Exposure with response prevention for Islamic religious OCD

Background

The standard treatment for obsessive-compulsive disorder (OCD) is exposure and response prevention (ERP) (see specific article). This behavioral therapy is primarily based on a functional analysis (see specific article) that identifies triggering stimuli, obsessive thoughts, and the function that behaviors (compulsions/rituals) serve within the context of the patient's fear. The patient is then gradually exposed, starting with a hierarchy of anxiety-provoking situations (see specific article).

Religious obsessions are common worldwide among those who suffer from OCD and for whom religion is a natural part of their lives. The challenges of religiously themed OCD (doubts, questions, blasphemous images or ideas, and in a Muslim context, the repetition of ablutions, prayer, fasting, etc.) stem from the fact that exposure can be delicate due to the sensitivity of the subject matter, which, for the believer, touches on the sacred. For example, directly exposing the patient to blasphemous or obscene thoughts or images involving figures considered sacred, or temporarily suspending certain acts of worship such as prayers and ablutions before gradually reintroducing them, can create reluctance in the patient, and even in the therapist if the latter is religious.

Furthermore, in a North African and Muslim context, the belief that OCD is the work of the devil, the evil eye, or a curse risks diminishing the patient's confidence in a therapy that may be perceived as "Western and secular." The risk is that the therapy will be perceived as not respecting, or even refuting, the patient's beliefs. The therapist, whether religious or not, is therefore faced with a challenge: How to apply the principles of ERRP while taking into account the religious and contextual dimensions of OCD?

Principles and practice

Before considering exposure therapy with response prevention (ERP) for this specific type of religiously themed obsessive-compulsive disorder (OCD) (this theme is sometimes called "scrupulosity," a concept that also encompasses moral themes but not necessarily religious ones), two fundamental elements are essential.

1) Understanding the principles of ERP

The theoretical basis of ERP (as with all exposure therapy, see dedicated article) is functional analysis (see dedicated article). To read the article on the principles of ERP, click here.

It is important not to view ERP as simply a technique that can be implemented mechanically. Every individual therapy needs to be personalized. Such personalized therapy involves combining, on the one hand, a thorough understanding of functional analysis, and, on the other hand, consideration of the patient's religious framework and beliefs, which allows for the definition of concrete therapeutic objectives and the conceptualization of personalized exposure exercises.

The therapist must systematically be aware of the function of what he says: Is what the therapist says reassuring for the patient (which can be a trap reinforcing OCD in the long term), or is it helping the patient defusing from his intrusive thoughts and helping the patient embark on a new path towards new experiences?

2) Taking the specifics of religious OCD seriously

With the patient, the therapist must explore these questions: How does the patient understand his or her OCD problems? What personal meaning does he give to his obsessions? What solutions (often mental compulsions) has he implemented to try to neutralize the anxiety? (see dedicated article on ERP) What is their religious understanding of their obsessions? The therapist can, of course, never replace any religious authority, but can guide the patient toward appropriate readings or, if the patient lacks guidance, facilitate contact with an imam or a religious person they trust.

Often, patients are unfamiliar with certain aspects of their religion or, conversely, interpret it literally and rigidly, which fuels anxiety and can, of course, influence the psychological disorder (the religious OCD). Sometimes, in therapy, through dialogue with the therapist, some of these misunderstandings can be corrected (in the same way that, for example, in contamination OCD, certain misunderstandings about some contagious diseases can be corrected). That is to say, in CBT, the therapist may provide information and advice to the patient, but always respecting his or her sensitivities, values, and beliefs. This approach strengthens the therapeutic alliance and lays the foundation for targeted psychoeducation, preventing the patient from feeling invalidated in their cultural and spiritual values.

The vicious cycle of OCD

It is important that the therapist does not become a mere "reassurance" by simply answering to the patient's obsessive questions. Instead, the therapist helps the patient to establishe a new relation to the fear, emphasizing that learning based on verbal rules (religious recommendations) is insufficient; it is the direct experience of exposure (facing feared situations) that truly produces change. The believing patient wants to be in situations related to his or her faith, but the psychological disorder prevents him or her from living and practicing this faith as wished. Through exposure, the therapist helps the patients, in a very concrete way, to reclaim the "religious space" that their OCD is trying to steal from them.

It is important to explain the vicious cycle of OCD (the function of compulsions and rituals in maintaining fear and anxiety; see the dedicated article on ERP). These rituals can be invocations or recitations of Quranic verses. For example, a patient might endlessly repeat Quranic verses each time an obsession arises, or imagine the image of Mecca while praying. These images, thoughts, or recitations function as compulsive behaviors (and thus reinforce OCD in the long term), even though they may also be part of a "normal" (non-obsessive) practice of Islam.

The vicious cycle of religious OCD can be explained to the patient in this way:

“You are performing rituals to dispel these doubts, banish these images, and lessen this fear of becoming a heretic; but in reality, this only provides temporary relief, and in the long term, you continue to suffer, and your daily functioning is disrupted. You are no longer acting in accordance with your values ​​and what truly matters to you. You are simply avoiding these images, these thoughts, your fears of the afterlife, of being rejected by God, of being punished on Judgment Day.”

Explaining the vicious cycle from this religious perspective allows us to initiate change by explaining the role of exposure and response prevention (ERP).

Imaginal ERP and exposure to obsessive doubt

One of the challenges faced in therapy is exposure to obscene or blasphemous ideas or mental images. Another challenge relates to doubt, such as: "God doesn't exist, what if the Quran is false, what if the Prophet was a liar...etc."

Faced with these two different types of content, the therapeutic approach must therefore be differentiated:

Obscene and blasphemous ideas or images

For a therapist, religious or not, it would not be truly ethical to ask the patient to say aloud or write down (as exposure) these obsessions, given that they pertain to what the patient considers as being sacred. Fortunately, in fact, there is no need to do direct exposure to these thoughts or mental images (through writing them down, voluntary vocalization, or visualization). The approach consists rather of exposing the patient to the triggering external situations (contexts, objects, places, interactions) that provoke the emergence of these obsessions, without ever asking them to voluntarily confront the blasphemous content itself (there is simply no need to do this, since the obsessions are automatically triggered in these external contexts). Sometimes, obscene images are not religiously considered blasphemous but rather a matter of moral preoccupation (religious obsessions often appear alongside sexual obsessions). In such cases, in addition to exposure to the triggering situations, one can recommend that the patient temporarily hold these images in mind and observe them as they arise, without suppressing them. In this way, the exposure mechanism is activated without offending the patient's faith.

For obsessions related to doubt

It is possible to invite the patient to write down their thoughts ("God doesn't exist, what if the Quran is false, what if the Prophet was a liar...etc."). Note that this writing must be done without reassurance, and that it is followed by exposure to uncertainty (do not try to "fix" anything).

The exposure hierarchy and prayer as a compulsion

Among the difficulties encountered in certain obsessions and compulsions focused on prayer is the application of the exposure hierarchy (see dedicated article). Repetition compulsions can involve Quranic verses, prayer as a whole, or certain of its components (bowing, prostration). The patient then finds themselves caught in cycles of repetition that lead them to spend long hours praying, sometimes to the point of abandoning prayer altogether. Following a hierarchical approach, one can begin by working on the prayer experienced as the least demanding, then gradually integrate the other prayers, according to an order established with the patient. This progression may raise a question for the patient: "Should I stop praying then? What about the other prayers?" For patients who no longer pray, the situation is relatively clear: a "lighter" prayer, without repetition, can be reintroduced as a starting point. However, for those who continue to practice, to respect the patient's faith, the therapist should not recommend stopping prayer. Instead, they can encourage the patient to "do what you can." The therapeutic approach, through gradual and hierarchical exposure, aims to enable the patient, over time, to perform all the prayers without becoming exhausted by compulsive repetition.

The power of values

We know that the therapeutic process is marked by "ups and downs," periods of relapse that often demotivate the patient on their path to recovery. In addition to the functional analysis of the "difficulties" and "obstacles" encountered during exposure exercises, the therapist can help the patient by reminding them that "the greater the challenge, the greater the reward." Reference can also be made to value-based therapeutic goals (see dedicated article), if this helps the patient commit to what truly matters to them (in this case, religous values).

The importance of certain religious contexts

Some contexts are often more complicated than others for the Muslim patient: for example, when virtuous seasons arrive, such as Ramadan or the first ten days of the Hajj pilgrimage, when believers dedicate more time to acts of worship. They fear that their acts of worship will be invalidated, and therefore they risk returning to compulsions and rituals, and are disappointed by the relapse. The therapist then explains, always within the framework of ERP, that these virtuous periods constitute a situation within the hierarchy of exposure, and that engaging in compulsions (such as repeating prayers) under the pretext that it is a virtuous period is a form of avoidance. ERP can then be addressed by reanalyzing difficult situations during these "virtuous periods" and reconstructing a new hierarchy of exposure.

Final remarks

In conclusion, exposure with response prevention (ERP) applied to Islamic religious OCD is not simply a mechanical and simplistic application of the ERP model. It requires the therapist to have a nuanced understanding of functional analysis and learning principles, while also taking into account the specificities of Islamic faith and practices. It is crucial that the therapist personalize the exposure exercises, never placing the patient in a situation where he or she might feel like transgressing what they consider sacred. This delicate articulation of an evidence-based psychotherapy respecting the patient's spirituality allows for the transformation of sometimes rigid beliefs into helpful therapeutic tools, strengthens the therapeutic alliance, and guides the patient toward a more peaceful religious practice, guided by their values ​​rather than compulsive avoidance.