Monday, March 24, 2014

Judaism and Obsessive-Compulsive Disorder, Part 3

...And here is the bibliography sheet.

UPDATE: The audio recording of the shiur is now available here.

Joanna Bourke, Divine Madness: The Dilemma of Religious Scruples in Twentieth-Century America and Britain, Journal of Social History 42:3 pp. 581-603 (2009)

Paul Cefalu, The Doubting Disease: Religious Scrupulosity and Obsessive-Compulsive Disorder in Historical Context, Journal of Medicine and the Humanities 31 pp. 111-125 (2010)

John P. Dehlin, Kate L. Morrison, Michael P. Twohig, Acceptance and Commitment Therapy as a Treatment for Scrupulosity in Obsessive-Compulsive Disorder, Behavior Modification 37:3 pp. 409-430 (2013)

Thomas A. Fergus and Wade C. Rowatt, Personal Uncertainty Strengthens Associations Between Scrupulosity and Both the Moral Appraisals of Intrusive Thoughts and Beliefs that Gd is Upset with Sins, Journal of Social and Clinical Psychology 33:1 pp. 51-74 (2014)

David Greenberg, Gaby Shefler, Obsessive-Compulsive Disorder in Ultra-Orthodox Jewish patients: A comparison of religious and non-religious symptoms, Psychology and Psychotherapy: Theory, Research and Practice 75:2 pp. 123-130 (2002)

David Greenberg, Gaby Shefler, Ultra-Orthodox Rabbinic Responses to Religious Obsessive-Compulsive Disorder, Israeli Journal of Psychiatry and Related Sciences 45:3 pp. 183-192 (2008)

Jonathan D. Huppert, Jedidiah Siev, Elyssa S. Kushner, When Religion and Obsessive-Compulsive Disorder Collide: Treating Scrupulosity in Ultra-Orthodox Jews, Journal of Clinical Psychology 63:10 pp. 925-941 (2007)

Steven Pirutinsky, David H. Rosmarin, Kenneth I. Pargament, Community Attitudes Towards Culture-Influenced Mental Illness: Scrupulosity vs. Nonreligious OCD Among Orthodox Jews, Journal of Community Psychology 37:8 pp. 949-958 (2009)

David H. Rosmarin, Steven Pirutinsky, Jedidiah Siev, Recognition of Scrupulosity and Non-Religious OCD by Orthodox and non-Orthodox Jews, Journal of Social and Clinical Psychology 29:8 pp. 930-944 (2010)

Jedidiah Siev, Lee Baer, William E. Minichiello, Obsessive-Compulsive Disorder with Predominantly Scrupulous Symptoms: Clinical and Religious Characteristics, Journal of Clinical Psychology 67:12 pp. 1188-1196 (2011)

John Turbott, The meaning and function of ritual in psychiatric disorder, religion and everyday behaviour, Australian and New Zealand Journal of Psychiatry 31 pp. 835-843 (1997)

Did not see - David Greenberg, The Behavioral Treatment of Religious Compulsions, Journal of Psychology and Judaism 11:1 Spring 1987 pg. 42

Did not see - H. Hermesh, R. Masser-Kavitzky, R. Gross-Isseroff, Obsessive Compulsive Disorder and Jewish Religiosity, Journal of Nervous and Mental Disease 191:3 pp. 201-203

Books or Book Chapters
Rabbi Dr. Avigdor Bonchek, Religious Compulsions and Fears

Joseph W. Ciarrocchi, The Doubting Disease: Help for Scrupulosity and Religious Compulsions (1995),

David Greenberg and Eliezer Witztum, Treatment of Strictly Religious Patients,

עצות והדרכות of Rabbi Grinwald and Rabbi Yaakov Kanaievsky –

יראה טהורה (available in Otzar haChochmah database)

General articles

OHEL, Totally Engrossed: Extreme Piousness or Obsessive-Compulsive Disorder?

Friday, March 21, 2014

Judaism and Obsessive-Compulsive Disorder, Part 2

Following up from yesterday, here is Part 2 of the source sheet; Part 3, the Bibliography, is set to post on Monday morning...

Treating observant Jewish patients with OCD: Recommendations for Psychologists
1.   Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 927-928
Appropriate behavior is environmentally determined, and just as healthy surgeons wash their hands relatively often, it may be the case that people in certain cultures or religious groups are slightly more bothered by intrusive thoughts.

2.   Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 932
Cognitive–behavior therapy for OCD requires a clear conceptualization of the individual patient’s core concerns and fears. For example, it is not sufficient to know that someone washes excessively. A fear of contracting HIV/AIDS is very different from one of touching dirt (just because it is disgusting), which is very different from an obsession that one will become like the person whom one touches. Thus, understanding the ultimate consequence or core fear is important.

3.   Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 936
In addition, there are times that OCD patients ritualize by praying to prevent bad things from happening after doing an exposure. Some therapists would encourage patients to “spoil” or undo this ritual by praying for bad things to happen. However, given that religious patients believe in the efficacy of prayer, they may be reluctant to engage in such an act. An alternate approach is to ask them to undo the ritual by praying instead to “allow God’s will.” This suggests that if the person is to die, then allow that, and if not, then not. It inserts ambiguity and removes active attempts to prevent the negative outcome.

4.   Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 934
There are notions within Judaism that one should not articulate bad things for fear of them happening (al tiftach peh), and that some thoughts are forbidden (hirhurim). When treating a religious patient with OCD, engaging in a debate about whether thoughts are inconsequential can sidetrack treatment because religious patients may believe that some thoughts are in fact sinful. Instead, it is more productive to address different aspects of OCD thoughts…

5.   Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 934
Other subtle differences in framing identical information during psychoeducation are also important. With nonreligious patients, for example, we often discuss the evolutionary function of anxiety and how it has gone awry in OCD. Some religious patients are resistant to the theory of evolution or find it heretical; for them, it can be useful to express the same concepts in religious terms: “Why did God endow us with the ability to feel anxious? What purpose does it serve?”

6.   Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 934
[O]vercorrection allows the individual to return to a normal level of behavior after they complete treatment… In Judaism, the concept of overcorrection was elucidated by the medieval scholar, Maimonides, who described the process in reference to working on one’s character traits. He advised that to refine character flaws one must adopt the extreme opposite behavior, and that by doing so, one will arrive at a middle path. Orthodox patients place great value on the study of rabbinic texts and are used to considering behavior in reference to sources in rabbinic literature. Hence, it can be useful to refer to the overcorrection process used in response prevention as part of the writings of a foremost Jewish scholar rather than a new scientific concept.

7.   Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 928
Understanding that OCD is not caused by religious adherence, but rather that such adherence can influence how OCD manifests in religious patients (i.e., in religious obsessions and compulsions) enables the clinician to use the patient’s religious beliefs as a framework to treat the disorder more effectively. Recruiting rather than combating patient religiosity in service of treatment supports the patient in reclaiming religion as an aspect of their life that brings meaning and comfort, rather than distress.

8.   Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 933
By providing a sensitive rationale, the therapist can alleviate the skepticism and create an open, therapeutic environment. For example, a number of patients have articulated “If I just weren’t religious, I wouldn’t have this problem.” Although not necessarily intended to test the therapist, a statement such as this creates an opportunity for psychoeducation and alliance building. One response might be, “You might not have OCD about halacha, but you would likely have it about something else instead. You cannot run away from OCD.” Such statements dispel concerns that the therapist believes that religion is part of the problem.

9.   Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 933
Another part of the rationale for treatment that should be conveyed early on is that OCD is likely a barrier to the spiritual connection religious patients want to have with God, and that EX/RP can be a way to help them rebuild that relationship.

10.      Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 933
When treating religious patients, we believe it is not necessary or appropriate to include exposure to actual sin. Obsessional fears are usually driven more by actions that lead to increased (albeit small) risk than by actions that truly cause the feared consequence. For example, patients who are afraid of touching a book on AIDS, leaving the house with the oven on, or handling knives around their baby, typically believe that these are risky behaviors, not ones that will definitely lead to the feared consequences. During EX/RP, it is helpful for patients to accept risks by acknowledging the possibility of their feared outcomes, but most individuals do not need to state that they are definitely going to get AIDS, burn their house down, or kill their child. Exposures do not usually require individuals actually to experience the ultimate negative consequences, but rather to tolerate risk, ambiguity, and uncertainty. Similarly, scrupulous patients need not actually sin or tell themselves that they are doing so; instead, they need to allow for slightly greater risk than others normally would, without actually making the violation occur.

Treating observant Jewish patients with OCD: How Judaism can help
11.      Talmud, Yoma 44b
בכל יום היה חותה בשל כסף וכו', מאי טעמא? התורה חסה על ממונן של ישראל.
"Every day, the kohen raked the coals with a silver receptacle [and then put the coals into a gold receptacle]." Why? The Torah spared Israelite property.

12.      Code of Jewish Law, Yoreh Deah 248:7
אדם שוע שנותן צדקה יותר מהראוי לו, או שמיצר לעצמו ונותן לגבאי כדי שלא יתבייש, אסור לתובעו ולגבות ממנו צדקה, והגבאי שמכלימו ושואל ממנו, עתיד הקב"ה ליפרע ממנו.
Regarding a generous person who gives more than is appropriate for him, or who pains himself to give to the collector to avoid shame, one may not demand and collect tzedakah from him. Gd will punish a collector who shames him and asks of him.

13.      Proverbs 3:17
דְּרָכֶיהָ דַרְכֵי־נֹעַם וְכָל־נְתִיבֹתֶיהָ שָׁלוֹם:
Her ways are pleasant ways, and all of her paths are of peace.

14.      Mishnah Pesachim 1:2
אין חוששין שמא גררה חולדה מבית לבית וממקום למקום דאם כן מחצר לחצר ומעיר לעיר אין לדבר סוף:
We are not concerned that a rodent may have dragged leaven from house to house or place to place, for then from yard to yard and city to city – there would be no end to the matter!

15.      Talmud, Yoma 30a
אמר רב פפא: צואה במקומה, אסור לקרות קריאת שמע. היכי דמי? אי דנראית, פשיטא! אי דלא נראית, לא ניתנה תורה למלאכי השרת!
Rav Pappa said: If feces is on the spot where it emerges from the body, one may not recite Shema.
What is the case? If it is visible, this is obvious! If it is not visible, the Torah was not given to the ministering angels!

16.      Nachmanides, Laws of Niddah 9:25
ומדיני החציצה: לא טוב היות האדם מחמיר יותר מדאי ומחפש אחר הספיקות לפסול טבילתה בדבר הקל, כי אם כן אין לדבר סוף... לא יכניס אדם ראשו בספיקות החמורות אשר אין להן קץ וסוף, כגון עצמה עיניה ביותר קרצה שפתותיה ביותר ומשאר הספיקות, כי מי יוכל להבחין בין עצמה ביותר ובין לא עצמה ביותר.
Among the laws of chatzitzah: It is not good to be overly strict, seeking doubts to disqualify her immersion for a light reason, for there would be no end to it… One should not insert his head into serious, interminable doubts, such as whether she closed her eyes too much or pursed her lips too much or other doubts, for who could evaluate whether she closed them too much or not?

17.      Deuteronomy 22:26
וְלַנַּעֲרָ לֹא־תַעֲשֶׂה דָבָר אֵין לַנַּעֲרָ חֵטְא מָוֶת כִּי כַּאֲשֶׁר יָקוּם אִישׁ עַל־רֵעֵהוּ וּרְצָחוֹ נֶפֶשׁ כֵּן הַדָּבָר הַזֶּה
You shall do nothing to her; the girl has no fatal sin. This is like someone who has been attacked and murdered.

18.      Talmud, Avodah Zarah 4b-5a
א"ר יוחנן משום ר"ש בן יוחאי: לא דוד ראוי לאותו מעשה, ולא ישראל ראוין לאותו מעשה; לא דוד ראוי לאותו מעשה... אלא למה עשו? לומר לך, שאם חטא יחיד - אומרים לו: כלך אצל יחיד, ואם חטאו צבור - אומרים להו לכו אצל צבור.
Rabbi Yochanan cited Rabbi Shimon bar Yochai: David was not suited for that deed, and Israel was not suited for that deed [the Golden Calf]… Then why did they do it? To teach you that if someone sins, we tell him, "Go to the individual." And if a community sins, we tell him, "Go to the community."

19.      Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 936
[T]he McDonald’s test is useful: “Is doing this the same as going to McDonald’s and eating a bacon cheeseburger?” Often this can help the person gain perspective about the reality of what they are being asked to do. They are not being asked to sin, but rather to tolerate a small (and halachically permissible) possibility that they may sin.

20.      Talmud, Berachot 17b
כיון דכולי עלמא עבדי מלאכה ואיהו לא קא עביד - מיחזי כיוהרא
[Regarding a personal stringency to avoid work on Tishah b'Av, in a place where the community normally does work:] Since everyone does work, and he does not do work, this will appear like self-righteous arrogance.

21.      Rabbi Shabbtai haKohen, Pilpul b'Hanhagat Hora'ot b'Issur v'Heter, Rule 9
כשם שאסור להתיר את האסור כך אסור לאסור את המותר... מפני שעל הרוב יש בו צד הקל במקום אחר...
Just as one may not permit the prohibited, so one may not prohibit the permitted… because generally, this will cause a leniency in some other area…

22.      Talmud, Bava Kama 91b
מאן תנא דשמעת ליה דאמר: אין אדם רשאי לחבל בעצמו? ... האי תנא הוא, דתניא: אמר ר"א הקפר ברבי, מה ת"ל: וכפר עליו מאשר חטא על הנפש? וכי באיזה נפש חטא זה? אלא שציער עצמו מן היין.
The view that says one may not harm himself matches the view of R’ Elazar haKappar BeRebi, who said: “Why does the Torah say that the Nazirite must bring an offering to atone for the sin he committed ‘against a life?’ Against whose life has he sinned?! It is because he pained himself by withdrawing from wine.”

23.      Psalms 2:11 and 100:2
עִבְדוּ אֶת־ד' בְּיִרְאָה וְגִילוּ בִּרְעָדָה:
עִבְדוּ אֶת־ד' בְּשִׂמְחָה בֹּאוּ לְפָנָיו בִּרְנָנָה:
Serve Gd with reverence, and rejoice in trembling.
Serve Gd with joy, come before Him with song.

24.      Rabbi Yaakov Kanaievsky, Etzot v'Hadrachot pg. 55, as cited at OHEL above
Such thinking is a tactic of the yeitzer hara in order to make observance of the mitzvos so burdensome that he will eventually, G-d forbid, shirk the yoke of the Torah.

25.      Rabbi JM Grinwald, Etzot v'Hadrachot pg. 85, cited by Greenberg/Shefler Ultra-Orthodox Rabbinic Responses to Religious Obsessive-Compulsive Disorder, Israeli Journal of Psychiatry and Related Sciences 45:3 pg. 186
[T]he person who, whenever he performs the will of the Creator, finds his soul and his energies contorted by feelings of discomfort, fear, tension and misery over the carrying out of the commandment — and, on the contrary, this is his usual state, and to carry out commandments out of joy is the exception — this then is clear proof that this was not God’s intention. For “strength and joy are in His place” (Chronicles I 16:27), meaning that the essence of performing commandments is joy, as Maimonides wrote…

26.      Yirah Tehorah pg. 18
אמנם נודע לנו גם מן המציאות וגם מאנשים העוסקים הרבה בסוגיא שלא היה אדם מעולם שפסקו אצלו הנערוון מאליהם אם לא שהכריזו כנגדם מלחמת חרמה מלחמת קודש!... גם המזניח הענין מחמת עצלותו בשב ואל תעשה "חבר הוא לאיש משחית"! מפני שהורס לעצמו לגמרי צורת התפלה.
In truth, it is known to us, from experience and from those who are very involved in the field, that no one ever had the nerves halt on their own, without them declaring a war of destruction, a sacred war!... Also, one who neglects the issue due to laziness, failing to act, "is a colleague to the destructive person (Proverbs 28:24)"! He destroys for himself, entirely, the structure of prayer.

27.      Rabbi Yisrael Ganz, cited in Religious Compulsions and Fears pg. 132
In cases that come before you regarding sufferers of religious compulsions, I think it is important to recall that which the gedolei Yisrael, such as the Steipler Rav, ztvk"l, and the gaon, Rav Shlomo Zalman Auerbach, ztvk"l, and others, have opined on this matter, that in every case of doubt in the halachah, one is to decide on the lenient side of the question. Likewise, even if it is unclear whether there is a doubt, one is also to be lenient…

28.      Rabbi Yaakov Kanaievsky, Etzot v'Hadrachot pg. 45, cited by Greenberg/Shefler Ultra-Orthodox Rabbinic Responses to Religious Obsessive-Compulsive Disorder pg. 185
It is forbidden to give him reasons or explanations, for every reason that he is given, he will undermine to contradict and reject completely whatever he was told.

29.      Rabbi Dr. Avigdor Bonchek, Religious Compulsions and Fears pp. 135-136
If, on the other hand, he does not think there is any problem with the bedikah, he should not give her an outright heter. He should say something along the lines of: "I don't answer such questions." She will pressure him to be more specific, but he should not budge from his one-sentence, non-committal answer. The rav should warn the woman before any questions come up that he will be giving her this kind of answer to her questions, so she should not think he is just being impatient or uncaring. He should not reassure her that the bedikah is clean; it is not to her benefit.

30.      Huppert/Siev/Kushner, Treating Scrupulosity in Orthodox Jews, J. of Clinical Psych 63:10 pg. 938
Ultimately, patients need to be willing to engage in the exposure and accept the uncertainty about whether it is permissible. The notion of accepting uncertainty and acting despite the anxiety is a guideline not only for a given exposure, but also for how OCD patients must live in general.

31.      Rabbi Dr. Abraham Twerski, Foreword to Religious Compulsions and Fears pg. 16
[A]n OCD sufferer may not necessarily be reassured by the opinion of the poskim. One woman with OCD threw out three sets of dishes because she could not accept the Rav's ruling that the dishes were perfectly kosher, saying, "The Rav did not understand my she'eilah."

Thursday, March 20, 2014

Judaism and Obsessive-Compulsive Disorder, Part 1

I expect to offer a shiur on Judaism and Obsessive-Compulsive Disorder on Monday night, and so I've been immersed in reading on the topic for a while. I'm posting my source sheets here, but there is a lot, so I expect to do it in three parts. Some of this won't make sense without the actual shiur, but some of it may help someone.

Here is Part 1:

What is OCD?
1.   Obsessions: Recurrent, persistent thoughts, impulses or images that are experienced as intrusive and inappropriate, causing marked anxiety or distress. They are excessive and unreasonable, not grounded in reality, and a product of one's own mind rather than someone else's conditioning.

2.   Compulsions: Repetitive behaviours that a person feels driven to perform in response to the obsession, to resolve and quiet the worries by preventing some dreaded event or situation, but that are an unrealistic or excessive response to the situation.

3.   Treatment approaches
·         Medication
·         Psychoanalysis
·   Behaviour Therapy – Includes Exposure and Response Prevention, Emotional Habituaiton, Response Repetition
·         Cognitive Therapy – Includes Acceptance and Commitment Therapy, Guided Imagery
·         Cognitive Behaviour Therapy

Linking OCD and Religion – Scrupulosity, Theomania, The Doubting Disease
4.   Obsessions include:
·         Fear that one has sinned, or will sin
·         Fear that one has taken a vow with some thought, to engage in some action
·         Fear of blasphemous or immoral thoughts
·         Fear that Gd is punishing or will punish them or others because of this person's inadequacies.

5.   Compulsions include:
·         Hyper-attention to the words of prayer, and to establishing proper concentration for prayer
·         Hyper-concern about washing one's hands and cleaning other parts of one's body, as in for prayer
·         Hyper-concern about dietary law, but specifically in the area of cleanliness
·         Hyper-concern about questioning Gd's existence and desires

The Relationship between Religion/Judaism and OCD
6.   Joseph W. Ciarrocchi, The Doubting Disease: Help for Scrupulosity and Religious Compulsions, pg. 8
A superficial view may lead an observer to conclude, as do some mental health professionals, that religion is the source of scrupulosity. After all, a scrupulous man obsesses about sinning if he feels attracted to a pretty woman only because he believes this constitutes "committing adultery in his heart." The superficial view fails to distinguish between religion causing the disorder from religion as its background. Religion does not cause scrupulosity any more than teaching someone French history causes him to believe he is Napoleon. All human beings exist in some cultural context… Cultural backgrounds provide the scenery around which emotional problems create the drama…

7.   David Greenberg and Eliezer Witztum, Current Treatments of OCD Chapter 10, pg. 175
It may be suggested, in summary, that obsessions of OCD appear to mirror the prevalent habits and values of a culture. Religious symptoms are common in OCD in cultures in which religious practice and ritual are important. It appears that if a topic is dealt with scrupulously in everyday life, then it is a likely focus for the symptoms of OCD that will emerge in that culture.

8.   David Greenberg and Eliezer Witztum, Current Treatments of OCD Chapter 10, pg. 176
OCD symptoms of a religious nature are not found in all areas of ritual, nor necessarily in the areas of ritual most hallowed by the religion. In our experience with religious Jewish patients, for example, Sabbath observance is a very important feature of religious life associated with many detailed laws but does not appear frequently among the religious obsessions of OCD in our clinic. However, cleaning the perianal region before prayer gets one line in the footnote of a latterday code of Jewish law, but this ritual presents often in patients with OCD in our practice. The presentation of OCD in a religious context is less typically religious than it is classically obsessive-compulsive…

9.   Religion's potential contributory role
·         Legitimizing obsessions – Thought-Action Fusion; Minutia; Punitive Gd; Flawed humanity
·        Complicating diagnosis – Is it religion or OCD?; Blaming bad training
·  Challenging treatment – Accepting secular aid; ERP challenges; Distrust for treatment; Clergy cooperation

10.      OHEL, Totally Engrossed: Extreme Piousness or Obsessive-Compulsive Disorder?
The key question to ask a religious person who is irrationally scrupulous about religious matters, is: "Are your chumros enhancing your religious development or impinging upon it?" Herein lies the answer. A person who davens an exceedingly long Shemoneh Esrei may merit the same heavenly assistance that allowed the Chassidim Harishonim to be involved in davening for nine hours a day while still mastering Torah study (as described in Gemora Berachos). He then is not suffering from any mental dysfunction. A person who is just repeating words over and over again, however, and feels frustrated and depressed by this imprisoning ritual, will not grow in his religious observance and is victim of mental illness, not piety. This person needs treatment. 

11.      Dr. David Greenberg's test (Current Treatments of OCD Chapter 10, pg. 180)
·         Compulsions transcend requirements of religious law
·         Compulsions have a narrow focus on one area of religious experience
·         Compulsions focus on something that is trivial to religious practice, but normal for OCD
·         Compulsions cause the patient to ignore, or to be unable to fulfill, other areas of religious law
·         The patient repeats actions because of doubt, where law would not require it.

Sunday, March 16, 2014

Best Purim Costume

Definitely the ideal Purim mascot, a latter-day King Achashverosh... our very own...

Everything's Fine T-Shirt

Mayor Rob Ford

Too bad I only thought of it on Shabbos Erev Purim...

Thursday, March 13, 2014

Shul Kavvanah Cards, for Purim

I know a few people who carry pre-printed cards in shul, to hand to those who try to converse with them during davening. The notes are meant to explain their owner's silence in a polite way.

In the spirit of Purim, here are a few that I've thought of; they may have too much snark to be handed out, but I had fun thinking of them, anyway [click to enlarge]:

What can you come up with?