Treating Relationship OCD
The Unique Challenge of Relationship OCD
In standard Obsessive Compulsive Disorder (OCD) treatment, one of the mains skills we learn is how to not respond to our brain’s intrusive thoughts (for more about how and why, read this first). With most OCD themes, the decision to ascribe irrelevance to intrusive thoughts is conceptually straightforward. For example, if someone has an obsessive fear that they have contracted HIV, they can establish a logical rule: unless they engage in any behaviors traditionally considered risky, they shouldn’t respond to their intrusive thoughts.
With relationship OCD (ROCD) however, we cannot throw out the baby with the bathwater. Relationships are complex and nuanced, and doubts about their quality exist in shades of gray. I have rarely ever spoken with an ROCD patient who has come to me with obvious objective relationship issues such as infidelity, abuse, or consistent unkindness. Instead, they struggle with subjective questions, such as "Is my partner attractive enough, smart enough, or kind enough for me?" In order to make a decision about a topic as complex, nuanced, and subjective as a relationship, we need to be able to understand not only how we logically think about it, but also how we truly feel.
How Traditional Exposure and Response Prevention Can Fail to Treat ROCD
When I was struggling with my own ROCD I tried to make conclusions through a purely rational lens. While being able to think rationally is an integral part of any decision making process, I was missing something very important: the ability to tune into and to listen to my emotions.
Through my understanding of exposure and response prevention (ERP) at the time, I developed a relationship with my emotions where I saw them as useless, burdensome, and things that would only interfere with my goals. I developed a perspective that if I was experiencing distress, the solution should be to automatically ascribe irrelevance to that distress and to quickly move on. What I didn’t realize was that, cutting off my connection to my emotions meant I was only in tune with half of my brain.
And because I was only in tune with half of my brain, I created a self-fulfilling prophecy. My biggest fear was that I wasn't able to make good decisions when it came to relationships. The irony was that by applying this rigid version of ERP, I was never in touch with how I was truly *feeling* about the relationship. It turns out I did have reason to doubt my ability to choose.
The Emotional Analysis Trap
How did ERP lead me to become so out of touch with my emotions? My disconnect stemmed from a simple cycle:
I would experience an emotion in reaction to my relationship (happiness, sadness, disappointment, etc)
Immediately I would try to analyze said emotion: "I'm feeling happy—does this confirm I'm in the right relationship?" or "I'm feeling upset—is this a sign I should leave?"
This analysis would generate anxiety, panic, a sense of overwhelm, and a sense of urgency to make an immediately large-scale conclusion about the quality of my relationship.
In noticing this panic, I would label the whole thing as OCD and apply my response prevention skills of resisting the urge to analyze anything.
As a result, I would discard the entire experience, including the initial authentic feeling.
Effective Treatment for ROCD
How then do we balance being in touch with our logical thoughts and our authentic emotions, all while separating out unhelpful and obfuscating OCD signals? The culmination of years of being a patient and therapist have finally brought me to the following model, which has been highly successful both for myself and many more patients I have worked with.
Step 1: Response Prevention
Response prevention, or the ability to notice thoughts/emotions/sensations/etc without immediately trying to figure them out or avoid them, must be established before any productive exploration can occur. Through traditional ERP, patients build up this ability to resist the urge to try to make an immediate conclusion about their fears (for more about how this is achieved, click here). For example, someone doubting their partner's intelligence would practice acknowledging thoughts like "Maybe my partner isn't smart enough" without immediately trying to understand if that fear is true or not.
This is a necessary step towards gaining clarity. When we make any decision about a major life choice, be it what job to have or where to live, we generally do so utilizing what I call passive insight. Rather than sitting down and obsessively and myopically combing through every pro and con of these decisions, most non-obsessive folks reach a conclusion about these topics through living their lives and letting their mind process information passively in the background, trusting that the right conclusion will emerge over time. If we have a heathy functioning mind, it generally does.
With OCD however we mistrust our brains. We believe that in regards to a given topic, everyone else has a well functioning brain, but we ourselves are missing that part. We believe that we need to supplement or replace our instinct or intuition with an exhaustive process I call active insight. Active insight involves bringing to mind detailed information that looks at every angle of a situation in order to try to reach a conclusion. While active insight can be useful in short bursts (reviewing applicants for a job, choosing against conflicting plans), for larger decisions that require a more holistic perspective, too much use of active insight can block our ability to access our passive insight.
Imagine holding a snow globe and vigorously shaking it next to your face to try to see what’s inside: it is only through placing it on a desk and letting it settle that you could see the situation clearly. The same goes for thinking: for many situations, actively trying to figure things out can block our ability to reach a conclusion, and letting go of this active pursuit gives the brain space and time to passively present a conclusion to us.
Step 2: Rational Assessment
Once our snowglobe is settled and we can think more clearly about our relationship, the next step is to develop a rational framework for evaluating relationship compatibility. Here, the first step is to make a conclusion about what our relationship needs are. It is paramount to distinguish between needs and wants:
Needs: Non-negotiable elements without which you cannot imagine relationship satisfaction
Wants: Preferences that would enhance but aren't essential to relationship satisfaction
Importantly, needs should be evaluated as binary (met/unmet) rather than on a spectrum. Questions like "Is my partner attractive enough?" are answerable, while "Is my partner as attractive as they could possibly be?" creates an OCD trap. This distinction is crucial, as statistically, there will always be someone who exceeds your current partner in some dimension. By creating a binary we can instead think through a framework of understanding if our needs are met, rather than get stuck in an optimization trap in which we could never be satisfied (as there will always technically be someone “better” than the partner you end up with).
If we are in a relationship in which our needs are met, it is then our job to tolerate our partner’s other imperfections, as is necessary in any healthy relationship. Of course, you can always work though things to maximize your “wants” to the extent possible, but these aren’t dealbreakers if a certain amount of gains aren’t met.
Step 3: Emotional Assessment
The final (yet integral) step in working through relationship OCD is learning to distinguish between what I’ll call “authentic” emotions and OCD-driven anxiety or despair.
Patients must learn to notice their genuine emotional responses without immediately analyzing them. By applying response prevention skills to both thoughts and the urge to analyze emotions, individuals can create space for authentic emotional experiences. When we don’t stop our feelings by trying to figure them out right away, we can begin to assess how frequent, intense, and long lasting each of those feelings would have otherwise been, and start to develop a big picture about how we generally feel.
This practice yields profound insights. Some discover that their authentic relationship distress is actually just brief and infrequent moments in an otherwise overwhelmingly happy relationship while happiness predominates. Others may recognize persistent dissatisfaction that merits attention. Either way, this information becomes accessible only when we stop interrupting our emotional processes with obsessive analysis.
How to Trust Yourself in a Relationship
When we are able to access both the rational and emotional parts of their brain, we can finally truly understand what our authentic experience is of being with our partner. We are able to logically understand if the relationship meets our needs and are emotionally in tune with how it feels. When we are in touch with all of our brain's signals, we can finally start to trust ourselves to make a decision about a relationship. If we make the decision to stay in a relationship, we feel safe and secure knowing that our radar is clear and well functioning, and we’d be able to tell if we need to re-evaluate our decision without being hypervigilant.
The truth all along has been that folks with ROCD do not have a fundamental inability to assess what relationships are right for them, but rather that they have been blocking their brain’s natural and valid signals and intuition.
If we can only learn to be a clear conduit to our brain’s signals, if we can stop using obsessions and compulsions to block the messages that our brain and heart are sending, we gain clarity and we learn that we had trustworthy intuition, instinct, and insight all along.