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The “Gold Standard” of Treatment

Fr. Thomas M. Santa, CSsR

Exposure, Response, and Prevention therapy is considered the “gold standard” of psychological treatment for OCD/scrupulosity. The results of the proper use and application of ERP therapy suggest it is equal to or superior than pharmacotherapy. These significant results encourage educated therapists to use ERP therapy to help a person living with the disorder. 

Unfortunately, sometimes the primary experience of this therapy produces pushback from clients. ERP therapy often uses religious imagery or directly confronts out-of-control compulsions, so it is not uncommon to hear a client charge that the therapist is trying to deprive the client of his religion. To the contrary, this mode of therapy is designed to restore a balanced application of religious practices and disciplines. It does not destroy them.

To help the community better understand ERP therapy, I will attempt to place it into a helpful context. I am particularly concerned with men and women who will not engage in a therapy that will help them because they believe that scrupulosity is their “cross to bear.” It most certainly is not. It is a serious disorder that needs to be managed.

A client may wonder if he or she and the therapist share the same religion. The client wants to know if the therapist fully understands the religion’s doctrines and practices. My response is that scrupulosity is about anxiety, fear, and shame. It uses skewered and misrepresented religious thoughts and images to provoke and maintain anxiety. Rather than be concerned with a therapist’s religious beliefs, I believe it is far more important that the therapist be highly trained and skilled in applying ERP therapy. Well-trained and skilled professionals will recognize there is a significant difference between authentic religious practices and the practice generated by OCD/scrupulosity. Ideally, a spiritual director or a trusted friend might be included in the ERP intervention to comfort and encourage.

ERP therapy requires the therapist to understand well the specific manifestation of scrupulosity that is present. This suggests that time will have been devoted to the process of listening that leads to understanding. The therapist needs to understand precisely how a person is suffering. This will require significant time building a relationship of trust and vulnerability. In short, ERP therapy must be targeted so it is respectful of and effective in the healing process. 

For a therapist to suggest ERP therapy without a full understanding of the specific content and how the scrupulosity is being manifested and experienced would be counterproductive. While insignificant improvement might take place, there is a real chance that the therapy would instead produce the dreaded response, “You are trying to make me lose my religion.”

Once a qualified therapist has been chosen, and the necessary time has been devoted to listening and understanding, it is helpful for the person who is suffering to have the therapeutic approach explained in a way that will help calm anxiety and hesitations. If the therapist helps the person who is suffering to understand that Exposure is the process through which you confront the thoughts, images, objects and situations that make you anxious, and the necessary time is spent in sorting through all of the different options, trust will grow and develop. Once the most helpful images, objects, and situations are identified, then the response-prevention process can be explained.

The second element in the application of ERP therapy is response prevention. That element entails learning to resist engaging in compulsive behavior that artificially reduces anxiety. For example, the sufferer slowly appreciates and understands the use and practice of a religious discipline that helps rather than harms. This outcome is measured by identifying the improvements in quality of life and the improvement in co-morbid conditions like depression and anxiety. 

Practical applications might include learning to reduce the frequency of confession, eliminating compulsive prayer and replacing it with a practice that is not motivated by fear but rather by faith, learning to resist the need to constantly seek reassurance, and reducing the avoidance of triggers that induce intrusive thoughts. ERP can help a person eliminate the internal analysis undertaken to determine whether there is sin in any action, thought, or desire. This practice is why scrupulosity is often identified as the “doubting disease.”

The few words in this column might help place ERP therapy into a perspective that could lead to more understanding and appreciation of the real value the therapy offers to the person who is suffering with scrupulosity. However, recognizing the value of something does not necessarily lead to its acceptance or use. The decision to engage in ERP is often a very difficult decision for the person who suffers. It is completely understandable. There will be real emotional and psychological pain and struggle in the process of engaging in ERP therapy. Many people report that it was the most difficult process that they have ever engaged in. On the other hand, those same people freely admit that though it was difficult, it was worth every minute. The relief and the management skills wrought from the application of the ERP process are spiritual gifts of healing that many thought was something they could never experience. It is simply that life-changing. 

It should also be noted that ERP therapy must be applied again and again in order to maintain a strong level of confidence and health. OCD is relentless and never gives up. The healthy response, using the lessons learned from your ERP experience and the spiritual lessons and applications you might have learned through spiritual direction, demands a lifelong commitment. Maintenance of the disorder must be practiced or the symptoms will return, often much worse.

Fr. Thomas M. Santa, CSsR

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