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As a teaching and research facility, the Institute publishes scholarly works, essays and articles for professional journals and newsletters. The following two articles appeared recently in Update, the quarterly newsletter for the Program for Psychology and Religion. To receive a copy of the next edition of Update, go to Feedback & Contact Info.
(Part 1) Paul Duckro, Ph.D. and Jason Williams What is this phenomenon that can cause such distress in everyone from school children to church leaders, to housewives and saints? The term itself derives from the Latin scrupulus, a tiny pebble. Kolvenbach suggests that its application to scrupulosity reflects the experience of catching such a pebble in your shoe. If it finds its way between the sole of your foot and the insole of the shoe, it can cause pain disproportionate to its size. He notes that scrupulus may also refer to a tiny weight used on a scale. "The more sensitive the balance of the scale, the more easily it can be tipped by the tiny weight of a pebble. This sense was subsequently transposed to the level of a delicate conscience: the more delicate a conscience, the more it will be agitated by an inconsequential thought and excessively disturbed by some trifling matter. And this can cause great pain." (p. 8). Scrupulosity involves "seeing sin where there is none...The person judges personal behavior as immoral that one's faith community would see as blameless" (Ciarrocchi, 1995). Not all scrupulosity is associated with religious issues. As Van Ornum writes, "Some define scrupulosity as excessive worry and concern over religious matters. John Cardinal O'Connor suggests a wider definition: '... clearly people become scrupulous over a broad spectrum of issues which are not explicitly religious. Because of the moral sensitivity of their conscience, people scruple over the moral dimensions of daily behavior'" (p. 5). Nevertheless, it is true that the great majority of persons with scrupulosity are or were committed to a particular religion. Scrupulosity grows in the soil of a sensitive, delicate conscience; such soil is more often to be found among those with religiously formed consciences, those concerned with sin (Kolvenbach). Scrupulosity may be particularly common among Roman Catholics (Van Ornum, p.5), but it can affect any person with a sensitive moral conscience. It is reported among Orthodox Jews, Protestants, and Muslims as well. Scrupulosity is characterized by excessive worry, self-doubt, fear of taking risks, anxiety, embarrassment, intrusive thoughts, rituals, guilt, crippling indecision, problems in social and occupational functioning, and avoidance of the fullness of life. How many people suffer from scrupulosity? Surprisingly, in this age in which everything seems to be counted, it is difficult to say with certainty. No prevalence study of scrupulosity using a representative sample of the population exists. Although over ten thousand people with scrupulosity participated in Van Ornum's research, the sample was drawn from an association of persons with scrupulosity. Ciarrocchi cites older studies based on specific sub-groups. These studies indicated that 25% of Catholic high school students and 14% of Catholic college students reported scrupulous behavior. Scrupulosity is not a new phenomenon. It has been frequently discussed by religious writers over the past 500 years. One of the most well-known persons who suffered with scruples was Ignatius of Loyola, founder of the Jesuits. Ignatius was afflicted by doubts about whether he was truly cleansed of sin, beginning with his conversion in 1522 (Van Ornum). The harder Ignatius tried to confess all his sins, the more he doubted he had, and the more he became disgusted with himself. As Kolvenbach (1996) writes, Ignatius' struggles with scrupulosity "exemplifies how the healthy sense of sin...can degenerate into an unhealthy sense of guilt, a morbid preoccupation with sin, a pathology" (p. 8). Ignatius was eventually saved by relying completely on the direction of his confessor, and following the direction to not confess his sins anymore. Spiritual advisors have profited from guidelines in Ignatius' Spiritual Exercises in counseling persons suffering from scrupulosity. Ignatius emphasized journal writing, listing sins, substituting new habits for old one, and opening up one's imagination to envision a loving God (Ciarrocchi). He favored such ideas as "a happy medium" and "everything in moderation". Other historical figures have felt the same excess of doubts, worries, and fears. St. Alphonsus Liguori, patron of confessors, suffered from the obsessions of scrupulosity. After he converted, Alphonsus required weekly confessions; he was always kind to others despite his severe reproach of himself (Van Ornum). Martin Luther's struggles with scrupulosity may have led him to the doctrine of justification by faith (Van Ornum). 17th century Christian spiritual master John Bunyan wrote a dramatic record of his ordeal with scruples. His autobiography, Grace Abounding, highlights the childhood origin of his concerns and moral sensitivity (Ciarrocchi, p. 32). Erasmus exhibited excessive fear of germs and sickness, and regularly requested that the church holy water and baptismal water be changed. Veronica Guliani, Catholic saint of the late 1600's and early 1700's, suffered from a combination of scrupulosity and eating disorders. She repeatedly confessed the same sins and, in a culture in which thinness reflected holiness, fasted herself into a state of emaciation. Julian of Norwich, Catherine of Siena, and Catherine of Genoa all seem to have suffered from similar combinations of scrupulosity and perfectionism (Van Ornum). Only recently has this affliction been discussed and studied by mental health professionals. The word "scrupulosity" appears nowhere in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, 1994). There are references to some forms of obsessions and compulsions which are essentially religious or moral in nature, but scrupulosity as a particular syndrome is not treated. In part, this lack of attention may be because persons with scrupulosity did not bring these concerns to mental health professionals. Because of the moral and religious nature of the anxieties and rituals involved in scrupulosity, many sufferers seek help from priests, pastors, and other religious professionals. In turn, mental health professionals may incorrectly identify such issues as different from other obsessions and compulsions. When people with scrupulosity seek help from mental health professionals, they may be disenchanted by the lack of sensitivity to their religious beliefs and spiritual experiences, particularly when treatment is ineffective. An increasing number of scientists have come to understand scrupulosity as a symptom of obsessive-compulsive disorder, often abbreviated as OCD. This disorder is an affliction of doubt and anxiety which involves obsessions (unwanted thoughts, urges, and impulses) and compulsions (repetitive acts performs to alleviate or avoid anxiety, often in response to obsessions). Since Freud's early work with patients with obsessional neuroses, much has been done to further the understanding, classification, diagnosis, and treatment of OCD. We know more about its prevalence, its pathophysiology, and effective multi-modal therapy. It is now considered a serious disorder, but treatable. As much as scrupulosity and OCD have in common, we know about scrupulosity. On the other hand, little scientific study of scrupulosity itself has been undertaken. In Part II of this article, we will review what we know about OCD and its treatment. From that base, and from clinical experience in our Institute and elsewhere in the treatment of clinical experience in our Institute and elsewhere in the treatment of scrupulosity, we will lay out what we believe has proven to be a rational, effective and holistic program for persons suffering with scrupulosity.
Bibliography Ciarrocchi, J.W. (1995). The Doubting Disease: Help for Scrupulosity and Religious Compulsions. Mahwah, NJ: Paulist Press. Greenberg, D. (1987). The behavioral treatment of religious compulsions. Journal of Psychology and Judaism, 11, 41-47. Higgins, N.C., Pollard, C.A. & Merkel, W.T. (1992). Relationship between religion-related factors and Obsessive Compulsive Disorder. Current Psychology: Research & Reviews, 11, 79-85. Kolvenbach, P. (1996). St. Ignatius's norms on scruples. CIS Review of Ignatian Spirituality: 27, 7-18. Fallon, B.A., Liebowitz, M.R., Hollander, E., Schneier, F.R., et al. (1990). The pharmacotherapy of moral or religious scrupulosity. Journal of Clinical Psychiatry, 51, 517-521. Van Ornum, W. (1997). A Thousand Frightening Fantasies: Understanding and Healing Scrupulosity and Obsessive Compulsive Disorder. New York: The Crossroad Publishing Company. Wagner, K.D. (1997). The child who left no fingerprints. Psychiatric Times, June 1997, 45.
Useful References and Resources Books: Y Ciarrocchi, J.W. (1995). The doubting Disease: Help for Scrupulosity and Religious Compulsions. Mahwah, NJ: Paulist Press. More of a self-help volume, Joseph Ciarrocchi's work also can be useful for the clinician. Ciarrocchi defines and describes scrupulosity, its development, treatment, and place in history and religion, including examples of both historical figures and modern people who suffer from scrupulosity. He thoroughly describes OCD and links scrupulosity to this more well known anxiety disorder. In discussing the identification of scrupulosity, he includes the Yale-Brown Obsessive-Compulsive Scale, a commonly used screen for OCD. A professor of pastoral counseling, Ciarrocchi provides a structured, cognitive-behavioral treatment for scrupulosity. He explores also the interface of psychological and religious professionals in the treatment of OCD. Y Van Ornum, W. (1997). A Thousand Frightening Fantasies: Understanding and Healing Scrupulosity and Obsessive Compulsive Disorder. New York: The Crossroad Publishing Company. William Van Ornum has produced a thorough discussion of scrupulosity and OCD drawing on his extensive reading on scrupulosity. In addition to sketches of historical figures, he provides anecdotes from an international survey of people with scrupulosity. This offers an unusually realistic and personal presentation of scrupulosity. He provides a brief screen for scrupulosity. Van Ornum has taken the time to poll many religious and psychological professionals on their experience, supplementing his personal expertise. As Thomas M. Santa, director of Scrupulous Anonymous, writes on the cover. "This book needs to be read by all clergy, spiritual directors, and mental health personnel before they walk the journey with the scrupulous person entrusted to their care."
Articles: Y Greenberg, D. (1987). The behavioral treatment of religious compulsions. Journal of Psychology and Judaism, 11, 41-47. David Greenberg describes the treatment of a Jewish man suffering from scrupulosity, using in-vivo exposure and response prevention. The author strongly recommends that therapists give due respect to the religious (not obsessive) values of the client, including enlisting the aid of a religious professional. Y Greenberg, D., William, E., & Pisante, J. (1987). Scrupulosity: Religious attitudes and clinical presentations. British Journal of Medical Psychology, 60, 29-37. In this article, Greenberg and colleagues describe the attitudes of Catholicism and Judaism toward scrupulosity, noting the similarity between the management programs of the two institutions and modern behavioral psychotherapy. The authors discuss scrupulosity as a distinct presentation of OCD, and describe cases from the 16th and 20th centuries. Y Higgins, N.C., Pollard, C.A., & Merkel, W.T. (1992). Relationship between religion-related factors and Obsessive Compulsive Disorder. Current Psychology: Research & Reviews, 11, 79-85. Nancy Higgins, Alec Pollard, and William Merkel conducted a study exploring the relationship of religion-related factors such as affiliation to mental disorders. They compare patients with OCD, panic disorder, and other non-anxiety disorders. The authors discuss the common presentation of religious themes in OCD. Not surprisingly, OCD was found to be associated with the experience of religious conflict. Though limited and inconclusive, some evidence was found for an association between Catholicism and OCD. The authors conclude with a discussion of the complex association between religion and OCD, recognizing that this relationship is not singular or linear. Y Kolvenbach, P. (1996). St. Ignatius's norms on scruples. CIS Review of Ignatian Spirituality, 27, 7-18. Based in large part on Ignatius' Autobiography, Peter-Hans Kolvenbach provides an insightful description of scrupulosity and Ignatius' struggles with the disorder. As he describes, Ignatius was able to alleviate his scruples in the principle of moderation and by relying on his own spiritual advisor.
Internet Resources: Y Mental Health Net: [online] Available http://www.cmhc.com/selfhelp/htm. December 1, 1997. Y Internet Mental Health: [online] Available http://www.mentalhealth.com/frol.html. December 1, 1997. Y Jenike, M.A. Drug treatment of OCD in adults. [online] Available http://pages.prodigy.com/alwillen/ocf16a.html. December 1, 1997. This is a reprint of a booklet commissioned by the Obsessive-Compulsive Foundation (OCF), funded in part by five pharmaceutical companies, and written by Michael Jenike, Professor of Psychiatry at Harvard Medical School and Chairman of the OCF Scientific Advisory Board. Questions and answers about OCD, drug treatment, behavioral treatment, and the common comorbidity of depression, are discussed thoroughly and understandably. An extensive list of helpful and informational books, articles, foundations, associations, hotlines, and Internet resources (some of which are listed below) is provided. Y National Alliance for the Mentally Ill. [online] Available http://www.nami.org. December 1, 1997. Y OC Anonymous. [online] Available http://members.aol.com/west24th/index.html. Y OCD mailing list: OCD-L This is an automated system, known as a Listerv, in which subscribers share e-mail about OCD. All the messages are automatically sent to an e-mail address. To subscribe, send the following command in the body of an e-mail message to listserv@vm.marist.edu Fill in your name as appropriate. Good Internet manners dictate that you listen in a while before sending a message, so as to avoid repeating an old topic or asking an old question. Link to the mailing list's archives and Frequently Asked Questions (FAQs) for more information. Y OCD www Server. [online] Available http://www.fairlite.com/OCD. December 1, 1997. Y Obsessive Compulsive Foundation. [online] Available http://www.prodigy.com/alwillen/ocf.html. December 1, 1997. Y Turn OCD Caterpillars into Butterflies: [online] Available http://members.aol.com/cherlene/occl.html. December 1, 1997. This one is a personal and informational site, with anecdotes and links to other sites. Recommended for those who suffer from scrupulosity or OCD.
Newsletter: Scrupulous Anonymous, Liguori Publications, One Liguori Drive, Liguori, MO 63057-9999 Scrupulosity: Age Old Problems, Holistic Responses
(Part 2) Paul Duckro, Ph.D. , Jason Williams, and C. Alec Pollard, Ph.D. As we discussed in Part I of this essay, there is a long tradition of religious writers who have discussed scrupulosity. Scrupulosity has long been known to grow in the soil of a sensitive, delicate, moral conscience. Its fruits are excessive worry, self-doubt, fear of taking risks, anxiety, embarrassment, intrusive thoughts, compulsive rituals, guilt, and crippling indecision. The scrupulous person suffers great limitations in quality of life &endash at home, in relationship with others, and on the job. Not withstanding the richness of understanding and pastoral care which may be found among these religious writers, scrupulosity has been recognized by priests, rabbis, spiritual directors and pastoral counselors who have tried to help as "a difficult malady to treat" (Van Ornum, p. 166). Scrupulosity has only recently become a focus of mental health professionals. It is not included as a specific entry in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, 1994). This relative neglect may reflect the extent to which persons suffering with scrupulosity have eschewed mental heath professionals. In turn, mental health professionals may have seen the struggles of scrupulous persons as a symptom of the supposedly neurotic commitment to religious faith, a bias which has only begun to change. In short, scrupulosity has often been understood as a religious matter only. However, with the resurgence of interest in the integration of behavioral science and religious commitment in promoting the health of our people has come greater recognition of scrupulosity as a significant problem worthy of scientific study. Current thinking suggests that scrupulosity is a sub-type of Obsessive-Compulsive Disorder (OCD). As such, although there remains very little empirical research regarding scrupulosity per se, there is a great deal of useful information which can be gleaned from clinical writings about scrupulosity in particular and from empirical study of OCD is general. What is OCD? In the DSM OCD is described as a disorder involving recurrent obsessions and/or compulsions. Obsessions are "persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress." To the sufferer, obsessions are what is known as "ego-dystonic" thoughts, referring to the uncomfortable experience of such thoughts as imposed and intrusive. Obsessions are to ordinary worries as migraine is to ordinary tension headache. Contamination obsessions involve fears that the sufferer has exposed himself or herself, or someone else, to germs or dangerous chemicals. Pathological doubt "occurs when the person cannot feel certain that even the most elementary tasks were completed" (Ciarrocchi, 1995, p. 21), as in doubts about whether one turned off the iron or fears that the bump you heard while driving was you hitting someone --fears that persist even if you go back and check. Somatic obsessions involve hyper-vigilance about signs of illness in your self or others, fears which often require repeated reassurance from medical professionals. A need for symmetry involves concerns for regularity and order in the placement of objects which goes beyond traits of neatness and orderliness, leading to intense anxiety and distress when things are not ordered, lined up, and symmetrical. Aggressive obsessions are ideas, urges, or images of hurting others, which may lead you to, for example, drive very slowly or avoid boiling water while others are nearby. Sexual obsessions "are unwanted, persistent ideas, images, or urges with a sexual theme" (Ciarrocchi, 1995, p. 22). Although any of these obsessions can be associated with scrupulosity, "blasphemous" thoughts are in our experience the most common. The person who suffers with obsessions is driven to relieve the anxiety which they bring. Often, this effort to alleviate the anxiety takes the form of repetitive thoughts or actions meant to neutralize the feared consequences of the obsessive thought. These thoughts or actions become compulsive and repetitive precisely because they do not get to the heart of the matter. They provide temporary relief only. The individual comes to depend on them as the only solace available, but as a person with chronic pain might come to depend on narcotic medication. In contrast to obsessions, these compulsions are (strictly speaking) voluntary but very strongly motivated. Checking compulsions arise from uncertainty regarding possible harm to others, such as the need to check and recheck the iron or the area where the bump was heard while driving. Often, the doubt remains, and the checking goes on and on. Washing compulsions arise from obsessions about contamination. Counting compulsions may arise from need-for-symmetry obsessions, as the sufferer may need a certain number of items present or acts completed. A compulsion to confess can arise from fears of hurting or contaminating others, somatic obsessions, or other obsessions involving moral or religious concerns. Symmetry and precision compulsions may involve doing things in a particular, rigid order, such as reading books in order of the Dewey Decimal System. Finally, hoarding compulsions involve collecting and gathering in excess of normal "pack rat" tendencies. This hoarding often is done with no real purpose, and usually results in huge, space-wasting collections of unneeded and/or outdated items (e.g., old newspapers or pieces of cloth). Until about 1987, it was believed that only one or two people per thousand suffered from OCD (Van Ornum). More recent studies have shown the lifetime prevalence to be approximately 2.5 per cent. The disorder is equally common among males and females, though it tends to begin earlier in men. The most common age of onset for men is between six and 15; whereas, women most often develop symptoms between the ages of 20 and 29, but symptoms can begin at almost any age. When children demonstrate symptoms of OCD they often do not perceive the obsessions and compulsions as ego-dystonic. If they do feel odd, children will hide their symptoms for fear of being perceived by others as "weird" (Wagner, 1997). In either case, children are less likely to ask for help. Children typically come fore treatment when their parents notice and become concerned about their washing, checking, or ordering rituals. An ordinary intrusive thought may be experienced as annoying or "weird," but an obsession becomes an experience which is feared. It may become a sin for which the individual must atone or suffer terrible consequences. Paradoxically, the anxiety associated with these thoughts then actually makes them more frequent and persistent. Worry, repetitive thoughts about normal stressors, is an inefficient coping mechanism, but one which almost all of us use at times. There is in it the unspoken belief that if we worry enough we might well keep the difficulty in question at bay somehow. Of course, in itself worry does very little which is productive. This is so largely because our focus is on the emotion (anxiety) rather than on the problem to be solved. Nevertheless, it is only when worry becomes pervasive, apparently independent of any particular focus or cause, that it becomes the clinical problem of Generalized Anxiety Disorder." For those who do not suffer with OCD, the rituals of everyday life do not seem to interrupt the flow of the day; they may actually help to make the person more productive. Many aphorisms point to the extent to which we value carefulness and systematic ways of proceeding. Even as prominent a person as Santa Claus confesses to "making a list" and "checking it twice." Compulsions are notable for the extent to which they control the individual's life (the tail wags the dog) and, ironically, for the extent to which they are ultimately ineffective in producing anything more than temporary relief, at best. For example, we might say that "confession is good for the soul;" however, in OCD confession becomes a compelling activity which must be done over and over again, perhaps even for the same offense. As in other clinical uses of the term, compulsion will always involve an effort to avoid some unpleasant state, seeking a goal which is in itself desirable, but in a way in which the goal cannot be fully realized. The compulsion brings enough relief to keep it going, and not enough to put it to rest. Hopefully, this way of thinking about obsessive-compulsive characteristics and Obsessive-Compulsive Disorder makes clear these important distinctions. Many persons have obsessive-compulsive characteristics; these are usually highly valued. A person may go to the extreme in this regard, and even merit the "title" of Obsessive-Compulsive Personality Disorder, but this inflexible pursuit of control in life is not in itself Obsessive-Compulsive Disorder. In fact, and perhaps surprisingly, the two disorders typically do not appear in the same person. In contrast to the pervasive concerns of the person with the personality disorder, persons suffering with OCD display a vary narrow focus of concern. For example, in OCD the individual may give inordinate time to cleaning the kitchen after preparing a meal, yet place little importance on personal appearance of keeping other parts of the house in order. Scrupulosity, in turn, is a unique form of OCD. It is characterized by obsessions and compulsions with a moral or religious focus. In scrupulosity, realistic moral issues are elaborated out of proportion. Most religiously committed persons have experienced some type of scrupulous concern at one time or another, especially in younger years. During periods of increased religious fervor, efforts to be better than good may have taken the form of unrealistically high standards for behavior. Sensitivity to imperfect realization of the desire for union with God may have led to periods of rigidity in prayer. Coming to know personal responsibility and sinfulness may have brought on painful guilt to which harsh treatment of the body seemed the only atonement and/or preventive. In scrupulosity as disorder, these concerns and responses persist, becoming more intense and more narrow. They do not lead to growth in trust and radical dependence on God, but seem to be resolved only in greater despair and the sense that all depends on human effort. Peace is sought assiduously, held for an instant, only to be lost again.
Treatment of Scrupulosity Initially, clients with scrupulosity are more likely to seek help from religious professionals than from psychologists or psychiatrists. By the time the scrupulous person arrives in a mental health setting, they often have developed depression in addition to the scrupulosity. Depression in scrupulosity is often associated with the losses which occur as others become unable to tolerate the repetitive behaviors. The scrupulous themselves may begin to feel trapped in their own prison of anxiety and undoing. It is not unusual to find, despite the exquisite moral sensitivity of the scrupulous person, a dramatic withdrawal from religious practice and the support which the religious community might otherwise offer. Unfortunately, scrupulous persons also often find little in the way of accurate empathy from mental health professionals. Many psychologists and psychiatrists are not themselves people of faith. Relatively few have been trained to understand and respect healthy religious practice. Many come with distorted views of religion, seeing it as a passion of the uneducated or even inimical to mental health. Not surprisingly, many professionals have tried to neutralize the exaggerated concerns of the scrupulous person by urging him or her to engage in wholesale revision of moral standards. This approach has not proven very helpful. In recent years, there is a growing recognition that understanding religious heritage is just as important an aspect of respecting diversity as is sensitivity to ethnic, racial and gender differences. The ability to recognize and work with the healthy religious commitment which co-exists with the aberrations inherent to scrupulosity is critical to effective treatment of this disorder. In addition, the scientific community has made great strides toward an empirical model of treatment for OCD in general. The most widely accepted treatment regimen today is a combination of medication and cognitive-behavioral psychotherapy. The most promising class of medications is the Selective Serotonergic Re-uptake Inhibitor (SSRI). Developed initially for the treatment of depression, these medications have been used as well for a variety of chronic medical disorders. In effect, they help normalize available levels of an important neurotransmitter, serotonin, associated with a sense of well-being. Such medication does not cure OCD. It is a way of managing the symptoms. Cognitive-behavioral therapy complements the biological work of medication management by helping the client change how he or she responds to the initial stimulus which raised anxiety. The first stage of therapy is often a combination of education and support which brings the client to the point of readiness. The client cannot proceed until there is some level of confidence in the therapist and in the rationales offered to explain the disorder and the treatment. Irrational beliefs which simply augment the obsessive response must be identified, articulated, and eventually revised. Cognitive and physical anxiety management techniques are learned so that they can be used in place of the "protective" rituals. When the client is ready, the therapist assists in setting up purposeful "exposures" to the obsessions. These may be presented in imagination or in realistic situations; however, the nature of a particular obsession (for example, a feared image or word) sometimes may limit effective exposure to imagination. The client agrees to use the alternative anxiety management techniques instead of the more familiar (and more trusted) rituals. For example, the client may purposefully make an imperfect prayer or limit confession to "new sins" only. This technique, known as "exposure and response prevention" (ERP), is very powerful, but it is important to remember that it is not done in isolation. Cognitive-behavioral therapy is not a cruel or manipulative process. The techniques are offered in the context of an empathic relationship and with the informed consent and involvement of the client. The overall process has been shown to be the single most effective type of psychological treatment for OCD in general. We have found it to be equally effective for scrupulosity as a sub-type of OCD. Clearly, there is an exclusively pastoral approach to managing scrupulosity. As we have noted in Part I of this essay, religious professionals have been dealing with scrupulosity for centuries, well before the development of modern scientific methods. Examined from the perspective of science, many of the pastoral methods can be understood in cognitive-behavioral terms. Such intrinsic areas of overlap do not detract from the validity and internal consistency of the pastoral approach. Nevertheless, it has been our experience that a holistic integration of medical, behavioral and religious approaches has been the more effective way to assist the scrupulous client. In preparing the client for behavioral therapy, the religious professional plays an important role. Most clients need assistance from religious leaders in challenging the beliefs which lead to anxiety and obsessive ritualizing. In the course of working through the hierarchy of "exposures" there is need for some reasonable "checking in" to reassure the client that their challenge is to their own irrational beliefs, not to God. In addition to this type of theological education, we have also found that spiritual direction, concurrent with cognitive-behavioral therapy, is also invaluable in assisting the client to develop in their own understanding of God. Many clients need to find their way to a greater sense of being loved for who they are rather than for what they can do. They need a greater appreciation for the extent to which they are already imperfect and are loved in that imperfection, not in spite of it. From that sense of being loved, it is much easier for the client to experience trust, optimism and relaxation. It provides the foundation for truly coming to love. In the end, as suggested so well by Van Ornum, the holistic approach best serves the client because it best reflects the nature of the disorder. The optimal plan incorporates medication, cognitive and behavioral techniques, supportive therapy, theological consultation, and spiritual direction toward the development of a more open and trusting relationship with God. It would be the rare person who could do justice to all these roles. A team approach offers the more realistic possibility. We have seen it work, another illustration of the burgeoning, synergistic collaboration between behavioral science and religious faith. In this type of collaboration lies reasonable hope that we are finding an effective response for an age-old problem all the more vexing because it afflicts such good people.
Forgiveness: An Annotated Bibliography of Recent Research, By Peter Brawer. McCullough, M. E., Sandage, S. J., Rachal, K. C. Worthington, E. L., (1997) A sustainable future for the psychology of forgiveness. Presented at the Annual Meeting of the American Psychological Association, Chicago, IL. (Copy available from Dr. McCullough, "mike@NIHR.ORG") Although this is one of McCullough's more recent papers it serves as an excellent starting point. It offers a brief but thorough history of the construct of forgiveness in psychology. McCullough points out where he believes research in this field should go, and what pitfalls to avoid. Most importantly McCullough clearly defines his conceptualization of forgiveness and its relationship to empathy. McCullough, M. E., Worthington, E. L., and Rachal, K. C. (1997). Interpersonal forgiving in close relationships. Journal of Personality and Social Psychology, 73, 321-336. In this paper the authors evaluate certain aspects of McCullough's model. In particular, they consider the hypothesis that the ability to forgive is associated with the extent to which one feels empathy. Two studies are reported. The first study consisted of developing scales of empathy and forgiveness. Results of this study supported the empathy-forgiveness relationship. In the second study the authors tried to further the process of forgiving by enhancing empathy. The results indicated that by using the intervention the authors increased empathy, and more forgiveness was demonstrated. Freedman, S. R., and Enright , R.D., (1996). Forgiveness as an intervention goal with incest survivors. Journal of Consulting and Clinical Psychology. 64, 983-992. Suzanne Freedman and Robert Enright examined the role of forgiveness in the treatment of incest survivors. The authors studied 12 female survivors of incest. An experimental group receiving treatment with forgiveness as its goal was compared to a wait list group. The people who received the treatment not only experienced greater forgiveness, but felt more hopeful, and had decreased levels of anxiety and depression. Coyle, C. T., Enright, R. D., (1997) Forgiveness with post abortion men. Journal of Consulting and Clinical Psychology, 65, 1042-1046. In this study Catherine Coyle and Robert Enright describe the treatment of post-abortion men with an intervention designed to foster forgiveness, and reductions in anxiety, anger and grief. Sunkoviak, J. J., Enright, R. D., Ching, R. W., Gassin, E. A., Freedman, S., Olson, L. M., and Sarinopoulos, I. (1995) Measuring interpersonal forgiveness in late adolescence and middle adulthood. Journal of Adolescence, 18, 641-655. Fair warning, this is a technical article. The study describes the development of the Enright Forgiveness Inventory (EFI). The measure was tested and operationalized in 197 college students. The results of the study suggest that the EFI is a psychometrically sound 60-item measure of forgiveness with high internal consistency. Al-Mabuk, R. H., Downs, W. R., (1996) Forgiveness therapy with parents of adolescent suicide victims. Journal of Family Psychotherapy. 7, 21-39. Al-Mabuk and Downs describe the treatment of a parent survivor of an adolescent suicide using a modified version of the forgiveness intervention model (Enright en al 1991). The model is used to enhance self-esteem, lower anger, increase hope and decrease depression and anxiety. Heble, J.H., Enright, R.D., (1993) Forgiveness as a psychotherapeutic goal with elderly females. Psychotherapy, 30, 658-667. The authors of the article employ a forgiveness based treatment with 24 elderly women. Heble and Enright focused on this population because previous research indicated that this age group suffers from higher levels of guilt, loneliness and poverty. The treatment which enhanced forgiveness of past hurts was shown to be effective. Fow, N. R., (1996) The phenomenology of forgiveness and reconciliation. Journal of Phenomenological Psychology, 27, 219-233. Neil Fow provides written descriptions of 6 situations when one individual forgave another person. From these cases, Fow concluded that forgiving does not always have to include "words and gestures", and that reconciliation is not essential to the forgiveness process. Hargrave, T. D., Sells, J. N., (1997) The development of a forgiveness scale. Journal of Marital and Family Therapy, 23, 41-63. Hargrave is working on yet a different model of forgiveness which incorporates ideas from both McCullough and Enright. The Interpersonal Relationship Resolution Scale (IRRS) is a self-report instrument designed to "assess one's perspective of pain resulting from relational violations and work toward relational forgiveness." Results indicate the IRRS to be a psychometrically sound instrument that can accurately measure forgiveness. |
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