Obsessive compulsive disorder - OCD treatment and therapy from NOCD

What’s the best therapy for Relationship OCD (ROCD)? What experts say

By Elle Warren

Mar 12, 202412 minute read

Reviewed byApril Kilduff, MA, LCPC

best therapy for relationship OCD

I know firsthand how important it is to find treatment for relationship OCD (ROCD). I have struggled with this theme of OCD myself, and it felt like a direct threat to my relationship—which is so valuable to me. My partner and I are getting married this year, and I worried that if I didn’t seek treatment to address ROCD, my anxiety would overshadow the love I feel.

Despite our fun, deep, and loving connection, I’ve had thoughts like, 

We’re doomed to break up.

Divorce rates are so high. Why would we be one of the successful ones? 

What if we’re just supposed to be friends? (I’ve heard that often cited as the reason for a break-up.)

What if I’m lying to myself about being attracted to her?

You and I are not alone. ROCD is one of the most common themes that therapists at NOCD—the leading telehealth provider for specialized OCD treatment—see in people seeking treatment for these very same experiences. ROCD involves excessive fears and worries about your relationship followed by mental or physical behaviors to try to “solve” those fears. It usually attaches to romantic relationships, but it can happen in other types of relationships, too, such as those with friends and family.

There’s good news for anyone who struggles with ROCD: it is highly treatable with specialized therapy. Keep reading to learn more about what specialized treatment looks like, the potential impacts of ROCD when it goes untreated, and how to get help, guided by the expert insight of Keara Valentine, PsyD, a clinical assistant professor at Stanford University School of Medicine who specializes in OCD treatment, and April Kilduff, MA, LPCC, LCPC, LMHC, Clinical Trainer at NOCD.

How is relationship OCD treated? 

“ROCD is probably one of the most misdiagnosed subtypes of OCD because the questions you have sound an awful lot like the ones that anyone in a relationship might ask. How do I know this is ‘The One’? or What if she’s cheating? Knowing to listen for and understand the need for absolute certainty—which is what ROCD demands—is a clinical subtlety that a lot of untrained therapists can miss,” says Kilduff. That’s why it’s so important to seek out a clinician who is specifically trained in OCD.

If you don’t have ROCD, you might have the same questions, but you can usually recognize that 100% certainty in any relationship isn’t possible, and move on feeling reasonably confident.

Once you’ve been evaluated and diagnosed by a trained specialist, the gold-standard, evidence-based treatment for ROCD (and all themes of OCD) is exposure and response prevention therapy, or ERP. It’s important to know that traditional talk therapy is not proven to be effective for OCD. In fact, sometimes it can even make the condition worse.

What makes ERP different from other types of therapy?

The goal of ERP, explains Kilduff, is to teach you how to tolerate the discomfort of ROCD intrusive thoughts. Will you totally get rid of them? No: intrusive thoughts are a universal human experience. But you’ll learn that they are not threats that you need to act on.

The process is geared to address your specific experience, so your therapist will take the time to understand your symptoms. They’ll ask about what your relationship-focused intrusive thoughts most often sound like, how they make you feel, and what your typical compulsions are. 

You’ll then work together to actually learn different responses to the things that worry you, cause you to seek reassurance, or do anything else to seek perfect certainty. In a talk therapy session, you might work with a therapist to disprove your fears and doubts, feel better about your relationship, or dig deeper into why your worries are coming up. While this can lead to helpful realizations, goals, and relief from some relationship issues, it doesn’t help with OCD: these methods of feeling better don’t do anything to keep the worries and “what ifs” from coming back, and actually reinforce the vicious cycle of OCD.

You’ll start with something relatively “small”—maybe you’ll just look at a photo of another couple looking happy. Some doubts and worries will start popping up: Why don’t we look that happy? What do they have that we don’t? What if I’m not capable of making anyone that happy? 

Those thoughts—like the idea that this couple, even though you don’t know them, might have a better relationship than you—will likely arise, but instead of doing anything to feel better or more certain, you’ll instead learn to sit with these thoughts and worries. By doing similar exercises over time, both within therapy sessions and on your own, you teach your brain that uncertainty isn’t a threat, and you can actually accept these thoughts and feelings, as uncomfortable as they may be.

“It’s incredibly important to find a therapist who specializes in ERP so they can lead you through confronting your compulsive responses to triggers—which will decrease those responses over time,” says Dr. Valentine. “You’ll learn that you don’t need to do anything about your intrusive thoughts, or let them determine your relationship’s trajectory.”

When I first started ERP therapy, exposing all of my intrusive thoughts to my therapist felt uncomfortable. I knew that the thoughts were illogical, and I worried they would make me sound insecure or unstable. Yet my therapist nodded along as I voiced the thoughts like What if my partner isn’t ‘The One’? or What if I’m not really attracted to her?

My therapist had heard these thoughts before. To her, the specific content of my worries was inconsequential. What mattered was that they were fueled by OCD, and I could learn to change the way I reacted to them.

Are there any other treatment options for ROCD?

ERP is effective in the vast majority of people and should always be the frontline treatment. However, there are some tools that can work well when used in conjunction with ERP. 

Certain medications, for example, can be highly effective in the treatment of OCD. The most common class of medication prescribed are selective serotonin reuptake inhibitors (SSRIs). They’re most commonly used to treat depression, but have also been shown to help with OCD symptoms. Whether medication is right for you will depend on the severity of your symptoms, your unique neurobiology, and whether you have any co-occurring conditions like depression or anxiety. 

A lot of the time, these prescription medications are used along with ERP therapy, in order to help people engage fully in treatment. Decades of evidence support both these forms of treatment, but it’s crucial to work with a licensed professional who has specialized training in OCD to help you determine the best course of treatment.

Another kind of therapy that can be used in conjunction with ERP and/or medication is acceptance and commitment therapy (ACT). Rather than specifically targeting compulsions, it aims to change your overall relationship to your obsessions and become more accepting of their existence. It guides you in acknowledging the thoughts without assigning them judgment or meaning. Note that ACT is far less proven than ERP, which is why it’s not recommended as a first line of treatment.

Thinking about seeking ROCD therapy but still not sure if you have it?

Here are the telltale signs.

1. You experience repetitive intrusive thoughts, images, urges, sensations, or feelings that don’t match who you are, what you believe, or what you really want—in clinical terms, they’re ego-dystonic. You find them uncomfortable, inappropriate, or disturbing. These are called obsessions.

Common ROCD Obsessions: 

  • What if my partner isn’t really “The One”?
  • What if I don’t love my partner enough?
  • What if my partner and I aren’t attracted to each other enough?
  • What if my partner and I don’t have sex enough and that means we’re doomed to break up?
  • What if I’m making the wrong choice by marrying them?
  • We argue sometimes—what if that means we’re just not compatible enough?
  • You have images of your partner making out with someone else 
  • You have a sudden urge to say something hurtful to your partner to “test” whether or not they love you enough to still be with you
  • You see a stranger you find attractive and feel a groinal response (then worry that it means you shouldn’t be with your partner)
  • You have feelings of disdain toward your partner 
  • You have feelings of doom about your relationship

2. You become highly distressed over your intrusive thoughts. You worry that they mean something, and are intent on figuring out that meaning so you can relieve the anxiety, fear, panic, guilt, or shame you feel so you can get rid of the intrusive thoughts, images, urges, sensations, or feelings. You feel like your relationship is being threatened.

3. As a result of this distress, you engage in physical or mental acts with the intention of relieving your anxiety and getting to the bottom of your intrusive thoughts. These are compulsions, and they can help you feel better in the short term. But because OCD is known as the “doubting disorder,” no amount of compulsions is ever enough. OCD will always creep back in and say, “But wait! What if…”

ROCD compulsions might look like:

  • Ruminating on your obsessions. Ruminating happens when you become fixated on a thought, worry, question, or idea and play it over and over in your mind. You have the sense that you can “think your way out” of your fears if you just keep focusing on it.
  • Reassurance-seeking from your partner or yourself. You might ask your partner repeatedly “Do you really love me?” or “Do you think it’s bad that we don’t have sex every week?” Or you might repeat to yourself Of course we have a good relationship. Of course they love me.
  • Researching online about what makes a good relationship. You might read article after article about “How to Know if They’re The One” or “Sneaky Red Flags” or “When to Break Up.” No amount of information ever feels like enough.
  • Comparing your relationship to other relationships. You might know a couple whose relationship you perceive as good and try to assess whether your relationship has the same exact elements.
  • Mentally reviewing past memories with your partner to see if you missed any red flags or signs that your relationship is doomed. You feel like you can’t trust your memories or how you perceive them.
  • Avoiding anything that triggers your obsessions. This could be places, certain movies, being intimate with your partner, hanging out with other couples, or anything else that makes you think about your fears.
  • Distracting yourself from your obsessions. People do this in a number of ways. You may use substances, sleep, television, social media, gambling, and other methods to drown out your thoughts.
  • Checking yourself for arousal responses or feelings or love. 

Remember, you don’t need to know for sure whether you have ROCD in order to seek help from an OCD specialist. They will be able to assess whether what you’re experiencing is OCD, something else they can treat, or if it could be a condition  that they could refer you to another clinician to treat. 

Why you shouldn’t wait to get treatment for ROCD

Regardless of the degree of distress that ROCD causes you, there’s no doubt that leaving it untreated can have a profound impact on the quality of your relationship and your life overall.  You may have a near-constant sense of anxiety, fear, and doom. Over time, this can be exhausting, and even lead to depression. Plus, when you feel like you can’t trust your choice of a partner, or your feelings toward them, it may also damage your self-confidence. 

In terms of the problems it can create in your relationship, Dr. Valentine says the most common thing that causes conflict is constant reassurance-seeking. You might ask your partner the same questions again and again, like, “Do you think we’re going to break up?” or “Are you sure you love me?” And it can wear on them. They may feel confused, or become tired of the questions—especially if they don’t understand OCD. And it can make them feel insecure about your relationship, based on the insecurities that you voice.

Without treatment and proper education about ROCD, your partner can also inadvertently enable your condition. No one likes to see their loved ones in distress, and if your partner is unaware that this is a compulsion that’s making your OCD worse, then of course they’d want to do whatever they can to make you feel better. 

Here’s the problem: Research shows that performing compulsions only feeds the OCD cycle. So, rather than getting better, it can fuel your OCD. Your brain continues to see intrusive thoughts as legitimate and possibly dangerous.

In some cases, your intrusive thoughts may become so loud and intolerable that you end the relationship just to get relief. You may have heard the viral phrase “letting the intrusive thoughts win.” It’s often used to describe picking up an expensive coffee on your way home from work—or getting delivery because you can afford to, and Netflix is calling. But the truth about intrusive thoughts is that they’re not a passing whim you feel on a random Friday night. They tend to be constant, debilitating and life-altering. 

Because of the ways that a partner can be wrapped up in your experience of OCD, Kilduff recommends that you involve them in your treatment in some capacity—and there’s plenty of research to support this idea. One meta-analysis found that including loved ones in OCD treatment had significant improvements in client functioning and overall outcomes. 

Kilduff says that your partner would ideally join in on one or more therapy sessions. If that’s not possible, you can ask your therapist to give you some guidance that you can pass along—such as how they can validate your difficult feelings without giving you reassurance.

Effective treatment for ROCD is more accessible than ever

Depending on provider availability in your area and your personal preference, you can seek ERP either in person or online—both are proven to be highly effective. That said, advantages of online therapy include accessibility, not having to commute, and being able to do exposures in your everyday environment rather than in a therapy office. Either way, there is a clinician out there ready to help you. ROCD does not have to call the shots or yell louder than the love you feel for your partner.

These days, when I have an intrusive thought about my relationship, I shrug and think Maybe. Maybe OCD is right, and maybe it isn’t. Instead of trying to figure it out, I come back to the present moment and my values, which include the loving relationship I have with my partner.

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