Mind Body and Soul

By Avigdor Bonchek, Ph.D.

The topic of obsessive compulsive disorder (OCD) has received much media coverage over the past decade. This is because we have recently seen remarkable progress in the treatment of this serious, debilitating, psychological problem, which for centuries had defied attempts at treatment.

The progress in treating OCD can be attributed both to medical advances (treatment with anti-depressants) and to cognitive behavioral therapy (CBT). CBT treatment has formulated clear, easy-to-understand treatment protocols. Sensitively following these protocols with consistency and compassionate understanding has proven remarkably successful in helping sufferers overcome a life ruled by their compulsions to be able to live a life free from them.

Compulsive Prayer

One area that affects religious Jews in particular, compulsive prayer -- has not received the attention it deservers. This is certainly because most OCD sufferers in the world aren't concerned with prayer, but another reason is because the CBT treatment formula of Exposure and Response Prevention is not applicable to this type of compulsion.

Exposure and Response Prevention
Briefly, Exposure & Response Prevention means that, for example, if a person suffers from compulsive hand washing, the treatment would be to expose him to touching "dirty" objects and then preventing him from washing his hands. While this seems quite simple-minded, its success can be explained by the way we learn to overcome anxiety. The apparently simple procedure can be remarkably helpful in reducing or stopping compulsions in a relatively short period of time.But this cannot be applied to compulsive prayer. Compulsive prayer means that individual, because of doubts, feels he must repeat certain words until he "gets it right." The repetitions can go on and on, causing a very painful and prolonged prayer session. Shemoneh Esrei, which normally can be said with normal concentration in five to seven minutes, may take a sufferer half an hour or more. The reason ordinary CBT has not been helpful is that while the therapist can stop excessive hand-washing by turning off the faucet, he cannot stop the urge to repeat the words of prayer. It happens so quickly there is no way to "take the word out of his mouth" to prevent repetition.

I will describe a treatment technique that has proven successful in treating this problem.

The Treatment ProtocolFor treatment, we need a kitchen timer that tracks times forward and backwards, and a buddy. The buddy is someone who can stand next to the sufferer as he prays (not in a synagogue) and who will both monitor and direct the sufferer to follow the instructions.

Let us say the person gets "stuck" at certain "hot spots" in the daily prayer. He cannot say the Shema without many torturous repetitions. Shemoneh Esrei is likewise a problem; usually the first brocha is the hardest. We first analyze the problem by recording baseline data. We will take as an example treating compulsions in Shemoneh Esrei. We time him with a precise stop watch (not a wrist watch) as he says the first brocha of Shemoneh Esrei. We also note and record the number of compulsive repetitions he makes as he goes through the first (hardest) paragraph. We can also time his completed prayer. All these observations must be made when he prays within the halachic time for davening.

Then we discuss with the person our first goals. We may set our sights at having him overcome all repetitions in the first brocha only. We will deal only with the first brocha, whatever happens in the rest of his Shemoneh Esrei is of no concern at this stage. Our goals are graduated and always arrived at through discussion with the sufferer. If he thinks our suggestion is too difficult, we try to accommodate his preference, with the proviso that we must always move forward. He sets the pace, but goals must show forward movement.

'Go-Back-To-Start' Rule

We tell him that if he repeats, we will say stop and ask him to go back over the whole previous first brocha. He is to read that brocha from the beginning. If he says the first bracha this time without repetition he continues on to the rest of Shemoneh Esrei. Since we are focusing only on the first bracha, we pay no attention to his compulsions in the rest of the blessing. If he repeats, we have him go back to the previous bracha as many times as it takes until he can say the particular bracha we are focusing on consistently with no repetitions.

This will happen if the buddy is both firm and encouraging. Once this is accomplished, we then focus on the next bracha. The "go - back, to- start" rule now applies to any repetition he makes within any of the brachos up to the one in focus. This procedure - with much verbal encouragement, proceeds to the next stages only after the person freely and consistently reads the previous stage with no compulsive repetitions.As can be seen, we continuously increase the length of his Shemoneh Esrei because he has proven he can say the earlier brachos without repetitions. We are strict, so that even if he got all the way to Retzei with no repetitions, but in Retzei he made one compulsive repetition, he goes all the way back to the beginning.This may look harsh, but as he progresses, so does his confidence. And as he progresses so does the challenge progress. He is able to take it.In addition to a written record (of time and number of repetitions), it is helpful to make an audio recording using an mp3 recorder so that both the buddy and the sufferer can hear how he sounded at the outset. The changes are often dramatic.Although the treatment may be done with a non-professional as buddy, it should be done under the supervision of a professional who understands the treatment. Obviously, as in all treatment there are good days and bad days, but the record should show constant improvement. If worked with at least three times a week, dramatic improvement should be seen within a month, although total relief will take longer.

Avigdor Bonchek, Ph.D. is a clinical psychologist and behaviorally oriented psychotherapist practicing in Jerusalem, anda retired lecturer at Hebrew University in Jerusalem. His book "Religious Compulsions and Fears: A Guide to Treatment" is published by Feldheim. His article "Compulsive Prayer and its Management" appeared in the Journal of Clinical Psychology (volume 65 no. 4 pp 396 404). He also published on the topic "What's broken with CBT Treatment of OCD and how to fix it" in American Journal of Psychotherapy (v.63, no.1 pp 69 -86).