Breaking the Rules: A Clinician's Guide to Treating OCD

Episode: Is it ROCD or is there a real problem in the relationship?
Hosts: Dr. Celine Gelgec (A) & Dr. Victoria “Tori” Miller (B)
Date: May 26, 2025

Brief Overview

In this episode, Dr. Celine Gelgec and Dr. Victoria Miller delve into Relationship Obsessive-Compulsive Disorder (ROCD), exploring how clinicians can distinguish between genuine relationship problems and OCD-driven doubts. Drawing from clinical experience and cultural observations, they discuss the diagnostic nuances, the role of doubt in relationships, and best practices for treating ROCD in the therapy room.

Key Discussion Points and Insights

1. Understanding ROCD vs. Genuine Relationship Doubt

• Cultural Influences and Relationship Ideals

  • The hosts note the prevalence of relationship perfectionism in media and its impact on clients’ expectations (“We are conditioned from such a young age to think, oh, you got to live happily ever after…” – A, 04:15).
  • Social media and celebrity portrayals often mask the complexities of real-life relationships, leading to skewed self-comparisons (06:31).

• What Makes Doubt Normal, and When Is It OCD?

  • Everyone experiences doubts, and periodic reassessment is healthy (“Checking in is actually a really healthy part of a relationship... Are my relationship needs still being met?” – B, 03:14).
  • The essential clinical question is: are obsessions and compulsions present, and are they causing significant distress or impairment? (09:07-12:57)

• Defining OCD and ROCD Criteria

  • Obsessions: intrusive, unwanted thoughts incongruent with personal values (“ego-dystonic”).
  • Compulsions: mental (rumination, scanning for evidence, comparisons), or behavioral (reassurance seeking, checking, testing partner).
  • Functional impairment and distress over a significant part of the day (exceeding an hour) is a key criterion (12:57).

• Context Matters

  • High preoccupation during relationship crises may be understandable and appropriate, not necessarily pathological (14:09-14:55).
  • Clinical discernment relies on understanding the context, patterns, and emotional tone of the client’s experience.

2. Navigating Clinical Conversations Around ROCD

• Caution Against Dismissal or Over-Labeling

  • Clinicians should avoid being dismissive or invalidating when clients express fears of ROCD, but also avoid over-pathologizing normal doubts (09:07).
  • The DSM does not specify OCD “subtypes”; labels like ROCD come from clinical practice and can be helpful or harmful depending on context.

• The Value and Risks of Diagnostic Labels

  • For some, naming the subtype brings clarity and guides treatment; for others, it may risk over-pathologizing or foster “label fatigue” (17:17-19:30).
  • Engage with clients collaboratively about what labeling means for them.

• Comorbid Themes and Scrupulosity

  • Clients with existing OCD may conflate real doubts with OCD-related themes or scrupulosity (“not wanting to be the bad person… triggers the scrupulosity” – A, 23:34-24:07).
  • Important to disentangle guilt/shame-driven rumination from true relational uncertainty.

3. Treatment Principles for ROCD

• Assessment and Formulation

  • Comprehensive assessment to distinguish between ROCD and genuine relational issues.
  • Clarify obsessions, triggers, worry beliefs (“what ifs”), compulsions, and functional impact (21:49-23:34).

• Exposure and Response Prevention (ERP) Approach

  • The ERP protocol for ROCD mirrors other OCD themes: build a trigger/compulsion hierarchy, apply mindful exposure, urge-surfing, and body regulation to build distress tolerance (21:49).

• Role of Mindfulness and ACT Principles

  • Encourage non-judgmental observation and curiosity over immediate “fixing” or reassurance (25:43-27:18).
  • It’s valid for therapists to take time discerning whether doubts are OCD or situational: “We’re not magicians, we’re not psychics… We can only know what our clients present to us” (25:46-26:21).

• Sitting with Discomfort as Exposure

  • Creating space for doubt and uncertainty is itself an exposure task; sitting with clients through uncomfortable ambivalence supports both ERP and genuine self-discovery (27:18-28:18).

Notable Quotes & Memorable Moments

“I think the point of this episode… is it’s okay to have doubt in relationships, and it might not be relationship OCD that you’re dealing with.”
— Dr. Celine Gelgec [07:07]

“People with OCD can have normal doubts too.”
— Dr. Victoria Miller [08:15]

“The DSM doesn’t have a whole list of subtypes… If the content is more harm related or relationship related… then the extra acronyms have kind of come along, but they’re not in the DSM.”
— Dr. Celine Gelgec [09:41]

“You don’t want to be dismissive…you want to be able to go, okay, let’s explore that together and see where it lands.”
— Dr. Celine Gelgec [09:07]

“We’re not magicians, we’re not psychics, but what we can do is be patient… You can be curious… This is where some ACT-based principles and mindfulness really kind of come in, which is just be an observer.”
— Dr. Victoria Miller [25:46]

“That in and of itself is an exposure task because you’re exposing the client to their uncomfortable doubts and thoughts and experiences.”
— Dr. Celine Gelgec [27:18]

Timestamps for Key Segments

| Timestamp | Topic/Quote | |--------------|------------------------------------------------------------------------------------| | 01:00–02:00 | Intro to ROCD and societal influence on relationships | | 04:13–05:03 | Disney, fairy tales, and unrealistic portrayals of relationships | | 06:10–06:31 | Social media, public vs. private relationship realities | | 07:07 | Importance of normalizing doubt in relationships | | 09:07–09:41 | Discussion of OCD diagnostic criteria and absence of subtypes in DSM | | 12:57–14:55 | Specific examples of compulsions and distinction of ROCD vs. normal doubts | | 14:09–14:55 | Preoccupation during relationship conflict | | 15:24–16:28 | Reassurance-seeking as part of OCD presentation | | 17:17–19:30 | Pros and cons of subtypes/labeling in clinical and client experience | | 21:49–23:34 | ERP structure for ROCD, exposure planning and skill-building | | 23:34–25:43 | Complexities when scrupulosity and guilt enter relationship doubts | | 25:43–27:18 | Encouraging clinicians to be patient, observe, and remain non-judgmental | | 27:18–28:18 | Sitting with discomfort and embracing uncertainty as an exposure |

Episode Tone and Language

The conversation is candid and supportive, blending clinical expertise with personal and cultural observations. The hosts embrace nuance, curiosity, and openness, encouraging clinicians to explore complex client presentations with empathy rather than rigid categorization. Their banter is warm, relatable, and occasionally humorous (e.g., reflections on Disney and Shrek), making clinical insights accessible and engaging for listeners.

Summary prepared for clinicians and mental health professionals interested in deepening their understanding of ROCD and its diagnostic/treatment complexities.