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See this link for our chapter on assessment and treatment of ROCD symptoms.
Assessment and treatment
Worrying, having doubts or even being preoccupied with a particular relationship does not automatically suggest a diagnosis of ROCD. Like other OCD symptoms, relationship-related OC symptoms require psychological intervention only when causing significant distress and are incapacitating. Assessing ROCD symptoms, however, is further complicated by the fact that such experiences, even if distressing, may still be a part of the normal course of a still developing relationship, mainly during the flirting and dating stages of a relationship, or reflect real life problems. Furthermore, treatment is frequently sought only during relational instability (e.g., increasing pressure from a partner, low relationship satisfaction) and ROCD is often comorbid with other disorders, such as depression, other anxiety disorders, and other OCD symptoms. Establishing that a person is suffering from ROCD, therefore, requires particular care.
Relational obsessions usually begin in the early stages of a relationship and exacerbate as the relationship progresses or reach decision points (e.g., cohabitation, marriage). Clinicians should keep in mind that relationship obsessions exist and persist regardless of relationship conflict. When suspecting ROCD, initial evaluation should include a clinical interview to ascertain the diagnosis of OCD and coexisting disorders or medical conditions. It is strongly recommended to use structured interviews, such as the Mini International Neuropsychiatric Interview (MINI; Sheehan et., 1998) or the SCID (First, Spitzer, Gibbon, & Williams, 2012), to ascertain disability and diagnosis of OCD. Additional instruments should be used to quantify ROCD symptom severity (e.g., the ROCI and the PROCSI), other OCD symptoms (e.g., OCI-R, Yale Brown Obsessive Compulsive Scale), OCD-related cognitions (e.g., Obsessive Beliefs Questionnaire; Moulding et al., 2011), depression, anxiety, and Body Dysmorphic symptoms.
A thorough history would include the presenting problem(s), background of the problem(s), and personal history with specific emphasis on relational history and family history and environment. It is of outmost importance to gain a clear understanding of the nature, pattern, and duration of clients’ symptoms within the current relationship context and in previous relationships. Therapists should collect detailed information about triggers of obsessions, their frequency and duration, the expected feared outcome or worry about the obsessions, and the responses to these intrusions. Responses include emotions (e.g., anxiety, guilt), overt compulsions (e.g., checking, comparing, reassurance seeking), covert compulsions (e.g., thought suppression, monitoring of internal states, self-reassurance), and avoidance or safety behaviors.
There are no known studies as to the effectiveness of pharmacotherapy to ROCD symptoms. Our clinical experience shows, however, that high doses of SSRI’s as accepted in the treatment of OCD (e.g., Montgomery et al., 2001) may lead to a reduction of ROCD symptoms for some individuals.
The effectiveness of psychosocial treatment for ROCD has yet to be tested. A successful therapeutic intervention, however, should be based on a theoretical understanding of the vulnerability factors and maintenance processes described above. We are currently developing a treatment manual that will address the maintaining processes and vulnerability factors of ROCD. Following current cognitive behavioral interventions for OCD, we believe such treatment should include assessment and information gathering, psycho-education and identification and challenging of dysfunctional thinking patterns, self-perceptions, and attachment-related fears and defenses. Exposure Response Prevention (ERP), and other behavioral experiments are believed to be very useful in this therapeutic process.
Psycho-education sets the tone for the rest of therapy. The psycho-education component should cover the cognitive model of OCD and ROCD (see Figure 1). It is important to provide the client with the rationale for the therapeutic process and discuss the course of therapy. The influence of ROCD symptoms on decision making should then be addressed and the difference between obsessive thinking and problem solving clarified. In this context, the impact of ROCD symptoms on one’s ability to experience feelings should be explored. Based on these understandings, it is best to reach an agreement to postpone decisions regarding the relationship until ROCD symptoms are significantly reduced.
Contingent on the client’s approval, one should consider involving the partner in the therapeutic process. In such cases, partner’s symptom accommodation should be assessed, ROCD psycho-education provided, and strategies for reducing dyadic influences suggested.
Monitoring of obsessions and compulsions should assist the client and the therapist to manage the reduction of compulsions and avoidance behaviors, such as comparing partner qualities to others, checking how they or their partner feel, reassurance seeking (e.g., asking friends to reassure that the partner/relationship/feelings are good/normal), and avoidance of behaviors that might foster intimacy (e.g., holding hands in public, or asking intimate questions).
The cognitive component of ROCD treatment may include identification and challenging of OCD-related maladaptive beliefs (e.g., importance of thoughts, intolerance for uncertainty). It is also important to challenge catastrophic beliefs about relationships (e.g., “If I stay in a relationship I am not sure about, I will always be miserable”; “If I commit to this relationship, I will never be able to get out of it” or “if I leave this relationship, I will always regret it”). In this context, ERP tasks including scripts related to fear of regret (e.g., finding yourself miserable with your partner in a few years and/or finding yourself miserable without the same partner), other feared scenarios (e.g., weddings), in vivo exposure to “triggering” sites or movies (e.g., romantic comedies) may be useful. Many clients with ROCD describe fears of reenacting their parental relationship, when applicable this information should be integrated in to the exposure scripts. An effective intervention may also address the meaning and consequences of increased monitoring of internal states. Suitable behavioral experiments for exemplifying the effects of excess monitoring may include in-session repetitive monitoring of internal states (e.g., feelings of “closeness” to the therapist).
Contingencies of self-worth on particular relational aspects (e.g., relationships, partner value) should be explicitly explored, such that the client understands the association between distress and perceived failure in these relational aspects. Effort should be given to identify and expand the rules of competence and boundaries of these relational sources of self-worth as well as to increase the dominance of other sources of self-worth (e.g., academic, physical).
Particular emphasis should be given to softening attachment worries and anxieties, mainly fear of abandonment (see Doron & Moulding, 2009, for a description of Attachment-based CBT). Helpful strategies may include challenging the link between OCD-related beliefs and abandonment fears (e.g., “over-vigilance will decrease the likelihood of being abandoned”), using behavioral experiments to increase tolerance for abandonment-related fears (e.g., writing/ thinking “does my partner really love me” without asking the partner for reassurance), and addressing beliefs associating abandonment with low perceptions of self-worth (e.g., “I am not worth anything and will therefore be abandoned”).
Many clients with ROCD prefer to avoid relational conflicts. Trying to avoid conflict, however, may exacerbate fears of future entrapment. Furthermore, conflict may be a result of ROCD symptoms, but also a trigger of relational obsessions. The link between ROCD symptoms and relational conflict should be assessed and addressed. Appropriate communication and conflict resolution skills should be taught and practiced using role playing for feared situation (i.e., potential conflictual interaction with a partner).
The goal of therapy is not to save the relationship, but to help the client reduce ROCD symptoms. ROCD symptom reduction is often associated with better understanding of one’s own feelings and with improved decision making capacity. In case of need, however, problem solving technics and decision making strategies may be introduced to help the client with important relational decisions.