Scruples and the Besieged
The obsessio of the manuals, and obsessive-compulsive disorder.
In the Texts
Beside the possessed, the manuals describe the obsessi, the besieged: tormented from without by blasphemous thoughts they abhor, by doubts of their own salvation, by the compulsion to confess the same sin again, and by a horror of the sacrament they long for. Canale is gentle with them; the confessors’ manuals of his century are full of advice for the scrupulous, and Loyola had described his own scruples at Manresa.
What Medicine Makes of It
Scrupulosity is the religious form of obsessive-compulsive disorder: intrusive thoughts the sufferer finds repugnant, a fear of having sinned that no confession settles, and rituals of prayer and checking that relieve the fear for an hour. It makes up a quarter or more of OCD in religious populations, and its content follows the faith, Catholic blasphemy, Jewish ritual purity, Muslim prayer validity. The treatment with the best evidence, exposure with the prevention of the ritual, is what Alphonsus Liguori prescribed in 1748: the scrupulous penitent is forbidden to repeat the confession and ordered to act against the doubt. The besieged of the manuals, who were not to be exorcised but counselled, were the one affliction the manuals treated as the clinic does.
The Evidence
- Scrupulosity, the religious form of obsessive-compulsive disorder, is marked by intrusive blasphemous thoughts, fear of having sinned, and compulsive confession and prayer; Abramowitz et al. (2002) built the standard scale for it from the Catholic and Jewish literatures.
- The confessors of Canale’s age knew it: Ignatius Loyola described his own scruples in his autobiography, and the manuals for confessors warned against hearing the same confession twice; Alphonsus Liguori’s rule for scrupulous penitents (1748) is a treatment by exposure.
- A quarter to a third of OCD patients in religious samples have religious obsessions (Tek and Ulug, 2001, in Turkey; Greenberg and Witztum, 1994, among ultra-orthodox Jews), with the content following the faith.
- The affliction that Canale calls being tempted or besieged, the obsessio, with its intrusive blasphemies and its horror of the sacred, is the obsessional picture; the besieged are not possessed, the manuals agree, and are to be treated gently.
- Exposure and response prevention, the treatment with the best evidence for OCD, forbids the compulsive confession and prayer, as Liguori did, and works in religious patients when the clinician respects the faith (Huppert and Siev, 2010).
Where They Part
The manuals located the blasphemous thought outside the sufferer, in the devil, which is precisely what the sufferer needs to hear: the thought is not yours. The clinic says the same in other words, that an intrusive thought is noise, not intention. Here the old and the new agree almost entirely, and the demon was a serviceable name for the disorder.
In the Materia Medica
Sources
- Abramowitz, J. S., et al. (2002). “Assessment of obsessive-compulsive symptom dimensions: the Penn Inventory of Scrupulosity.” Psychological Assessment 14.
- Liguori, A. (1748). Theologia moralis, on the scrupulous conscience.
- Huppert, J. D., and Siev, J. (2010). “Treating scrupulosity in religious individuals using cognitive-behavioral therapy.” Cognitive and Behavioral Practice 17.
- Greenberg, D., and Witztum, E. (1994). “The influence of cultural factors on obsessive compulsive disorder: religious symptoms in a religious society.” Israel Journal of Psychiatry 31.
Historical and interpretive; not medical advice.