J Med Humanit (2010) 31:111125

DOI 10.1007/s10912-010-9107-3

The Doubting Disease: Religious Scrupulosity

and Obsessive-Compulsive Disorder in Historical Context

Paul Cefalu

Published online: 2 February 2010

# Springer Science+Business Media, LLC 2010

Abstract Psychologists and cultural historians typically have argued that early modern
theologians such as Martin Luther, John Bunyan, and Ignatius Loyola exhibited behavior
that the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) classifies as a
subtype of obsessive-compulsive disorder termed religious scrupulosity. This essay
argues that, although early modern theologians do manifest scrupulosity, such religiosity
was a culturally acceptable, even recommended component of spiritual progress, a
necessary means of receiving an unmerited bestowal of Gods grace. The larger aim of
the essay is to point out some of the limitations of current DSM criteria when attempting
retrospectively to diagnose historical figures with mental pathology.

Keywords Religious scrupulosity . Obsessive-compulsive disorder . Reformation theology .

John Bunyan . Martin Luther

In the popular imagination, at least, Martin Luther, the sixteenth-century German Reformer,
is more typically associated with bawdy outbursts and seeming obsessive behavior than fine
points of theology. Fond of comparing the devil to the hind parts, for example, Luther once
chastised himself by exclaiming, I am like ripe shit, and the world is a gigantic ass-hole.
We probably will leave each other soon.1 Drawing on the Freudian contention that anal-
retentiveness and a preoccupation with filth reflects a colorful spectrum of pathologies
ranging from improper toilet training to outright parental abuse, Luthers biographers have
often claimed that Luthers anal-fixation belies his obsessive-compulsive temperament. So
Luthers remark that the more you cleanse yourself, the dirtier you get is interpreted by
the intellectual historian Eric Erikson as a classic obsessive statement.2 Because Luther

1
Cited in E.H. Erikson, Young Man Luther: A Study in Psychoanalysis and History (W.W. Norton, 1962),
206.
2
Ibid., 61.
P. Cefalu (*)
Department of English, Lafayette College, Easton, PA 18042, USA
e-mail: cefalup@lafayette.edu
112 J Med Humanit (2010) 31:111125

suffered form severe anxiety and would often wake up in a cold sweat (one which Luther
described as the devils bath), Erikson concludes that Luther developed a phobia of the devil
which in the way of typical obsessive ambivalence gradually included the fear that the very
highest good, such as the shining image of Christ, might only be a devils temptation.3
Erikson wrote his psychobiography of Luther in the 1950s, well before obsessive-
compulsive disorder became the subject of intense medical and scholarly scrutiny. Yet
Luthers quirky nature has recently become newsworthy once again. Several of the recent
best-selling books on obsessive-compulsive disorder point not only to Luther but also to
other early modern theologiansnotably the English Puritan writer, John Bunyan and the
Spanish founder of the Jesuits, Ignatius Loyolaas exemplary obsessives. Judith Rapaport,
author of the influential study, The Boy Who Couldnt Stop Washing, remarks: Obsessive
doubts and impulses . . . plagued . . . Martin Luther. From 1517, when he first celebrated
mass, Luther worried greatly for fear he had carried out some trifling act of omission which
would be a sin. Blasphemous thoughts pressed in on him; he wanted to confess several
times each day.4 Ian Osborn, author of Tormenting Thoughts and Secret Rituals: The
Hidden Epidemic of Obsessive-Compulsive Disorder, claims that Luther endured
tormenting obsessional doubts and, to a lesser degree, other types of obsessions as well.
Religious doubts, a form of scruples, were indeed a common problem in past centuries.
They qualify as obsessions when they are persistent, tormenting, and recognized as
inappropriate.5
Perhaps the most detailed account of Luthers obsessiveness can be found in Norman O.
Browns Life Against Death: The Psychoanalytic Meaning of History. Brown concludes
that Luthers association of the devil with anal imagery is explainable in terms of Freuds
notion of the death instinct. Freud explained that obsessive behavior or the compulsion to
repeat could be seen as an ongoingly perverse and futile attempt to return to stasis or
death. What links Luthers obsessive anality to the death instinct is his abiding notion that,
because even Gods faithful are hopelessly corrupt and convicted of sin, temporal life
already marks a kind of spiritual death-in-life, which can only be escaped through
glorification in the afterlife. The supposed causal nexus among Luthers anality, obsessive-
ness, and tendency toward the death instinct is muddled in Browns account, but the basic
idea is that, since anality usually signals an obsessional temperament and tendency to repeat,
which itself is a manifestation of the death instinct, Luthers obsessiveness implies his belief
that only death proper could release him from the sway of the devil.6
Luther, however, is not the only early modern theologian who has been labeled by
contemporary psychologists as, historically speaking, precociously obsessive. Osborn also
claims that the seventeenth-century English Puritan writer, John Bunyan (most famous for
his spiritual allegory Pilgrims Progress) had clear-cut, moderate to severe OCD; his case
is our best historical example of the illness.7 Basing his claims on selections from
Bunyans conversion narrative, Grace Abounding to the Chief of Sinners, at which I will
look in some detail, Osborn continues that, while most of Bunyans obsessions were of
blasphemy, or the fear thereof, he endured perhaps murderous or sexual obsessions. He

3
Ibid., 148.
4
J. Rapaport, The Boy Who Couldnt Stop Washing: The Experience and Treatment of Obsessive-Compulsive
Disorder (New York: Penguin, 1989), 263.
5
I. Osborn, Tormenting Thoughts and Secret Rituals: The Hidden Epidemic of Obsessive-Compulsive
Disorder (New York: Random House, 1999), 58.
6
See N.O. Brown, Life Against Death: The Psychoanalytic Meaning of History (New York: Random House,
1959), chapter xiv, passim.
7
Ibid., 53.
J Med Humanit (2010) 31:111125 113

concludes that Bunyan showed the insight of a true obsessional. He knew his worries were
irrational; he just couldnt stop thinking them.8 Osborn legitimates such claims by citing
William Jamess passing comment in The Varieties of Religious Experience that Bunyan
had a sensitive conscience to a diseased degree, beset by doubts, fears, and insistent
ideas.9
Similarly, in The Doubting Disease: Help for Scrupulosity and Religious Compulsions,
Joseph Ciarrocchi writes that Bunyans Grace Abounding illustrates all the major symptoms of
OCD: scrupulous obsessions with undoing compulsions . . . the need to resist, the pervasive
nature of the obsessions, the resultant anxiety and depression, the notion that some thoughts
are dangerous, and the insidious nature of the obsessions which defy logic or the persons
own value system.10 Finally, Rapaport devotes an entire section of her book to Bunyan,
noting that Grace Abounding provides an incomparably vivid account of his obsessive
disorder, particularly relating to his persistent concern with having blasphemous thoughts.11
For Osborne, Rapaport, Ciarocchi, and others, early modern theologians exhibit a
particular subtype of OCD, what has come to be known as religious scrupulosity.
Scrupulosity manifests as an inordinate concern with having troublesome blasphemous or
sacrilegious thoughts, as well as an excessive preoccupation with moral rectitude.
Psychiatrist David Greenberg provides four principles for distinguishing normal from
pathological religious scruples:
1) Compulsive behavior that goes beyond the requirements of religious law. Such as
practices that are more Catholic than the Pope. If rules of fasting call for no food or
drink, scruples can transmute into obsessions about not swallowing saliva.
2) Compulsive behavior that has a narrow focus. Persons may direct their attention to one
aspect of religious experience but exclude others such as, spending all their energy
avoiding sexual misconduct.
3) Compulsive behavior that often focuses on what is trivial to religious practice. A
person may worry about allowing holy water to fall on the floor when making the sign
of the cross upon entering the church.
4) Scruples that tend to misconstrue biblical maxims as laws. For example, Matthew 5:30
decrees that if your right hand causes you to sin, cut it off and throw it away, a
maxim that can clearly become perilous if taken too literally.12
A related problem is that the scrupulous person cannot make extrapolations from
overriding maxims to particular, context-sensitive circumstances. General guidelines such
as Love your neighbor as yourself would understandably send the pathologically
scrupulous among us into a frenzy. One theologian gives an example of a man named John
who worked in a government agency employing thousands of workers. He convinced
himself that loving ones neighbor meant that he was obligated to greet with a good
morning or nod of his head every single worker whom he passed. This became a tall order
indeed when he might pass hundreds of persons any time he stepped out of his office. If he
missed greeting someone, he felt an impulse (and sometimes acted on it) to circle the
corridor to catch up with and greet the slighted person.13

8
Ibid., 55.
9
Ibid., 53.
10
J.W. Ciarrocci, The Doubting Disease: Help For Scrupulosity and Religious Compulsions (Paulist Press,
1995), 39.
11
Rapoport, The Boy Who Couldnt Stop Washing, 262.
12
Cited in Ciarrocchi, The Doubting Disease, 51.
13
Ibid., 119.
114 J Med Humanit (2010) 31:111125

Religious scrupulosity might seem like a rare subspecies of OCD, a disorder that might
have beset medieval and early modern sacred, rather than post-Enlightenment cultures.
However, Jennifer Traigs recently published memoir, Devil in the Details: Scenes from an
Obsessive Girlhood, details, often in hilarious terms, her experience of growing up with a
severe form of religious scrupulosity, focused in particular on her inability to meet her own
skewed perception of the stringent requirements of Jewish law. I cite Traig at length, since
her account is unrivalled in contemporary literature on the subject:
If you happen to be both compulsive and Jewish, youre in for the ride of your life.
The Jewish scrupulous experience is extraordinarily rich. Sure, Christians have that
snappy What would Jesus do catchphrase to govern their ruminations and inspire
new ones, but Jews have an endless supply of minute laws. They have the devil; we
have the details. Scrupulous Christians have only the Bible for crazy source materials.
Jews have the Talmud, the Code of Ethics, and a host of other texts, all chock-full of
obsessive minutiae legislating matters as esoteric as the cleanliness of hairnets. There
are 613 commandments, which is enough to keep even the most industrious
compulsive busy all day long. Every movement and moment is regulated, from the
morning prayer to the bedtime Shema. The order in which you put on your shoes, the
order in which you tie them, the way in which you wash and dress and eat and
speakall these things are prescribed in exacting detail. Almost every activity
requires a blessing before and after. Theres even a blessing for using the bathroom,
which, considering the binding capacities of traditional Jewish cuisine, is totally
understandable. . . .[These rules were just] so hard to follow. There were so many
laws, and they were so weird. The Old Testament sex laws alone. My high school
was full of harlots. Was I required to stone them? And what was I required to do with
this: And whoever sits on anything on which he who has the discharge has sat shall
wash his clothes, and bathe himself in water, and be unclean until the evening.
Suddenly I would have to determine who had sat at my desk before me, and whether
or not he had had the discharge recently. Great. That was just what I wanted to spend
my time thinking about. The Levitical regulations regarding bodily fluids are a rich
vein indeed, and they troubled me greatly. Because I couldnt be sure what was
issuing forth from people in the privacy of their pants, I regarded everyone past
puberty as ritually impure.14
Traigs account illustrates the fundamental difference between her experience with a
clinical form of religious scrupulosity and the rather common form of excessive, what I
describe as non-pathological, religiosity experienced by many of the most prominent early
modern theologians. One notable difference is that, while Traig is careful to relate her
scrupulosity both to her immediate family setting and wider social context, psychologists
tend, when describing the scrupulosity of early modern theologians, to generalize from
selected excerpts of treatises and conversion narratives without situating such passages in
the larger literary, historical, and above all, theological contexts in which these authors
wrote.
I would argue that there is something amiss and deeply ahistorical in projecting twenty-
first century criteria for obsessiveness onto early modern theologians. For those of us who
spend time trying to unravel the intricacies of the sixteenth-century Protestant scheme of
salvation and Saint Pauls knotty notion of justification by faith, such attributions seem

14
J. Traig, Devil in the Details: Scenes from an Obsessive Girlhood (New York: Little, Brown and Company,
2004), 3564.
J Med Humanit (2010) 31:111125 115

especially reductionistic. My main argument, which I will elaborate momentarily, is, I

believe, straightforward: early modern Reformed theologians do evidence obsessive
religiosity, but, to the extent that such religiosity is considered to be an integral stage in
the Protestant order of salvation and meaningful to the conversion experience, it should not
be conflated with the clinical form of OCD that psychologists term religious scrupulosity
proper. As we can see from Traigs account, the clinical variant more often involves
senseless, irrational obsessions and compulsions, those that hamper rather than facilitate
spiritual progress.
We will see, then, that early modern theologians are indeed obsessed with their
salvation, but what separates their non-clinical or non-pathological religiosity from the
clinical form of religious scrupulosity is that early modern scrupulosity is fitted into a larger
life-narrative, a necessary means to a spiritual end. We will also see that in early modern
spiritual autobiographies, the Protestant order of salvation serves, somewhat paradoxically,
as both the cause and resolution of obsessive religiosity in its non-pathological incarnation.
However, before rescuing those sixteenth-and seventeenth-century theologians from an
obsessive-compulsive labeling phenomenon among psychotherapists, I will summarize in
some detail the nature of the early modern order of salvation, especially according to the
Reformed or Protestant variant.

Protestant scrupulosity: An historical case study

The fundamental sixteenth-century, Reformed critique of Catholicism is that Catholics too

readily believe that the commission of good works (for example, devotional worship,
prayer, receiving the sacraments, and giving alms) can improve ones prospects for
salvation. Following Saint Pauls epistles, Protestants argue that only through justification
by faith can salvation be achieved. Justification is a forensic term signifying that certain
sinners have been relieved of their sinful status by Christs sacrifice and passion. While
different Protestant denominations split hairs over the precise meaning of faith as such,
there is consensus that faith involves both a cognitive understanding and acknowledgement
of Christs intervention and an affective embrace of Christ and God, usually described as
agapeistic love, or top down love from God to the sinner. The important point is that,
according to the Reformed point of view, Catholics believe in active righteousness, while
Protestants believe in passive righteousness. Where or at what point, then, do good works
enter into the Protestant order of salvation? While the caricatured view is that good works
are unimportant or extraneous to Protestant salvation, the official view, articulated most
clearly by Luther, Calvin, and English Puritans like William Perkins, Bunyan, and others, is
that good works necessarily follow from grace rather than precede it. Good works serve as a
manifestation of grace already received rather than a meritorious means of achieving it.
What are the implications of this fundamental distinction between Catholic works-
righteousness and Protestant notions of justification for the clinical forms of religious
scrupulosity? We should perhaps first note, recalling Traigs account of her scrupulosity,
that the Catholic experience of scrupulosity bears some kinship to Jewish scrupulosity. Just
as a Jewish religionist might ruminate over meeting the rigorous demands of moral law and
the Decalogue commandments, so a Catholic penitent might overly preoccupy herself with
works-righteousness. As we have seen, pathological scrupulosity can set in when the
believer becomes too preoccupied with parsing the ambiguities of bare commands and
laws, those that do not prescribe conduct in difficult cases. Regarding this manifestation of
scrupulosity, in particular, we should perhaps have some sympathy: Can most readers claim
116 J Med Humanit (2010) 31:111125

with confidence to know exactly what Augustine means when he baldly pronounces, for
example, Love and do what you will?
The Protestant experience of salvation, however, significantly diverges from the Catholic
and Jewish. Protestants come to learn through trial and error that they cannot ever meet the
rigorous demands of natural and divine law. In fact, the moral law functions not as
something to be upheld but rather to remind the penitent of his constitutional weakness and
to further convict him of sin. Some form of scrupulosity would inevitably set in, since the
experience of momentarily convincing yourself that youve acted properly only to be
reminded that you havent or that you cant sustain what propriety you have achieved,
would make you hypervigilant about maintaining whatever feeble, ultimately illusory
spiritual progress that you believe you have made.
Moreover, most English Puritan writers follow Martin Luther in assuming that no
convert is able to achieve full sanctification or moral regeneration during creaturely
existence; that is, every convert will backslide and experience an ongoing battle between
his old man (Adam) and his new man (Christ). In one of his most influential treatises, Two
Kinds of Righteousness, Luther describes justification as not merely passive righteousness
but alien righteousness: This alien righteousness, instilled in us without our works by
grace alonewhile the Father, to be sure, inwardly draws us to Christis set opposite
original sin, likewise alien, which we acquire without our works by birth alone. Christ (the
new man) daily drives out the old Adam more and more in accordance with the extent to
which faith and knowledge of Christ grow .15 Luthers sense that every convert contains a
residually sinful old man, or old Adam, and the new man in Christ is one of the hallmarks
of his theology. The two are related, we might say, in a hydraulic manner: the old man of
flesh and sin will lose its hold in proportion to the new mans gaining its force. As such,
Luther maintained that every convert should be simultaneously considered a sinner and one
who is saved. It is fitting, in this context, that one of the most frequently invoked Biblical
passages by Reformed theologians is found in the Book of Jeremiah, verse 13:23: Can the
Ethiopian change his skins, or the Leopard his spots? Then you may also do good who are
accustomed to evil. The implied answer is, of course, nonot without divine aid. When
Luther writes, therefore, that the more you cleanse yourself, the dirtier you get, he is
making a comment that, as we can see, can be extrapolated from a literal interpretation of
scripture, the kind of literalism for which Reformed zealots like Luther and Bunyan after
him were well known. But in order to make clear that early modern religiosity should not
be described as examples of early modern OCD, I would like to turn to the more complex
case of John Bunyan.

John Bunyans Grace Abounding

Who is John Bunyan, and why are psychotherapists saying such unfounded things about
him? Bunyan is a late seventeenth-century Puritan or nonconformist writer who lived from
16281688 and is famous for his Christian allegory, The Pilgrims Progress, first published
in 1688, even though his spiritual autobiography, Grace Abounding to the Chief of All
Sinners, published in 1666, is the more intriguing of his writings. As a way of reconsidering
the question of the relationship, if any, between early modern, Reformed theology and
OCD, I would like to look in some detail at Bunyans Grace Abounding. Bunyans spiritual
progress can be divided up into three discrete stages: a first stage, in which the sinner,

15
Martin Luther: Selections from his Writings, trans. J. Dillinbeger (Garden City: Doubleday, 1961), 89.
J Med Humanit (2010) 31:111125 117

following Augustine, recognizes his and all fallen individuals tendency to sin habitually; a
second stage, in which the individual mistakenly relies too heavily on scriptural doctrine,
particularly moral laws, as a hopeful, but ultimately ineffective and hypocritical means of
overcoming habitual sin; and a third stage, in which the sinner comes to understand that
only an abdication of creaturely willfulness to impel ones salvation can prepare the
individual to receive transformative bestowals of divine grace. We will see that this third
stage is, counterintuitively, achievable through the very means of non-pathological
obsessive religiosity; simply put, the sinner needs to be trained to realize that even his
most obsessive righteous habits will fail to motivate his salvation without an imputation of
grace by God.
The first stage is quite evident in the following passage: These suggestions (with many
other, which at this time I may not, nor dare utter, neither by word or pen) did make such a
seizure upon my spirit, and did so overweigh my heart, both with their number,
continuance, and fiery force, that I felt as if there were nothing else but these from
morning to night within me, and as though indeed there could be room for nothing else; and
also concluded, that God had, in very wrath to my Soul, given me up to them, to be carried
away with them, as with a mighty whirl-wind.16 This is the sort of habitual sinning that so
overtakes Bunyan he seems to have relinquished all subjective agency to the repetitive
nature of both sinful intentions and actions. Bunyans complaint here is reminiscent of a
long tradition, beginning with Saint Augustine and extending throughout the seventeenth
century, of imagining that a habit of sinning can become so hardened as to become
ineradicable. In his prototypical spiritual autobiography, The Confessions, Augustine
describes the force of habit as a nearly permanent addiction: My enemy held my will in his
power and from it he had made a chain and shackled me. For my will was perverse and lust
had grown from it, and when I gave in to lust habit was born, and when I did not resist habit
it became a necessity.17
If we return to Bunyan, we can mark a second stage in his conversion narrative, in which
the sinner falsely believes that satisfying moral lawfor example, the Ten Commandments
and Golden Rulewill effect his salvation. This is clearly represented in the most famous
passage in Bunyans autobiography Grace Abounding, one which nearly all modern
commentators point to as exemplifying his clinical obsessiveness, namely Bunyans
recounting of his fear that bells from a steeple he frequented would fall on him:
Now you must know, that before this, I had taken much delight in ringing; but my
Conscience beginning to be tender, I thought such practice was but vain, and
therefore forced myself to leave it, yet my mind hankered; wherefore I should go to
the Steeple-house, and look on, though I durst not ring: But I thought this did not
become Religion neither, yet I forced myself, and would look on still: But quickly
after, I began to think, How if one of the Bells should fall? Then I chose to stand
under a main Beam, that lay overthwart the Steeple, from side to side, thinking there I
might stand sure. But then I should think again, Should the Bell fall with a swing, it
might first hit the wall, and then rebounding upon me, might kill me, for all this
Beam: This made me stand in the Steeple door; and now, thought I, I am safe enough,
for if a Bell should then fall, I can slip out behind these thick walls, and so be
preserved notwithstanding. So after this, I would yet go to see them ring, but would
not go further than the Steeple-door; but then it came into my head, How if the
16
J. Bunyan, Grace Abounding and The Pilgrims Progress, ed., J. Brown (Cambridge: Cambridge
University Press, 1907), 33.
17
St. Augustine, Confessions, trans. R.S. Pine-Coffin (London: Penguin, 1961), 164.
118 J Med Humanit (2010) 31:111125

Steeple itself should fall? and this thought (It may fall for ought I know) when I stood
and looked on, did continually so shake my mind, that I durst not stand at the Steeple-
door any longer, but was forced to flee, for fear the Steeple should fall upon my
head.18
Registering both his sense that he should not return to the steeple and a strong
countermanding desire to do so, Bunyan capitulates in this passage to what he perceives to
be untoward desires to frequent the steeple because, as he states immediately before this
passage, he has both made significant spiritual progress elsewhere in his life by upholding
the Commandments. He therefore reasons that, since he has impressed himself and his
neighbors with his saintliness, he can afford to indulge some otherwise questionable, even
base desires:
Wherefore I fell to some outward Reformation, both in my words and life, and did set
the Commandments before me for my way to Heaven; which Commandments I also
did strive to keep, and, as I thought, did keep them pretty well sometimes, and then I
should have comfort. . . . My neighbours were amazed at this my great Conversion,
from prodigious prophaneness, to something like a moral life. They began to praise,
to commend, and speak well of me . . . . Now I was become a right honest man. But
when I understood that these were their words and opinions of me, it pleased me
mighty well: For though as yet I was nothing but a poor painted Hypocrite, yet I
loved to be talked of, as one that was truly Godly.19
This passage immediately precedes the account of the steeple and should be read in
conjunction with the framing passage that immediately follows that account. Bunyan
writes: But, poor wretch as I was, I was all this while ignorant of Jesus Christ, and going
about to establish my own Righteousness; and had perished therein, had not God, in mercy,
showed me more of my state by nature.20 Bunyans move here is typical of seventeenth-
century Puritan conversion narratives. He records an initial conversion to legalism, in which
he preens himself on his exceptional ability to obey moral law; he then realizes his self-
righteousness and hypocrisy (neither sinner nor saint can truly uphold Gods laws),
chastises himself and acknowledges the need for divine assistance and an imputation of
grace. It is the moment one finds in nearly all Puritan conversion narratives in which Old
Testament morality is displaced by justification by faith, or more generally, when the Old
Covenant gives way to the New.
The Steeple episode thus ought to be read as a stylized and allegorical account of
Bunyans awareness of the extent to which, upon the heels of his false conversion, he
erroneously believes that he can unilaterally govern his own salvation. The account
represents Bunyans vacillation between trying to convince himself that it is fine to indulge
his desire (after all, he mistakenly believes at this point that he has been converted and has
shown his goodness elsewhere), and his conscientious sense that there is something
untoward and un-Christian in such an indulgence. What is interesting about the description
is the way in which Bunyan continues to revise his strategy for visiting the Steeple by
attempting essentially to hide from the physical structure itself. This strategy is, of course,
unavailing because every seemingly safe vantage point turns out to be as potentially
dangerous as every other, as if the Steeple miraculously follows Bunyan wherever he takes
cover. It is not much of an imaginative leap to assume that, at some level, the Steeple itself
18
Bunyan, Grace Abounding, 15.
19
Bunyan, Grace Abounding, 15.
20
Ibid., 16.
J Med Humanit (2010) 31:111125 119

stands in for God, whose all-seeing power to ferret out sin can never quite be eluded and
whose wrath always threatens to descend on the unregenerate of which Bunyan is painfully
aware at this point in his narrative.
The final stage recorded in Grace Abounding is the most interesting for our purposes.
Bunyans conversion occurs not because of his persistence in keeping scriptural doctrine
uppermost in his mind; but occurs when he realizes that no amount of scrupulosity will conduce
to his salvation. As all Protestants eventually learn, overweening moral righteousness, often
construed as the performance of good works, will not change their status in Gods eyes;
salvation occurs, rather, at the moment that God somewhat arbitrarily decides that they are
saved, precisely what Bunyan realizes just prior to his final conversion:
Now was I as one awakened out of some troublesome sleep and dream, as if I heard
this sentence expounded to me by God, Sinner, thou thinkest that because of they
Sins and Infirmities, I cannot save thy soul; but behold, my Son is by me, and upon
him I look, and not on thee, and deal with thee according as I am pleased with him.
At this I was greatly lightened in my Mind, and made to understand that God could
justify a sinner at any time, it was but his looking upon Christ, and imputing of his
benefits to us, and the work was forthwith done. And as I was thus in a muse, that
Scripture also came with great power upon my Spirit, Not by works of
Righteousness that we have done, but according to his Mercy he hath saved us.21
Convincing yourself that you are an obsessive sinner is the surest means of realizing that
God doesnt consider the magnitude of your sinning when he deigns to act mercifully. God
saves you precisely when you have convinced yourself that you are beyond saving. This
realization is eventually capped by another, equally fateful moment when an awareness of
the meaning and force of scripture comes unbidden in Bunyans mind, as if an affective
conversion seals the purely cognitive conversion exemplified in the preceding passage:
After I had been in this condition some three or four days, as I was sitting by the fire,
I suddenly felt this Word to sound in my Heart, I must go to Jesus; at this my former
darkness and Atheism fled away, and the blessed things of Heaven were set within
my view. While I was on this sudden overtaken with surprize; Wife, said I, is there
ever such a scripture, I must go to Jesus? She said she could not tell; therefore I sat
musing to see if I could remember such a place; I had not sat above 2 or 3 min, but
that came bolting in upon me, And to an innumerable Company of Angels; and
withal, Hebrews the twelfth, about the Mount Sion was set before mine Eyes.22
Bunyan does not apply scripture in a lawlike way to his life; scripture rather applies itself to
him as a means to suspend not his habitual sinning but, paradoxically, his habitual goodness, or
at least the seemingly endless exchange and circulation of good and bad habits. It is reductive to
argue that Bunyan has been liberated from both pathological obsessive sinning and
scrupulosity; it is rather correct to say that, in order to find salvation, he needs to relinquish
subjective agency, and in order to relinquish subjective agency, he needs to realize the
ineffectiveness of scrupulosity to attain his election. Scrupulosity is the positive condition of its
own negation and eventual supercession.
Perhaps this can be made clearer through the following thought-experiment. If one asked
David Sedaris, now a prolific, middle-aged best-selling writer, whether his adolescent
obsession with licking banisters and slavishly arranging kitchen appliances, as recounted in

21
Ibid., 79.
22
Ibid., 81.
120 J Med Humanit (2010) 31:111125

Naked, had some positive impact on his career as a writer, or, more generally, whether he
regards his youthful obsessive phase as somehow meaningful or integral to his life, he
would most likely respond with a resounding, No!.23 If one asked a sixteenth- or
seventeenth-century theologian, however, if obsessive religiosity can be fitted into his or
her larger life-narrative, the answer would probably be something like, Yes, thank God for
my obsessiveness. This is not to say that such early modern theologians saw their
obsessiveness as worthwhile only after the fact; most embarked on their spiritual sojourns
knowing in advance that a degree of obsessive religiosity was a constituent of the Protestant
order of salvation.
Compare the retrospective ascription of OCD to seventeenth-century theologians to the
much different claim made by psychologists that several influential artists manifested
symptoms of depression or bipolar disorder. In Touched with Fire: Manic-Depressive
Illness and the Artistic Temperament, Kay Jamison provides a detailed cultural and
historical account of manic-depressive illness and suggests that Hector Berlioz, Gerard
Manley Hopkins, Emily Dickinson, Hart Crane, Sylvia Plath, and many other artists
suffered from some version of the disorder. Nearly all of these writers offered memoiristic
glimpses into not only the unique phenomenology of the disorder but also the extent to
which the evils of the disorder often impeded their artistic processes and completion of their
goals. In an 1885 letter written just before his death, Hopkins complained that his
depressive moods were paralyzing: The melancholy I have all my life been subject to has
become of late years not indeed more intense in its fits but rather more distributed, constant,
and crippling . . . .24 Similarly, Berlioz complains in his memoirs that his bouts with
depression count among the most terrible of all the evils of existence, and he underscores
the crippling effects of the disease: I Had stopped composing; my mind seemed to become
feebler as my feelings grew more intense. I did nothing. One power was left meto
suffer.25 These first-person remarks differ in important ways from the comments made by
seventeenth-century theologians regarding the latter groups religiosity. Hopkins and
Berliozs experiences with mental illness interrupts rather than is of a piece with their work
and livelihoods (testimonials that, one might add, help to undermine the myth according to
which great artists achieve their most inspired work while under such pathological spells).
In no sense is depression or even mania conducive to their artistic ends, nor do the disorders
seem to serve larger cultural ideologies or to be unusually prevalent in their local cultural
contextsas is the case with early modern religious scrupulosity.

Cognitive therapy and scrupulosity

Bearing in mind, then, the functional and adaptive nature of Puritan scrupulosity, we can
briefly consider religious scrupulosity in relation to some of the basic tenets of cognitive
therapy, a brief history of which will be helpful. In 1966 Victor Meyer, a psychologist at
Middelsex Hospital in London, established the first effective behavioral therapy for OCD,

23
See D. Sedaris, Naked (New York: Little, Brown and Company, 1997), in which Sedaris remarks: My
bedroom was right there off the hallway, but first I had business to tend to. After kissing the fourth, eighth
and twelfth carpeted stair, I wiped the cat hair off my lips and proceeded to the kitchen, where I was
commanded to stroke the burners of the stove, press my nose against the refrigerator door, and arrange the
percolator, toaster, and blender into a straight row (10).
24
Cited in K.R. Jamison, Touched with Fire: Manic-Depressive Illness and the Artistic Temperament (New
York: The Free Press, 1993), 25.
25
Ibid., 19.
J Med Humanit (2010) 31:111125 121

exposure and response therapy. ERP consists of exposing patients to the trigger that calls
forth obsessional thoughts and then preventing them from engaging in compulsions that
might otherwise relieve the subsequent distress. Meyer would tell a patient to leave her
house, for instance, but prevent her from returning to check whether she had left the stove
on. Or he would have her touch all the doorknobs in a public building but not allow her to
wash her hands afterward. Without too much reflection, one can discern some of the
limitations of classical conditioning strategies for eradicating OCD. Too much trauma may
be involved in coercing patients from performing compulsions to allay obsessions, and,
more generally, classical conditioning tends to demote the cognitive abilities that patients
have to help themselves overcome OCD.
In the 1970s, behavioral therapy was seen as too reductionistic, and, through the
pioneering work of psychologist Aaron Beck and others became coupled with cognitive
therapy for overcoming refractory obsessions and compulsions.26 One of the goals of
cognitive therapy is to convince the sufferer of OCD that he or she harbors erroneous and
maladaptive beliefs. Cognitive-behavioral therapy is still considered the treatment option of
choice as adjunctive therapy to otherwise effective pharmacological treatment. For example
in their best-selling book, Stop Obsessing: How to Overcome Obsessions and Compulsions,
clinical psychologists Edna Foa and Reid Wilson, suggest that patients can help themselves
alleviate obsessions and compulsions by 1) postponing the obsession; and 2) changing the
manner in which one obsesses by altering the picture or image associated with recurring
ideation. Postponement strategy is self-explanatory, the idea being that one should make a
commitment to pay meticulous attention to ones worries, but simply take control of
precisely when the worrying is undertaken. The goal of such a technique is to stall a
particular obsession so that, at a later time, its overwhelming force might seem mitigated.
The second strategy involves reminding oneself that it is okay to have momentary
obsessions, but changing ones emotional response to the obsession by taking specific
actions: for example, writing down the obsessions, on the assumption that writing out
unwanted, recurrent ideas will make clear to the patient the repetitive and senseless nature
of such ideas. As for changing the mental image of an obsession, the authors even suggest
that patients should mentally animate their obsessions in order to defuse them. As they
write: Another useful approach is to replay the obsessional image but change the
distorting, frightening components in some cartoonlike fashion. For example, if you are
intimidated by your bosss criticism, see her about two feet tall and yourself next to her as
your normal size. When she attempts to yell at you, see bubbles coming out of her mouth
instead of words.27
Finally, Foa and Reid recommend listening to a loop tape of ones obsessions. Loop
tapes vary in length from ten seconds to 3 min and are typically used to record outgoing
messages on a telephone answering machine. When the tape is left running, it will play the
same message continuously. The authors write: To practice this technique, write down the
sentence or narrative exactly as it comes spontaneously into your mind. Then record it on
an appropriate length of loop tape. Listen to the tape for 45 min or longer each day. While
listening to the tape, try to become as distressed as possible. Use the tape daily until the

26
The foundational study of cognitive therapy is A.T. Beck, Cognitive Therapy and the Emotional Disorders
(New York: New American Library, 1976); see also D.D. Burns, Feeling Good: The New Mood Therapy
(New York: Morrow, 1980), for an early study of cognitive therapy in relation to a spectrum of psychological
disorders.
27
E.B. Foa and R. Wilson, Stop Obsessing: How to Overcome Your Obsessions and Compulsions (New
York: Bantam Books, 1991), 79.
122 J Med Humanit (2010) 31:111125

content of the message no longer distresses you.28 This last method apparently works,
much as pure behavioral therapy does, on the principle that habituation to distress relieves
it. Foa and Wilson explain that, since many OCD sufferers hold onto the idea that having a
bad thought is the same as actually acting on such a thought, patients should learn that they
can indulge their fearsome thoughts with impunity. For example, the new mother who has
the repeated thought, I may drop my baby, feels that she actually is dropping her baby. By
repeatedly imagining dropping her baby, she comes to realize that her thoughts do not have
the consequences of actually harming her newborn. I will return later to the authors
conclusion that obsessives collapse distinctions between having bad thoughts and acting on
bad thoughts, since it is precisely this sort of conflation of thinking and doing that early
modern, Reformed theology encourages rather than discourages.
As might be expected, theologians and psychotherapists have appropriated some of the
current strategies outlined by cognitive-behavioral therapy in their treatment of religious
scrupulosity as described by Traig. For example, one recently published self-help manual
ominously entitled, A Thousand Frightening Fantasies, suggests that those who say prayers
over and over again should deliberately insert a mistake into the prayer; this way the
prayer would be considered imperfect but still acceptable.29 Foa and Reid themselves note
that since many people are afraid of Satan, and become obsessed with their religious
backsliding into sin, a good form of aversive conditioning is to have them watch a film like,
The Exorcist.30
Consider the principles of cognitive-behavioral therapy in relation to a recent, influential
self-help program that is outlined Jeffrey Schwartzs book entitled, The Mind and the
Brain: Neuroplasticity and the Power of Mental Force. Building on the foundational work
of Foa and Wilson, Schwartz has established a four-step plan to overcome obsessions.
Basing his regimen on what he describes as structured introspection and the Buddhist
concept of mindfulness, Schwartz argues that patients should 1) relabel their symptoms as
false signals, symptoms of a brain disease and not weakness of will; 2) reattribute such
symptoms to pathological brain circuitry (which would seem to involve, minimally, some
detailed knowledge of the ways in which the basal ganglia go awry during bouts with OCD; 3)
refocus obsessive urges onto more constructive behavior; and 4) revalue obsessive symptoms,
acknowledging once and for all that they have no intrinsic value or power.31 Schwartz
documents hundreds of cases in which his four-step method has significantly improved the
quality of life of those obsessives who, in particular, have not improved with pharmacological
treatment.
As another instructive thought-experiment, we can imagine that such therapies, if
applied to John Bunyans conversion experience, would seriously hamper rather than guide
his spiritual pilgrimage. True, in Schwartzs terms, Bunyan learns both 1) to relabel and 2)
to reattribute his tendency toward sin as sourced outside of himself. Rather than say, It is
not me, it is my brain chemistry, he would say, It is not me, it is the devil. This is not to
suggest that Bunyan displaces blame and evil onto an external source, as a Manichaean
dualist would; it is just to say that he recognizes that he has inherited, as do all sinners, the
taint of original sin.

28
Ibid., 88.
29
W. Van Ornun, A Thousand Frightening Fantasies: Understanding and Healing Scrup-ulosity and
Obsessive-Compulsive Disorder (Eugene: Wipf and Stock Publishers, 1997), 132.
30
Foa and Reid, Stop Obsessing, 133.
31
J.M. Schwartz and S. Begley, The Mind and The Brain: Neuroplasticity and the Power of Mental Force
(New York: Harper Collins, 2002), 14.
J Med Humanit (2010) 31:111125 123

Now the third step, refocusing, would involve Bunyans redirecting his habitual sinning
toward more acceptable pursuits; for example, we have seen that such refocusing entails an
intense study and application of scripture. This tendency to refocus, however, brings with it
a form of religiosity that structurally analogizes his habitual sinning; after refocusing,
Bunyan simply ranges scrupulous devotion against refractory sinning. The crucial point is
that the mistake would be to assume, as cognitive-behavioral therapies might, that the last
step, revaluing, should convince the patient that his scrupulosity is not of intrinsic value,
that it is pointless and irrational, to return to Schwartzs nomenclature. Instead, Bunyan
acknowledges that his excessive devotion involves both learning moral law and scripture,
and then learning that neither is sufficient in and of itself to grant him salvation. This is a
modification of the Socratic doctrine of learned ignorance: one needs scripture to teach the
Protestant sinner that the all-sufficiency of obedience to moral law and the commission of
works are Popish illusions.

OCD in history

What is the bigger picture here regarding not only the relationship between OCD and
religion, but the ways in which one should theorize obsessive-compulsive disorder
generally? Any attempt to project OCD onto earlier historical figures should take care to
consider the social, philosophical, and theological contexts in which such figures lived.
Arguably, the sources of religious scrupulosity for Early Modern devotional writers were
not their idiosyncrasies or faulty neurochemistry, but scripture itself, or at least the narrow
sort of scriptural exegesis carried out by Reformed theologians. The importance of
historicizing when considering cases of obsessive religiosity might seem obvious, but it is
worth underscoring, since it points up one of the fundamental limitations of the DSM IV
and so-called biological or diagnostic psychiatry generally as guides for measuring OCD.
As Ian Hacking has noted in his revisionist work on multiple personality disorder, the DSM
reductively organizes mental illness according to presenting symptoms, rather than
underlying causes or etiological factors.32 What early modern non-pathological obsessive-
ness shows is that a cultures organizing worldview can create both the conditions under
which obsessions and compulsions might emerge, as well as historically particular
evaluative criteria that might depart from 21st-century measurements of OCD. It is worth
noting that the compilers of the DSM IV seem to anticipate this historicizing objection to
their ahistorical list of symptom clusters for OCD by maintaining that culturally prescribed
ritual behavior is not in itself indicative of Obsessive-Compulsive Disorder unless it
exceeds cultural norms, occurs at times and placed judged inappropriate by others of the
same culture, and interferes with social role functioning.33 But this actually compounds
rather than resolves the problem of retrospectively diagnosing cases of OCD. Users of the
DSM are tacitly asked to become interpreters of not only individual symptoms but also
cultural norms. Every psychiatrist need be something of a sociologist, anthropologist,
theologian, and, when extrapolating from stylized conversion narratives and thick
descriptions like Bunyans, semioticians and literary critics as well.

32
See I. Hacking, Rewriting the Soul: Multiple Personality and the Sciences of Memory (Princeton:
Princeton University Press, 1995).
33
Diagnostic and Statistical Manual of Mental Disorders (Washington, D.C., American Psychiatric
Association, 1994), 459.
124 J Med Humanit (2010) 31:111125

Moreover, the DSMs notion that ritualistic behavior can be considered a clinical
manifestation of OCD if it is judged inappropriate by other individuals of the same culture
begs the question of what would constitute, given all of the denominational biases and
debating among early modern theologians, an informed, bounded theological culture during
the sixteenth and seventeenth centuries. To be sure, Luthers Catholic opponents would
have been happy to have diagnosed him and Calvin, Bullinger, Zwingli, Bunyan, and
William Perkins as all pathologically obsessive, but I wage that if Galileo had invented the
PET scan instead of the telescope, we would have hard evidence that some of these
pioneering Protestant were running on healthy, serotonin-rich brains.

Religious scrupulosity and genre

In closing, I would like to make some provisional claims as to why contemporary self-
help manuals have taken such an interest, however skewed, in the obsessions of early
modern Protestant theologians. One way of approaching this question is in terms of genre
theory. If we were to situate divergent mental illnesses under generic categories, we might
say that narratives of depressive illness are typically tragic in nature; psychosis, too,
would seem to be categorizable as tragic, but at least some have argued that there is
something romantic about psychosis. Recall, for example, R.D. Laings controversial
notion in the Divided Self that psychotics were off explor[ing] the inner space and time
of consciousness . . . . Future generations will see that what we call psychosis was one of
the forms in which, often through quite ordinary people, the light began to break through
the cracks in our all-too-closed minds.34
If depression tends toward tragedy and psychosis can be perceived as romantic, under
which genre should we situate OCD? OCD clearly has comic elements, but we should bear
in mind (and this is probably not well-represented in Traigs account) that OCD is classified
as an anxiety disorder in the DSM IV. Like severe depression, OCD is often chronic,
debilitating and life-altering. I would suggest that obsessive-compulsive behavior is most
aptly described as tragicomic in nature. However, if tragicomedy helps to generically
categorize modern OCD narratives, it does not all seem to capture early modern
representations of religiosity, which, although not entirely colorless, are hardly comic in
nature. I would argue further that there is nothing especially tragic either about early
modern spiritual autobiographies like Bunyans because the script seems to be laid out for
him in advancethe Protestant ordo salutis having a clear beginning (calling), middle
(justification) and end (sanctification), so all of Bunyans tribulations would be considered
as part of his telos of conversion. Indeed, one almost feels that, throughout Bunyans
narrative, he is going through the motions, playing the role of abject sinner, and that, his
protestations to the contrary, there will be a happy resolution to his worthwhile suffering.
There is, in a word, something deeply melodramatic about Bunyans and most Puritan
conversion narratives.
How does this help explain the contemporary psychotherapeutic interest in early modern
religiosity? Well, if modern OCD is tragicomic, it is so precisely because obsessive-
compulsive symptoms seem both so anxiety-producing and meaningless. In this sense, at
least, OCD seems to be the quintessential postmodern illness, divorced from any
overarching, explanatory meta-narrative, belonging to a mixed genre like nearly all
postmodern narratives. Perhaps contemporary self-help manuals (often written, by the way,

34
R.D. Laing, The Divided Self (New York: Pantheon, 1969), 276.
J Med Humanit (2010) 31:111125 125

by self-proclaimed sufferers of OCD) project contemporary notions of OCD onto early

modern as a means, however unwitting, of turning what is unbearable and tragic into what
is familiar, predictable and melodramatic. The obvious objection to this is that, as I have
argued, psychotherapists neglect to consider the providential scheme guiding early modern
spiritual autobiographies; but that is not to say that psychotherapists are unaware of the
happy endings of such autobiographies, endings that are seldom enjoyed by their actual
patients. Is it so far-fetched to imagine that, at some point in the future, psychotherapists
will use early modern spiritual autobiographies as Bunyans less as evidence of obsessive-
compulsive disorder and more as a cure?

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Osborn, I. Tormenting Thoughts and Secret Rituals: The Hidden Epidemic of Obsessive-Compulsive
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Rapaport, J. The Boy Who Couldnt Stop Washing: The Experience and Treatment of Obsessive-Compulsive
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