’s easy to assume that a person who excessively washes their hands is afraid of being sick. But they may be more concerned with getting others sick. Or, getting themselves or others sick may not even enter into it. They could be simply measuring their moral integrity against the certainty that they are being hygienic. In this case, exposure to the fear of getting or causing illness will be less effective than exposure to the fear of possibly being socially deviant or inadequate.

Here are some common compulsions related to moral scrupulosity:

  • Common compulsions
    • Reassurance seeking about moral issues
    • Confessing perceived immoral acts or thoughts
    • Mentally reviewing/checking for acts to determine moral integrity
    • Mental rituals
      • repeating neutralizing “good” thoughts
      • ruminating on hypothetical moral scenarios to test responses
      • repeatedly rationalizing why a past act was not immoral in context
    • Avoidance of morally ambiguous situations
    • Self-punishment to prove moral concern
    • Excessive apologizing for perceived/potential moral failures
    • Washing and checking behaviors connected to moral concerns
    • Excessive donating or other acts of exaggerated altruism/generosity

At the core of any obsession is the misguided demand for certainty. Certainty seeking in some areas may, at least, appear more fruitful than in others. For example, you could compulsively check to make sure you’ve turned off the stove. You will see that it is off and that will produce in you a sense that it has been turned off. It’s unlikely to last, of course, but that’s the subject for another blog. But how do you check your morality to make sure it is on or off? You could assign a list of moral guidelines to follow that are consistent with your cultural context, and you can even convince yourself that confidence in this list (as opposed to some other list) is warranted. But at some point you are still going to have to decide whether or not you trust your own judgment, your own memory, and your own self-talk. Though everyone is entitled to a reality check now and then (as in, “come on, it’s not that big a deal), repeatedly reassuring oneself to get certainty always ends up colliding with the wall of reality, that something may be getting missed.

ERP and Moral Scrupulosity OCD

Exposure and response prevention (ERP) is the most effective way to treat any kind of OCD. But you may be concerned that exposure to moral concerns means doing immoral things or may have consequences that are not immediately revealed. In other words, if you have a fear of lying, you may think the best way to do exposure is to lie, but this is not necessarily the case. The exposure to the fear of lying is to engage in behaviors where it is unclear whether a lie has taken place (or the significance of the bent truth is unknown).

Or you may have a fear that you have behaved in an immoral way and that there may be negative consequences that won’t be known for years or decades (e.g. your or someone else’s life is ruined later). This confusion is why it is so important to remember that the battle with OCD is a battle of uncertainty tolerance. The fear to confront over long term damage is the fear that you cannot tolerate sitting with the uncertainty now and for the unknown future.

The Goals of ERP

The goal of ERP is never to prove that you’re a good person. That’s a trap. Any goal that by definition is impossible is obviously no goal worth pursuing. Here are the actual goals of treating your moral scrupulosity with ERP:

  • Improve uncertainty tolerance
  • Violate the expectation that uncertainty about morality is intolerable
  • Improve ability to commit to value-based behaviors despite unwanted thoughts/feelings

Will my therapist make me do terrible things?

ERP therapists make a lot of jokes about doing terrible things, but the truth is we are as invested in preserving your morality as you are. We just don’t believe in certainty. We always work within the client’s moral framework and without the intention to violate it. This requires a fair amount of collaboration so that both the therapist and the client have enough trust between them to take the risk of getting mastery over OCD. First, we need to identify what lines will not be crossed. This is as true in moral scrupulosity as it may be obvious to those with religious scrupulosity. We wouldn’t ask a religious person to knowingly sin and we wouldn’t ask a morally scrupulous person to take money out of a homeless person’s cup – not because we’re especially good people, but because it just doesn’t work. Head on confrontation with uncertainty is what works. So once we’ve identified the lines not to be crossed, we want to explore the area near the line and learn to walk around it more casually, without compulsions, and take ownership of the fact that a gust of wind may accidentally push us over it.

In addition to doing exposures to real life experiences, which often boil down to behaving in ways that are consistent with those around you but without checking and reassurance-seeking about whether you have done so in the most moral way, imaginal exposures can be very useful. Writing scripts articulating that uncertainty will be accepted about morality, that immoral acts could bring about unwanted consequences, or that the scripts themselves are immoral acts can all be effective.

Well, that’s good enough for now…

For now, consider this – OCD is driven by compulsions, behaviors you engage in to make yourself feel certain that you, in this case, are moral. To get you to do compulsions OCD has to cut you down. It has to inundate you with mental spam mail about your perceived moral failings. Learning to live joyfully with uncertainty, even about your inherent “goodness” as a human being is the best strategy for beating OCD and feeling good about yourself. OCD uses the fraudulent concept of “bad person” to con you into trying to prove you are otherwise. I was once asked why OCD never tries to convince you that you are a good person. The answer is that this does not need convincing.

In the next installments of this series I will take a look at some case examples of moral scrupulosity in OCD and how cognitive approaches, self-compassion, and the role of mindfulness can be used in treatment. All of these can be used to enhance your ERP work and liberate you from the irrational fear of being unlovable.

Jon Hershfield, MFT is a psychotherapist in private practice and director of The OCD and Anxiety Center of Greater Baltimore.  Follow him on Twitter and Facebook