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Totally Engrossed: Extreme Piousness or Obsessive Compulsive Disorder?

Yaakov was admired from a distance. Many boys in the yeshiva were amazed at his ability to daven such a long Shemoneh Esrei. He would spend close to an hour every Shacharis, seemingly intensely engaged in tefilla. However, his closest friends and his Rebbe knew the truth: Instead of davening with kavanna, most of Yaakov’s time in Shemoneh Esrei was spent agonizing over the possibility that he missed or mispronounced a word, compelling him to carefully repeat words and phrases over and over. Yaakov was not engaged in a deep mystical exercise. Rather, he was engaged in a torturous battle with himself. He sought the advice of his Rebbe, who would constantly assure him that he was worrying about nothing, but it did not make a dent in calming Yaakov’s fears. One time, after an extremely frustrating give and take over Yaakov’s endless worries about tefilla, his Rebbe became exasperated and told him, "Yaakov, I promise that you will not be held accountable for missing a word of prayer. I personally guarantee that I will take you out of Gehinnom with my own two hands. Now, stop worrying!" After that, Yaakov still worried, but he was afraid to bring it up anymore with his Rebbe, so he suffered in silence. 

Rivka is a happily married young mother. She was always careful about halacha; her friends used to call her "the rebbetzin." Lately, though, she has become overly concerned with kashrus. She keeps coming up with interesting but strange she’eilos that don’t seem to bother most people. For example, she wonders why it is OK to use the same water pitcher for milchig and fleishig. She watches how everyone in the family touches the handles with greasy hands and then goes on with eating and touching the food. When she brought it up to her husband, he shrugged off her concerns saying, "They don’t have separate pitchers at my Rosh Yeshiva’s house, so why should we!" But Rivka remained uneasy. Because of this, Rivka feels obligated to clean and scrub every kitchen counter and every shelf in the refrigerator. After watching all this, her husband says, "Rivka, it’s not Pesach. You can take it easy on the cleaning." Instead of bringing her comfort, her husband’s mention of Pesach only causes Rivka more distress giving her something new to worry about. 

Locked in Ritual 
Obsessive Compulsive Disorder (OCD), a mental illness that affects 2-3% of the population, imprisons people inside rituals and routines they feel compelled to follow, as a way to ward off intrusive fears or thoughts. When a person who has OCD attempts to resist these compulsions, he or she experiences extreme anxiety and panic, with a feeling of impending doom unless the rituals are followed. Some of the typical rituals manifested by persons suffering from OCD are: 

- Excessive hand washing out of a fear of becoming contaminated. 
- Checking behavior. Such as before going to sleep repeatedly checking to see if the door is locked.
- Needing to get dressed in a certain order, to avoid certain words, or say certain words to fend off doom, or to ward off what the person considers to be dangerous or harmful thoughts and impulses. 
- A fear that a blessing was not recited correctly or a word was mispronounced or not said properly, necessitating several repetitions of the same prayer. 

The treatment found to be most effective for OCD is Cognitive Behavioral Therapy. Cognitive Behavioral Therapy (CBT) helps people learn to identify and challenge irrational thoughts, which then helps people to change their behaviors. Persons suffering from OCD benefit from a specialized form of Behavior Therapy called Exposure and Response Prevention, which helps them learn to challenge their fears and feelings of doom, and to tolerate anxiety via various supportive exercises and a controlled, increased exposure to the situation that causes the obsessive thoughts which trigger the OCD behaviors discussed above. In addition, depending on the severity of the symptoms, certain medications may be used in conjunction with the therapy. However, a full survey of available treatments is worthy of a separate article. This article will be limited to defining and diagnosing OCD within the context of religious ritual. 

Devotion or Disorder? 
Since it is at times appropriate to be scrupulous about religious matters, one of the questions that come up for persons suffering from OCD and their family members is how to differentiate between behavior that stems from piety and religious devotion, and behavior that stems from OCD. Someone who is ignorant about Yiddishkeit and observes a balabuste before Pesach could easily conclude she was obsessing over crumbs, or someone watching a baal kriah prepare the weekly leining would think, "This guy is crazy, making sure he has each syllable properly pronounced." And consider recent current events: The Torah observant community was turned upside-down over hairs and microscopic bugs! Any of these behaviors would appear compulsive and irrational to a person from a different culture than ours. Yet, to us, scrupulousness in these areas is considered a Torah ideal. 

The problem that often arises when a religious person becomes obsessed about an observance is that it is hard for others to convince him that the behavior is irrational. When such persons ask a Rav for advice, the Rav might say, "It’s OK, don’t worry," but the person suffering from OCD may keep asking, "But I forgot to mention this detail, or maybe you misunderstood this point, etc." This can lead to the Rav, and the petitioner, becoming very frustrated. 

How then can we separate compulsion from choice and religious devotion from emotional disturbance? 

According to the DSM IV (Diagnostic and Statistic Manual for Mental Disorders), Obsessive Compulsive Disorder is built upon the presence of two factors: Obsessions and Compulsions. Meaning, the person must experience recurrent anxiety-provoking thoughts (obsessions), which then induce the person to behave in a manner to address these fears (compulsions). For example, because a person is persistently and irrationally afraid that robbers will enter his house (obsession), the person keeps checking the door to see if it is locked (compulsion). Or, because the person is afraid of germs (obsession), she keeps washing her hands over and over again (compulsion). 

In addition, these behaviors must be significantly debilitating, such as causing extreme distress or disabling social or occupational function. The DSM also requires that the person suffering from the disorder acknowledges or recognizes at some point that the obsessions or compulsions are excessive or unreasonable. In other words, if the person is irrationally obsessing over some matter, but he or she never feels any distress about it and considers it normal, it is not a diagnosable case of OCD. 

Technically, the final criterion above would seem to rule out a pious person who engages in what appears to be excessive and irrational rituals. But in practice, such persons may still be suffering from OCD. This is because if a person was worried about a drop of chametz falling into the reservoir on Pesach, the person might acknowledge that he is unusually obsessed with the matter, and that he wishes he could be freed from his "chumros" (stringencies) so he could live life like others. In addition, the DSM does acknowledge that children may be diagnosed with OCD even if they do not recognize that the obsessions or compulsions are excessive or unreasonable. This is due to a child’s lack of life experience and inability to realize the unreasonableness of certain behaviors. If so, perhaps a person who is under the sway of mistaken interpretations of religious law could also be considered as a child. 

Applying The Key Criteria 
The key question to ask a religious person who is irrationally scrupulous about religious matters, is: "Are your chumrosShemoneh Esrei may merit the same heavenly assistance that allowed the Chassidim Harishonim to be involved in davening for nine hours a day while still mastering Torah study (as described in Gemora Berachos). He then is not suffering from any mental dysfunction. A person who is just repeating words over and over again, however, and feels frustrated and depressed by this imprisoning ritual, will not grow in his religious observance and is victim of mental illness, not piety. This person needs treatment. enhancing your religious development or impinging upon it?" Herein lies the answer. A person who davens an exceedingly long 

Along this line of thinking, the Steipler Gaon l"xz was asked advice regarding someone who was unable to stop worrying, no matter how many times he verified that halacha requirements were met. The Steipler wrote the following: 

"Such thinking is a tactic of the yeitzer hara in order to make observance of the mitzvos so burdensome that he will eventually, G-d forbid, shirk the yoke of the Torah. He should realize he will not endure this suffering forever because it will eventually pass over time. The main point is that he should follow the rulings of rabbinic authorities without analyzing their reasons and without second guessing them." (Eitzos Vehadrachos Meyosad Al Michtavei Maran Baal Hekehillos Yaakov, p. 55, Torah Graphic, Monsey, New York.) 

Although those who are familiar with the Cognitive Behavioral Therapy techniques that are used to treat OCD may employ a variety of interventions, they might find themselves quite comfortable with the essence of the Steipler’s directives and observations. 

In summation, persons suffering from OCD can free themselves from their emotional and behavioral prisons. Depending upon personality factors such as motivation, emotional flexibility, openness to change, and willingness to tolerate uncertainty and risk, relief can be obtained within a relatively short time frame. Successful treatment for OCD requires involvement and commitment to the therapeutic process. Keep in mind, as with many illnesses, it is more accurate to think in terms of recovery instead of cure. The term "recovery" refers to a process whereby a person achieves symptom relief and improvement in function via an intensive initial therapy, but then continues with some form of maintenance to remain symptom free. This may take the form of participation in ongoing support groups, a regimen of cognitive/behavioral exercises, medication, "refresher therapy sessions," or all of the above. 

Resources 
- The Obsessive Compulsive Foundation 203 315 2190 (secular). 
- Relief 718-431-9501 (under Orthodox Auspices). 
- Rabbi Simcha Feuerman, CSW serves as Director of Community Services in Ohel Children’s Home and Family Services in Brooklyn.

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