The Man Who Couldn’t Stop (12 page)

Grit your teeth in the face of your thoughts and for God's sake be more obstinate, head strong and wilful than the most stubborn peasant or shrew. Indeed, be harder than an anvil … If necessary speak coarsely and disrespectfully like this: Dear devil, if you can't do better than that, kiss my toe.

‘Kiss my toe, OCD', that's what I should have said. But I wasn't ready. Not yet.

 

SEVEN

The God obsession

If almost everybody experiences intrusive thoughts, and intrusive thoughts are the raw materials for obsessions, then why does almost everybody not develop OCD?

The mind is a thought factory. Every day it processes a conveyor belt of thousands of thoughts, good and bad, happy and sad, useful and intrusive. The factory must decide how to act on them and then issue instructions to respond. We each do this differently, based on our unique combinations of early experience, environment and biology; our biases, preconceptions and knowledge. The thought factory must work fast. The conveyor belt always rolls and new thoughts arrive in a constant stream. Something always comes in and something always goes out.

Chemical engineers call a system like that a continuous process. It's the opposite of a batch system, in which they dump all the ingredients in a pot and leave them largely undisturbed to do their thing. Continuous processes are more efficient because you don't have to turn them off and start again to change the quality and the quantity of product. Turn up the temperature, increase the pressure, slow down the flow and you can tweak how the process converts the raw materials into something useful. Our thought factory does that too. In different circumstances, under pressure or stress, when we are tired or angry, we alter the way we process our thoughts.

The thought factory works pretty well. But it has a flaw. No chemical engineer would design a continuous system in which the inward flow of raw materials could not be turned off. That is a recipe for disaster. It can turn a minor problem into a full-scale catastrophe.

To understand OCD we must look at the conditions inside the thought factory, prising off the lid to see how two different minds can process the same thought in radically different ways. This was a task beyond the behavioural psychologists. In fact it was a concept that the behaviourists firmly rejected. They had no interest in what went on between the ears, only in how it showed itself as action. The mind was a black box and the thought processes inside, they claimed, unimportant.

It took until the 1980s for a new group of scientists, cognitive psychologists, to challenge that view. They argued that thoughts and how they were processed were crucial, not just to understand mental disorder but to treat it. They were ready to lift the lid on OCD. And when they did, one of the first places they looked for an answer was religion.

I'm an atheist but I have no specific axe to grind with religion. That's important to say because what follows could easily be construed as an attack. For the record, I'm not saying that religion is a mental illness, or that OCD and religious beliefs are the same thing. I'm not saying that OCD makes people religious, or that religion causes OCD.

Religion does not cause OCD, but, as we've seen, attempted suppression of intrusive thoughts probably does. Unrealistic demand for pure thoughts probably does. And to be told that if you think certain things then you will forever burn in Hell probably doesn't help.

*   *   *

In 2002, psychologists risked their eternal souls for science and deliberately misled dozens of Catholic friars and nuns, scattered across the convents and nunneries of northern Italy. The psychologists wrote to religious institutions and asked for volunteers to help with a study. The scientists wanted to look at the link between religious belief and obsessive symptoms, but they didn't admit that at first. They said only that they were interested in how people think. They kept the information intentionally vague, they said, to avoid a ‘defensive attitude' from the pious.

Dozens of the nuns and friars came forward to help and the scientists sent them questionnaires to assess their personalities and to judge how obsessive-compulsive they were. They repeated the exercise with two other groups: citizens actively involved in church activities, and university students who said they had no interest in religion. The psychologists found that the friars and the nuns, together with the regular churchgoers, were more likely to report thoughts and behaviours consistent with OCD.

OCD and religion have walked hand in hand through the centuries. The initial spiritual interpretation of obsessions and compulsive behaviours means that most early accounts of what would now be considered medical problems are set in a religious context. Plus, it was the clergy to whom most people turned with their concerns. Obsessive thoughts of sin – that one had committed a sin or that one was perpetually tempted to sin – have long plagued the devoted. As far back as the sixth century a Mount Sinai monk called John Climacus wrote of intrusive, blasphemous thoughts, which would invade an individual's mind against their will and which proved almost impossible to evict: ‘This deceiver, this destroyer of souls, has often caused men to go mad.'

By the fifteenth century, intrusive thoughts of sin were called ‘religious melancholy', or ‘scrupulosity'. The latter term was popularized by Antoninus, an archbishop of Florence. A scruple, he said, was a state of fear and indecision, which arose from mental questions that were impossible to answer and doubts that could never be settled. It comes from the Latin word
scrupulum
, which means a small sharp stone. The church compared the stubborn moral doubt of scrupulosity to the feeling of a pebble in your shoe. No matter how often you stopped to remove it, when you next took a step it was still there. Say what you like about medieval Italian religious leaders and their contribution to science, they knew a good analogy when they saw one.

One reason we can be confident that religion does not cause OCD is that obsessions and compulsions crop up with similar frequency in both secular and strictly religious countries. But, although the total number of people with OCD is unaffected by a country's religious leanings, the more religious a place, the more the clinical obsessions of these people centre on religious issues. Religion might not provoke obsessions, but it does provide an outlet for them.

Various studies over the last few decades display this trend. Just 5 per cent of OCD cases in England feature obsessions and compulsions that relate to religion, 10 per cent in the United States, 11 per cent in India and 7 per cent in both Singapore and Japan. Numbers shoot up in the Middle East: 60 per cent of people with OCD in Egypt report religious obsessions, 50 per cent in Saudi Arabia and Israel, and 40 per cent in Bahrain. In Turkey, a secular country with pockets of intense religiosity, the burden of religious OCD shadows the geographical influence of Muslim culture and increases as you travel from west to east.

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Psychologists who have studied this link between OCD and religion say it could come down to ways of thinking called dysfunctional beliefs. Most people have dysfunctional beliefs, which we usually pick up in childhood. They are not mental disorders, they are lenses placed across our cognition. They distort the way we perceive the world and can help explain why different people interpret identical situations in different ways. Some people are more likely than others, for example, to focus on the negative outcomes of their actions, and to exaggerate the way these outcomes damage themselves and others. That's a dysfunctional belief called catastrophizing. It makes people more likely to be anxious.

Psychologists have identified three types of dysfunctional belief important in the development of OCD. The first is an inflated sense of threat and personal responsibility. The second is perfectionism and intolerance of uncertainty. The third is a belief in the over-importance of thoughts and the need to control them. To be clear, to have one of these dysfunctional beliefs is not to have OCD, but it does increase the chance that someone will develop OCD, because they will then incorrectly process the intrusive thoughts that are common to most people. What's more, the strength of the dysfunctional belief – how hard people with OCD cling to it in the face of contrary evidence – might influence the degree of insight they have into their condition.

The different types of dysfunctional beliefs could explain the range of symptoms seen in OCD. Perfectionism could underpin a compulsive need for symmetry, while inflated responsibility and overestimation of threat could combine to promote checking obsessions about dirt and disease. And beliefs about the over-importance of thoughts – bad thoughts lead to bad deeds – could drive obsessive thoughts of dangerous or inappropriate behaviour.

Dysfunctional belief about the over-importance of thoughts is sometimes called thought-action fusion, because it implies to someone that a thought is the moral or the physical equivalent of an action. Thought-action fusion, for example, can make people believe that to ‘think' about having sex with someone – a married man or a child – is as bad as actually doing it. Does that sound familiar?

‘I say to you that everyone who looks on a woman to lust for her has already committed adultery in his heart.' According to the Gospel of Matthew, Jesus Christ says that to his followers during the Sermon on the Mount. It's a good description of thought-action fusion. Thoughts, in other words, are equivalent to actions. The tenth commandment goes further and forbids people to want (covet) property owned by somebody else. Just to think an impure thought is itself a sin.

Psychologists say that thought-action fusion could explain the way OCD shows itself among religious people. Some Christians, for instance, are often distressed to discover they can even conceive of sin. Their impure thoughts, they believe, must show they are not as devout as they hoped. Thought-action fusion makes these people believe that their thoughts – their thoughts alone − represent moral failure that makes them more likely to face God's punishment. These distressing sinful thoughts are, of course, ego-dystonic, they run contrary to the individual's faith. This makes the person more likely to try to suppress the thoughts, and so for the thoughts to return.

This link between religious belief and thought-action fusion can be tested. In 2012, psychologists asked dozens of senior figures in the Lutheran church how they would respond if one of their parishioners sought their help for scrupulosity. The scientists created a hypothetical worshipper, who they said was worried that she was going crazy because she could not get unwanted thoughts of cursing God out of her mind. She no longer read the scriptures, they said, because of the intrusive urges she felt to desecrate the pages. The thoughts caused her great anxiety and she prayed for up to eight hours a day for forgiveness.

Most of the spiritual leaders were sympathetic. They said they would reassure the woman that God was merciful and forgiving and that He understands the difference between involuntary and deliberately sinful thoughts. But significant numbers said they would also recommend action that, however well intentioned, we know (from the white bear effect of how suppressed thoughts return harder), would just make the situation worse.

They said they would tell the woman to pray harder, and attempt to replace her sinful ideas with more acceptable thoughts. Some said they would warn her that God expects purity in thought and deed, while a few would go as far as to point out that to think sinful thoughts risks God's punishment. The church elders who themselves showed the most signs of thought-action fusion were the most likely to offer this unhelpful advice.

There are different forms of OCD and so too, of course, are there different forms of religion. What's of interest to scientists is how the demands of each faith seem to influence the way obsessions and compulsions develop among the devout. Protestant Christianity places strong significance on thoughts: beliefs, intentions and motivations. Sure enough, studies of Protestant Christians show that the more religious they are, the more likely they are to report the signs of thought-action fusion. Islam puts great emphasis on ritual. Muslims are expected to wash in a set manner and perform repetitive prayer routines several times each day. Obsessive and intrusive thoughts that interfere with these are called
waswaas
, or whispers of Shaytaan. They can force people to doubt whether they performed prayers properly, and so make worshippers repeat, or start actions again. The Islamic text
Sahih al-Muslim
addresses intrusive doubts a Muslim may have about the number of performed prayers:

If any of you doubts during his prayer and he does not know how many he has prayed, whether it is three or four, then he should discard and cast away his doubt. He is to continue upon what one is sure of [the lesser] then perform two prostrations before making tasleem.

Scrupulosity in Catholic Christians often includes a mix of thoughts about impure beliefs – an urge to worship Satan – and behavioural doubts, such as obsessive thoughts they will drop the Eucharist in Communion. Contamination fears are common in religious OCD, but again, the specific nature of the contamination depends on the demands of the religion. Jewish people can develop OCD centred on thoughts that they cannot avoid non-kosher food.

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Religious or not, most people can hold several dysfunctional beliefs at the same time. Inside our thought factories, these various cognitive biases spin our thoughts in different directions to clash, collide and bounce off each other. If the combined effect is to make people more likely to react badly to an intrusive thought, then the result can be OCD.

Joan reacted badly to an intrusive thought. A 43-year-old, Joan had worked as a training officer with a large company in the south of England when a young man who worked under her was fired for misconduct. Joan already suffered from obsessions and compulsions. She had to retrace journeys to make sure she had not hurt anyone. Now, she started to think that she had telephoned the sacked man's parents, and told them about an embarrassing incident. She worried that the phone call would lead to him being severely punished, and that he would be driven to suicide. Joan was married with three children. She had made no such phone call. But the obsessive guilt she felt about it was so strong and so real that she tried to kill herself.