Perfectly Obsessed

Last night, via VIN, I read an excerpt of an excellent piece in the Jewish Press by Rabbi Dr. Jonathan Schwartz. I contacted him, asking for permission to re-post that piece; he sent me a more full version of the article, along with another, related piece that I thought was even better. I am going to post both of the pieces below this one in full; they're important reads, as I think we've all seen cases where people act like this, and it can cause or be a manifestation of a more serious problem.

As a slight commentary on the articles, I felt that in the Jewish Rituals piece the examples used are slightly extreme and therefore too easily shrugged off as "well, I would never act like that". It seems that even smaller examples which are similar are often indicative of a problem, which simply doesn't seem to be "that bad" because of its less obvious nature. Beyond that nitpicking, I thought both pieces were quite good and are important reads.

The differentiation R' Dr. Schwartz makes between proper zehirus and Scrupulosity is very good. His clear summary of points is also very good, such as

Healthy and scrupulous religious beliefs do not interfere with the normal practice of the religion. Scrupulosity frequently interferes with the proper practice of religion.

Please read the articles - I think that you will find them very worthwhile.

Jonathan Schwartz, PsyD is a practicing Rav in NJ and Senior Clinical Psychologist at the Center for Cognitive Behavioral Psychotherapy (www.ocdonline.com) in Manhattan. He can be reached at Schwartz.ccbp@gmail.com

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.

Am I Too Perfect?

Am I too Perfect?
Jonathan Schwartz, PsyD1

• Have you ever been told that you spend too much time making lists and schedules? Do you think you do?
• Have you been so involved in the small details of what you were doing that you lost sight of the main thing you were involved in?
• Would you describe yourself as perfectionistic? Would others?
• Do you have difficulty making decisions because no side of a particular issue is 100% correct?
• Have you ever failed to complete a project on time because of your attention to organizing or your high standards for that project?
• Would you call yourself a workaholic? Would others? If so, do you spend so much time working that you have little time for family, friends, or entertainment?
• Do you do jobs yourself because no one else will do them to your satisfaction?
• Do you take over other people's responsibilities to make sure things are done right?
• Do people describe you as stubborn?

If you have answered “yes” to most of these questions you might want to consider if you meet the diagnosis for OCPD. You see, Obsessive Compulsive Personality Disorder (OCPD) is a pervasive disturbance involving one's generalized style and beliefs in the way one relates to themselves and the world. The behavior style is often characterized with a preoccupation with details, rules, lists, & order, a perfectionism that interferes with task completion, an excessive devotion to work and productivity, an overconscientiousness and inflexibility about matters of morality, ethics, or values, excessive interpersonal control and rigidity and stubbornness. People with OCPD are usually so typically deeply entrenched in thinking that their way of functioning is the only "correct" way, they hold family and friends to their own strict (often errant) standards. While people with this style of thinking will tell you that "all is not well," they tend to be deeply committed to their own beliefs and patterns. It is the belief that "my way is the correct way" that makes them resistant to changing one’s life. Yet, letting go of this rigidity is paramount in their recovery.

At this point, you might still be asking, “Wait a minute, now ambition and striving for perfection are also psychological disorders?” You might even be wondering how psychologists reconcile this diagnosis with a healthy Hashkafas HaTorah. After all, who among us hasn’t noted the concept of Shleimus – of perfection, as a primary goal of Yahadus? Why be concerned with a pervasive preoccupation with perfection?

The Malbim (HaCarmel) distinguishes between two similar Torah concepts – Temimus and Sheleimus. While on the surface these two concepts seem similar, Temimus refers to perfection. It is a notation that implies no blemish whatsoever. Sheleimus, refers to a complete achievement – doing the best that is possible for the particular type. Rav Hirsch (Berashis 33:18) adds that this concept of Sheleimus must involve a certain internal harmony within the individual striving for it. To the person with OCPD, these stages are never possible.

Perfectionism as expressed by the OCPD is not the admirable quality often sought by the world at large. The OCPD perfectionism entails checking and rechecking "completed" tasks to be absolutely sure that there are no imperfections. It could literally take upwards of 10 to 20 minutes to fill out a check or mail an envelope due to a rigid need to ensure that there are absolutely no mistakes. It is as if, to make a mistake which might be noticed would ruin ones reputation for life. Perfectionism could also take the form of a need for over completeness -- reading and rereading material until a sense of absolute clarity exists. Not only is it extremely time consuming but the overall content of the story is lost. The forest is missed while examining each leaf, of each branch, of each tree. This disposition can also have an adverse impact on one's conversational style. In the course of a conversation sometimes information is sought which involves such minutiae that the questioned person becomes lost and frustrated. Slight inconsistencies or mistakes, within another's conversation, are often perceived by the OCPD sufferer. These details, no matter how peripheral to the conversation, must be brought out into the open and clarity must be achieved.

Dovid, a 20 year old Yeshiva bochur, was suddenly faced with a dilemma. While in High School he was a genius, completing Bekius Mesechtos and acing exams both in Limudei Kodesh and secular studies. Now involved in full time learning, he couldn’t concentrate on the text of the Gemara if he couldn’t visualize every word. The Gemara’s concepts he got but his Chavrusos complained to him that he was spending too much time “visualizing” trivializations like what Rava or Abaye looked like or intoned when they made a particular statement.

These issues can create problems at school and in the workplace. From early adolescence, through college, perfectionism can take an otherwise straight "A" student and bring him to the brink of failure due to incomplete assignments. Having to get the term paper exactly correct is an almost impossible task. At work too, perfectionism and a need to repetitively check minor details for errors can prevent OCPD employees from finishing projects by their deadlines. Additionally, an insistence on observing even the most insignificant regulations, the need to micromanage projects, and obvious criticism and contempt for subordinates, can lead to conflict with, and alienation from others.

Menachem’s hard work finally paid off. He was hired by a major accounting firm to work – where else – in the auditing division. His boss asked for a quick assessment on a particular assignment that he was working on. After two days, the boss complained to him that the assessment was long overdue. Menachem noted that he had done the assignment within the first 2 hours of its request but was reluctant to call it “complete” until he had reviewed it to his own satisfaction. That satisfaction, he told the frustrated superior, was still forthcoming.

Even home relationships suffer from one’s OCPD. One’s behavior with significant others is likely to be disrespectful and even domineering. The goal is not necessarily to behave negatively, but rather to get the entire family to a pattern of orderliness, discipline, and safety. In addition, their “no nonsense” rigidity make them unlikely to “let the hair down.” Even vacations become times of intense stress to “guarantee” that they are resting and vacationing “correctly.”

Shani, a 25 year old recently married Kalla returned from her first vacation with her husband in tears. “This is not how vacation was supposed to be,” she noted. The major difficulty of the vacation was that “nothing ran according to my plan.” Therefore, it was not “perfect” but “ruined.”

When events stray from what a person's sense of how things "should be," bouts of intense anger and emotional discord are characteristic. But Shani’s case highlights yet another aspect of OCPD- dichotomous thinking. Dichotomous thinking is the tendency to categorize all aspects of life into one of two perspectives -- "All good" or "All bad." It can take only one stain or blemish to have the person completely find justification in discarding anything which evidences a flaw. With such high consequences at stake, the desire to maintain “perfection” is evident. At the same time, the tension of maintaining that perfection is anything but Shaleim.

Indecisiveness: Another critical aspect of the OCPD thinking style is indecisiveness. When almost all decisions seem to take on the same paramount importance and being correct is imperative, making even simple choices can become a nightmare. Persons with OCPD can become stymied in life due to an inability to establish with certainty which choice is the correct one. Not unusual would be for someone to spend over ten minutes attempting to choose the correct pair of socks which best matches their tie. They tend to place a great deal of pressure on themselves and on others to not make mistakes. Within OCPD the driving force is to avoid being wrong. Since continuously making the correct choices in life, seems to be an impossible task for us humans, there is a regular source of discontent available for OCPD sufferers.

Malki’s parents were exasperated. A bright, beautiful girl of 26, Malki had been “on the market” looking for a Shidduch for 6 years. In Malki’s case, the same pattern seemed to repeat itself constantly. First she would be interested in a guy. Then they would date and become somewhat serious. However, Malki would “hold back” when the proposal of marriage would come. Each time she would find something apparently trivial that would “bother” her and slow her down. “I don’t know” she would say, “I can’t decide if he is THE ONE.” She would seek advice from anyone who would listen but then reject it for one reason or another. Eventually, the guys would end the relationship. She had been “serious” with 5 great guys already.

Treatment options: The treatment of OCPD is incredibly complex and thus beyond the scope of this article. Generally speaking the focus of Cognitive-Behavioral treatment for OCPD entails helping these individuals develop a greater tolerance to the notion that the world is exclusively made up of navigational gray, not the clearly defined black and white lines of rigidly held beliefs. Having someone identify that these thinking styles are a handicap at all is a monumental achievement. The treatment would most likely focus on breaking down and intervening on specific individual aspects within the spectrum of OCPD. Social skills training and role-playing might help facilitate a more effective style in relationships. Assertiveness training would facilitate one's ability to make requests or provide feedback such that the receiver of the information not be alienated. Overriding all of the specific interventions would be a sensitivity to helping the sufferer relinquish their dogmatic belief system. Letting go of “perfection” is a tremendous ambition. The dividend it pays is incomprehensible.

Relevant websites

• One great resource for articles on OCPD and OCD is Dr. Steven Phillipson’s website www.ocdonline.com.
• More great information can be garnered here: http://www.realmentalhealth.com/personality_disorders/obsessive_compulsive_personality_disorder.asp
• Good resources for OCD and Psychological information are available here: www.ocfoundation.org and here: www.apa.org
• An email support group is available here: http://health.groups.yahoo.com/group/OCPD/
• The Frum community is blessed with a great resource for mental health issues in the form of Relief Resources. They can be contacted at (718) 431-9501 or at their website: www.reliefhelp.org
• Dr. Bentzion Sorotzkin has three terrific articles on the Jewish perspective on perfectionism. They can be accessed here: http://www.drsorotzkin.com/pursuit_of_perfection.html