Treatment and Challenges for Relationship OCD

Guy Doron and Danny Derby are pioneers in exploring and defining Relationship OCD (ROCD). ROCD, a distinct type of obsessive-compulsive disorder (OCD), plagues individuals with relentless doubts concerning the compatibility of their romantic relationships and partners.

Drawing from their extensive research and expertise, Doron and Derby have authored numerous research papers on ROCD and have formulated a tailored treatment framework for the condition^1-7. This part of our discussion centers on the treatment of ROCD, spanning both psychological and pharmacological avenues. They were kind enough to answer some questions on the topic.

Ran Littman: What are the key components of ROCD treatment?

Danny Derby: To begin with, we guide the client towards recognizing that their previous approach—relying on compulsions and actively doubting and engaging in continuous deliberations to resolve relationship doubts—ultimately fails, proving counterproductive and costly. One effective method involves employing motivational interviewing techniques, wherein the therapist and client delve into the underlying motivations for engaging in these compulsions. We also meticulously assess the short- and long-term consequences of resorting to compulsions, alongside the potential advantages of relinquishing them.

Our next objective is to collaborate on reducing compulsive behaviors. This constitutes a pivotal step in ROCD treatment and is at the core of this therapeutic process. Consequently, clients are tasked with temporarily setting aside these compulsive actions. They embark on a journey to explore alternative, non-compulsive strategies for managing their doubts and distress, subsequently evaluating how their relationship unfolds without the reliance on compulsions.

Guy Doron: A cornerstone of this treatment involves acknowledging, alongside the client, that the persistent questions plaguing them—such as doubts about the suitability of their relationship or partner—cannot be answered during bouts of obsession or by engaging in compulsive rituals. In fact, compulsive behaviors hinder clients from fully experiencing their relationship and “collecting the data” necessary to address these queries. It’s only by diminishing the grip of these obsessive cycles that one can genuinely engage with their relationship and make well-informed choices.

Our therapeutic efforts also aim to help clients differentiate between autonomic and more controlled thought processes. An example of an autonomic process is a thought like “they are attractive” popping into the client’s mind about someone other than their romantic partner. The ensuing inner discussion regarding the meaning of this thought occurrence, its content, or future implication regarding the relationship is a more deliberate, effortful, and controllable thinking process that can be reduced.

In therapy, once clients acknowledge the maladaptive nature of their perpetual engagement with more deliberate thought processes, we equip them with tools and techniques to disengage from interacting with it, thereby diminishing ongoing distress and consequent compulsive behaviors.

RL: What are some common challenges therapists may encounter when working with clients with ROCD?

DD: One significant challenge, particularly when therapists are not well-informed about ROCD, is the inadvertent participation in the client’s compulsions. This can manifest in various ways, such as providing reassurance about the relationship, directly addressing the client’s relationship-related inquiries, analyzing the pros and cons of the relationship, or becoming entangled in the client’s deliberations. Unfortunately, when we engage in these behaviors, we inadvertently reinforce the ROCD cycle rather than empower the client to break free from it.

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Clients with ROCD often seek reassurance through their questions, which can be a subtle form of compulsive behavior aimed at quickly resolving their doubts. Identifying these reassuring questions can be challenging. As therapists, it’s crucial to remain attuned to the emergence of such questions and resist the urge to provide immediate answers and resolutions. Instead, we should empathize with the client’s distress and avoid becoming complicit in their compulsive efforts to find instant resolution.

GD: Another common challenge for therapists is recognizing when clients shift their focus back to questioning the suitability of their relationship or partner, rather than addressing their obsessive thought patterns. These transitions occur frequently during therapy, and therapists must be highly attentive to these shifts. It’s essential to guide clients back to managing the obsessive-compulsive cycle rather than getting caught up in new doubts about the relationship.

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Furthermore, therapists must remain vigilant for any overt or covert compulsive behaviors that clients may employ. These compulsions can be subtle, and it’s important to identify and address them as part of the therapeutic process.

RL: Should individuals with ROCD consider using psychiatric medications in addition to psychotherapy?

DD: There are two different guidelines to this question. The first guideline suggests commencing treatment with psychotherapy, primarily cognitive-behavioral therapy (CBT) and exposure and response prevention (ERP), especially when the severity of ROCD is categorized as mild to moderate. After completing 12 sessions of psychotherapy, both the client and therapist evaluate the effectiveness of psychotherapy up to this point. If psychotherapy alone is not deemed sufficiently effective, the recommendation is to consider augmenting treatment with psychiatric medications.

In cases of high severity, it is advised to initiate medication alongside psychotherapy right from the outset. In instances of extreme severity, where clients are unable to effectively engage in ERP, it may be advisable to start with medication and introduce psychotherapy once the compulsion urges have diminished to a manageable level.

The second guideline recommends the simultaneous use of psychotherapy and medication right from the start, regardless of the severity level. Commencing treatment with medications alongside psychotherapy can be advantageous as medications can help reduce the urge to engage in compulsions. However, it’s worth noting that some individuals may experience side effects from medications, or they may have personal reservations about medication use for various reasons.

Typically, we present both approaches to clients, allowing those with mild to moderate ROCD to choose which guideline aligns better with their preferences and needs.

RL: Is it advisable for individuals to share their ROCD struggles with their partners?

GD: One of the fundamental reasons people enter into relationships is to feel less lonely in coping with the world around them and to have a close confidant with whom they can openly discuss their fears and desires. When an essential part of one’s experience is concealed from one’s partner, it can foster feelings of loneliness and isolation within the relationship.

However, considerate disclosure of ROCD to one’s partner can help individuals alleviate the sense of loneliness stemming from their fears and doubts. Such disclosure also has the potential to transform their partner into a valuable ally in coping with ROCD. Hence, we do encourage involving the partner when the client is ready and to do so in a way that is suitable to the client and their partner. (Further elaboration on the sensitive issue of partner involvement can be found in a previous post).

DD: In certain cases, we may also consider involving family members, particularly when individuals regularly seek reassurance from their families regarding the suitability of their relationship or partner. Family members, often motivated to assist, inadvertently provide reassurance. In such scenarios, our goal is to educate family members about ROCD and equip them with the tools to cease this reassuring behavior, alongside expressing empathy for the individual’s distress.

This post is part III of a three-part interview with Prof. Guy Doron and Dr. Danny Derby. Part I focuses on the conceptualization and main features of ROCD. Part II explores the facets of diagnosing ROCD, its emergence, and its impact on people’s lives and their romantic partners.

To learn more about Relationship OCD, click here.

To find a therapist near you, visit the Psychology Today Therapy Directory.