When good intentions go haywire.
Uh oh, did I misrepresent myself when talking to my friend last night? Was I 100% truthful and honest in depicting what happened? They felt badly for me... Do I even deserve their sympathy?
The rug at the grocery store has a fold in it. What if an older woman walks on that, trips, and breaks a rib? How could I live with myself knowing I could’ve fixed it?
Did I mislead a client (patient, coworker, friend) accidentally? Or even on purpose and am just realizing it now?
Is it morally wrong to have ______ intrusive thought? Does this mean I secretly want to do these things?
The above are examples of intrusive thoughts when dealing with moral scrupulosity themed OCD. Within this subtype, there is excessive concern with morality and what it means to be a good person. It makes it hard to live by our values, because OCD questions every decision we make. Social interactions become stressful. Work tasks become stressful. Day-to-day life becomes stressful, all because OCD has hijacked our mind.
Those suffering from moral scrupulosity OCD are often riddled with guilt. Feeling like they are missing the mark when trying to be the best person possible, they may engage in self-punishment or self-criticism in the hopes of not “messing up” again. Unfortunately, these acts of self-punishment are what keeps the cycle going. The more we punish, criticize, mentally review, seek reassurance, and avoid, OCD becomes stronger.
It goes without saying, most people want to be a “good” person. Very few wake up every day wanting to cause harm to others.
For someone without OCD, “good enough” is the expectation. Walking by a piece of litter on the road is done without difficulty. Reflecting on past mistakes can sting, but the individual isn’t reviewing, seeking reassurance, and diving into it to the point of extreme distress. If someone suffers from OCD, the uncertainty of being “good enough” will feel intolerable, and prompt an urge for compulsions.
Moral scrupulosity can show up in practically every theme, being an undercurrent for Harm OCD, POCD, Real Event OCD, Contamination OCD and more. The key is knowing the OCD cycle and how we can disrupt it.
Every subtype of OCD is made up of obsessions and compulsions. Examples below:
What if I mislead my team member during my group project? (Obsession)
[insert feelings of guilt, anxiety, uncertainty, panic]
Reaching out to team member to clarify / make sure they knew what you meant (compulsion)
Giving self-reassurance that you wouldn’t do that on purpose, you’re a good person based on XYZ (compulsion)
I had a tickle in my throat this morning, it would be morally wrong to walk around my neighborhood without a mask… (obsession)
Skipping that day’s walk due to fear of getting others sick (compulsion)
Ignoring the fact that you have seasonal allergies, taking the risk would be too careless (compulsion)
With both of these examples, the individual is sending a message to their brain that they can’t tolerate uncertainty. That the anxiety they’re feeling needs to go away, therefore they need to do compulsions to lower the discomfort. The issue is that the brain never learns we can handle uncertainty. You are stronger than you think!
Treatment:
The gold standard treatment for OCD is exposure with response prevention (ERP). That means we expose ourselves to feared situations, and resist engaging in compulsive behavior. The goal of ERP is to sit with uncertainty. To teach our brain that “good enough” is tolerable, and that we don’t have to jump through hoops to prove we’re a good person for OCD sake. It does not mean we have to deliberately do immoral activities that go against our values.
With an ERP therapist, you’ll identify the situations that drive compulsions. You’ll learn the ways your OCD grows (through compulsions) and how to resist engaging in those behaviors. You’ll think of OCD like a skilled con artist, who has tricked you into doing its bidding.
For the examples above, it may look like this:
Noticing an urge to clarify / seek reassurance from a classmate, and resisting that urge
Having a scratch in your throat and taking your dog for a neighborhood walk without a mask on
Throwing something away in the wrong bin at the coffee shop (plastic in trash, etc)
Exposure work is collaborative. Your therapist should never force you to do an exposure, but it is their job to discuss, collaborate and help motivate toward challenging exposure work. They will be your guide, cheerleader, and coach all in one.
Learn more in Part 2: Essential Tools for Moral Scrupulosity
Madeline Moersch, LCSW is a psychotherapist in private practice in Los Angeles, CA specializing in the treatment of OCD and Anxiety Disorders.