Thursday, March 19, 2009

Did I Do It Right? Mikvah With Tikvah

Did I do it right??: Mikvah with Tikvah
Jewish rituals and OCD
By: Rabbi Dr. Jonathan Schwartz
Center for Cognitive Behavioral Psychotherapy
Sarah, a 30 year old mother of 2, is preparing for her trip to the Mikvah. She removes her nailpolish, cuts her nails, combs her hair carefully to remove all potential Chatzizot (separations) that may impede the path of the Mikvah water. However, instead of feeling a sense of wholeness and fulfillment at a job well done, Sarah dreads her mikvah experience. For as soon as she completes her preparations, she begins them anew, worried that she might have missed something, rendering her Mikvah trip “useless” and she, “unclean”.
Is Sarah unique? Many look to her and admire her Frumkeit and sense of devotion. However, those close to her know that her monthly inner-torture with the Mikvah is not a result of her personal scruples. What they do not know is that Sarah, like many other Jewish women, suffers from Scrupulosity.

Scrupulosity is a term given birth to in the 1600s. Today, it is a well-documented form of Obsessive Compulsive Disorder (OCD). It is typically evident in people who believe that their religious behavior is in some way displeasing or disrespectful to Hashem. This preoccupation is often accompanied by the emotional experience of anxiety, common to all forms of OCD, as well as a presence of guilt which exacerbates the pain. The guilt in displeasing Hashem and the feeling that one can never “do it right” often contribute to an associated depressive quality in this OCD subtype. One of the great Chassidishe Rebbes, Rabbi Nahum of Stephanesht described the intertwining of these elements in Scrupulosity: “Scrupulosity is a cloak made of pride, lined with guilt and sewn with melancholia.” As a result, many engage in repetitive and excessive prayer or other religious behavior to correct the pain, as part of the disorder.

Consider the following:
  • A 17 year old Yeshiva Bachur worries that he cannot concentrate fully during Kriyas Shema. He repeats each word over and over in order to make sure that he pronounced it correctly. And, despite his constant review of the words, he fears that he didn’t Daven with the proper Kavanna. He spends 50 minutes a day saying Shema and, he views the Mitzva as a burden he cannot manage.
  • A 22 year old Kalla from a prestigious Jewish family is tortured by thoughts of Religious doubt that pervade her mind during the day. She ruminates about the thoughts constantly, repeating to herself over and over that she is a Baalas Emunah, and spends hours during the day trying to prove her religious commitment.
  • A 21 year old Kollel Yungerman wonders if his Tefillin are on straight. He puts on the Shel Yad and readjusts it 18 times before attempting to put on the Shel Rosh. He constantly rechecks and re-examines the Shel Rosh to be sure that it is EXACTLY between his eyes, using a ruler to measure the space between them and the placement of his Tefillin in the proper location. The process of putting on Tefillin takes so much of his time that he often misses Tefillah B’Tzibbur due to the pressure of “getting it right”.
Although these cases seem extreme, they are some of the examples of Scrupulosity cited by the Divrei Chaim of Sanz (Shut Divrei Chaim II: 6) and the Steipler Gaon (Kriyna D’Igrisa). To the outsider, these behaviors appear to be nothing more than Frumkeit. But to the person with this condition Scrupulosity OCD takes Ahavas Hashem out of Mitzva observance, leaving the individual anxious, depressed and often fearful about doing Mitzvos. These Gedolim recognized the difference between healthy religious Shmiras HaMitzvos and Scrupulosity and were able to advise those writing to them appropriately.

The Halachos of Niddah in general, and of Mikvah in particular, are a fertile ground for Scrupulosity to rear its head and torture those who suffer with it. Some women suffer from extreme anxiety when performing Bedikot – constantly worried that they did not perform the Bedikot properly. In the extreme, this leads to repeated unnecessary Bedikot which can irritate the area and cause unnecessary bleeding. Others, engage in repeated examination of Bedikah cloths, unable to determine if a stain is present or even if there is a Shaila to be asked. Still others become unable to accept the reassurances of the Mikvah attendant and the Rav that the Tevilah was indeed complete and that they are, indeed, Tehorot.

How can one tell when observance is Frumkeit and when it is only Scrupulosity. Psychologists have noted five key features that distinguish Frumkeit from scrupulosity:
  • When practices go further than the requirements of religious law, one might be mistaking Frumkeit for scrupulosity. For instance, if a ritual requires washing Netilas Yadim twice on each hand, the person with Scrupulosity will repeatedly wash to be sure that he covered each hand twice until the wrist often washing twenty times or more. If a woman must do a Bedikah twice a day during the Shiva Nekiyim and redoes them twice an hour, she might suffer from scrupulosity.
  • When the person becomes overly preoccupied with a focus on a seemingly trivial part of the ritual instead of the whole picture, s/he is likely to be expressing behavior more akin to Scrupulosity. When a religious patient is more focused in prayer on “pronouncing it perfectly” instead of developing a sense of proper Kavanna, the focus is more like scrupulosity than Frum. Similarly, the woman concerned about the perfect pronunciation of the Beracha in the Mikvah instead of on the Tevilah, might be expressing a sense of Scrupulosity.
  • Healthy and scrupulous religious beliefs do not interfere with the normal practice of the religion. Scrupulosity frequently interferes with the proper practice of religion. For instance, when a person with Scrupulosity OCD does not attend Minyan because of the fear that s/he cannot contain intrusive thoughts, s/he is expressing scrupulosity. The woman who automatically adds onto her Yimei Tumah because the Bedikah cloth “didn’t come out perfectly white” without asking a Rav, limits her ability to complete her Tahara process and resume a healthy family relationship. Such indiscriminate decision-making may be a result of Scrupulosity.
  • The person with Scrupulosity spends excessive time and energy on minute, trivial aspects of spiritual life while ignoring more important aspects of spiritual life including Mitzvos Bein Adam L’chaveiro, Gemilas Chessed, Tzedaka and Ahavas Hashem.
  • The pre-occupation with doing rituals until they are “perfect”, the repetitive praying, vigilant repeated Mikvah preparation and dunking and unnecessary penance-seeking found in Scrupulosity closely resemble the typical OCD symptoms of checking, repeating and asking for reassurance. The person with Scrupulosity often demonstrates behaviors that are persistent, unwanted and repetitive.
Remember: Strong religious convictions do not cause or imply Scrupulosity. Rav Yisroel Salanter (Ohr Yisroel, Letter 25) recognized the difference between Zehirus and Scrupulosity. Scrupulosity is a type of OCD, which is a psychological disorder. In these cases, a person’s religious convictions are merely one aspect of his or her being that OCD uses to cultivate doubt and create anxiety. It is not connected to Torah observance or religious life at all. If OCD didn’t attack a person’s religious beliefs, it would surely take on a different form, whether that be a contamination fear or a checking compulsion or another arena for OCD to unleash anxiety. Scrupulosity takes strong religious ideals and blows them out of proportion, making them distorted and corrupt.

Treatment Considerations:

One of the most successful approaches to treating Scrupulosity is with cognitive behavioral therapy (CBT). CBT therapists encourage their patients to see that their behaviors can vary and that one’s sense of self is better off being accepted rather than always being constantly critically evaluated. Given our religious culture that is constantly encouraging us to become or “be” better persons, it is easy to see how patients find it hard to navigate these new ideas. Therefore, it is not unusual for therapist and patient to consult with a patient’s Rav during this initial phase of therapy in order to sanction and help navigate this apparently “irreverent” therapy. The Rav and patient need to be assured that the treatment course is not designed to adversely impact one’s religious beliefs. Rather, they should know that treatment is solely targeting a disruptive anxiety disorder which produces seemingly devout behavior that is actually unrelated to one’s genuine degree of religious commitment. In fact, often the ability to distinguish real religious from scrupulosity often helps enhance one’s devotion to Yiddishkeit.

Often, patients balk at the idea of cognitive therapy for OCD. In the case of Scrupulosity, especially of a religious subtype, many opt for medication therapy instead. Although medication is a very powerful frontline treatment for OCD in general, it can have limited benefit for people with scrupulosity. The medication can help reduce the experience of the anxiety but it cannot help someone change his way of thinking. This is where the cognitive therapy is most necessary and effective.

The actual treatment course for Scrupulosity does not deviate significantly from other types of OCD. Generally, a hierarchy is constructed, in which persons are gradually exposed to accelerating levels of risk. This is in accord with the concept expressed by the Chovos Halevavos that one of the principles of Zeheirus is not to be too Zahir where improper to do so. Exposure exercises at a lower level might entail things like lowering the amount of time spent on examining a Bedika cloth. An example of a more moderate range exposure could involve the limiting of total Mikvah preparation time to 1 hour, knowing that the preparation might not have been completed fully.

Often, people with Scrupulosity are referred to by family, significant others, Mikvah attendants Rebbetzins or by Rabbonim and Roshei Yeshiva due to the tendency for those with scrupulosity to misperceive their excessive behavior as functional (See the list of Haskamos to Yaakov Grinvald’s Eitzos v’Hadrachos for a listing of Gedolim who understood the difficulties).

So when taking scrupulous stock of Taharas HaMishpocha, keep these guidelines in mind. Where resolve for the Mikva preparation is a drive to keep the Mitzva in the best manner possible, then one becomes filled with a sense of fulfillment and Tikvah through the Mikvah. However, when the scrupulous preparations are purely driven by a fear that passing up a specific opportunity would be indicative of your overall poor character due to your lack of scruples, you might be suffering from Responsibility OCD or Scrupulosity and it might be in your best interest to seek professional help.

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