Themes	Description	Examples
Exposure with Response Prevention	•Gold-standard intervention to reduce excessive, impairing thoughts and accompanying compulsions associated with religious/moral beliefs deemed excessive to a particular belief system. •Goal of patient practicing within the bounds of their belief system. •Builds distress tolerance and allows for experiential, inhibitory learning.	•Patient adhering to Christian faith feels prayers must be said perfectly and may “start over” if a “bad” or sinful thought intrudes or if the prayer does not feel “right”.  Exposure: Praying a new or spontaneous prayer  Response prevention: Praying out loud with  family who can prevent repeating or starting over •Hindu patient excessively rewashes hands prior to touching an idol in the home temple.  Exposure: Turn off the bathroom lights after washing hands and before entering home temple  Response prevention: Praying out loud with  family who can prevent repeating or starting over
Understanding Individual Faith Approaches	•A provider should familiarize self with a patient’s specific beliefs and a patient-center context. •Identify a patient’s priorities, such as: spiritual connection, joy in faith, salvation, bringing positivity to one’s environment, following up-to-date doctrines, being a good person.	•A female Catholic teenager is interested in pursuing church leadership and begins to align with other Christian approaches that would allow her to lead a church or preach. (Not OCD) •An individual apologizes frequently and is concerned with putting out “good into the world”. This is not due to true character and identity development but out of fear of being “bad” or of something “bad” happening. (OCD, not individual morality)
Family & Faith Community Consultation	•Collaboration with faith leaders for the purpose of gaining insight related to normative practices within a specific belief system. •Building understanding of what would be considered excessive or unusual practice for members of a patient’s family or for most in their community.	•Consulting with an Imam regarding typical cleansing practices or number and frequency of prayers within the context of a specific Muslim faith. •Discussing family rules and teachings with caregivers to understand family culture with ideas such as “doing right” or being “good,” lying, judging others, or being helpful. •Collaborating with a Rabbi to understand prayer rituals and adherence to Sabbath rules for a family’s level of orthodoxy or traditionalism.
Identifying Values	•Understanding and incorporating patient values is crucial for effective E/RP, particularly with scrupulosity. •Emphasizes living in faith or living out one’s morality versus living and doing out of fear. •E/RP allows patients to move toward values and engage in spiritual practices in a non-ritualized manner, without acting contrary to their beliefs/morals. Scrupulosity may actually distance one from their values.	•Exposures in alignment with values:  Saying the Lord’s Prayer “correctly” and in its entirety, even if a “mistake” is made  Setting a budget and donating to a cause of interest  Not eating meat or eating certain vegetarian foods without receiving reassurance that it is safe •Exposures not in alignment with values:  Saying a satanic prayer  Donating more than affordable or fiscally responsible to a cause of interest  Intentionally eating something that contains meat
Embracing Uncertainty	•Uncertainty is inherent in both OCD and faith/morality. Building uncertainty and related distress tolerance is a useful target. •Providers can help patients and families identify and accept uncertainty in their beliefs, practices and daily lives.	•Guiding an adolescent through E/RP of declining an ask for help from a peer without reassurance or knowing if it will lead to being a “bad” person or something “bad” happening. •Discussing certain topics of faith or morality as being ambiguous or grey, e.g., is there ever a time when it is “okay” to lie. •Helping a child through an exposure of saying a prayer out of order (in a manner not expressly forbidden by their faith) not knowing if this will anger a Higher Power.