← Breaking the Rules: A Clinician's Guide to Treating OCD
Breaking the Rules: A Clinician's Guide to Treating OCD
Is it ROCD or is there a real problem in the relationship?
00:30:05
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- [00:04]
A
This is Breaking the Rules, a show for mental health professionals designed to help you build confidence in treating obsessive compulsive disorder. I'm Dr. Celine Galgic, and I'm a clinical psychologist who works extensively with OCD.
- [00:17]
B
And I'm Dr. Victoria Miller, but you can call me Tori. And I'm a clinical psychologist who works with young people, including those with ocd. Through our shared professional experience, we've found that effective treatment of OCD requires commitment. Commitment, creativity, and the recognition that things can sometimes get a little messy.
- [00:34]
A
They sure can. We want to empower clinicians to be able to work with their patients in new ways to treat OCD with confidence. Hello and welcome back to our next Skills episode. Today we are diving into the world of relationship ocd. We are social beings, and relationships make up a key part of how we function in life. It's something that a lot of our clients can grapple with when dealing with ocd.
- [01:01]
B
In this skills episode, you're going to hear us talk all things rocd. We discuss what relationship OCD is and how to treat it. And we also explore the reality of doubt in all relationships and the influence our society and culture have on our beliefs about relationships and the impact that this can have on someone who has ocd. Let's get started.
- [01:27]
A
Hi, Tori.
- [01:28]
B
Hello, Celine. Let's do it. You and I have both seen a lot of stuff on social media, and we've had people talking to us about relationship ocd. And it does seem like the idea of ROCD is so hot right now.
- [01:44]
A
Yeah.
- [01:44]
B
You know, like a lot of people are talking about it. One of the things that we're hearing is the question of is relationship OCD actually a thing? Because people are talking about how they've got doubts in their relationship. They're not sure if this person is right for them or maybe this person's cheating on them, and they just can't seem to get this thought out of their brain. And so they've got rocd. And that, I think, aligns itself with the way a lot of people think about ocd, which is, oh, I just have to clean my hands so much, or like, I just like things to be neat and tidy, or I love it when things are, now I really need my kitchen to be spotless, therefore I have ocd. And I do think that this kind of questioning about ROCD is kind of the same thing.
- [02:32]
A
Yeah, I would agree. I think it's one of those things where sometimes when we are experiencing something that feels unusual or unfamiliar to us, we look For a reason to try and explain what it is. Right.
- [02:45]
B
So total human behavior. Right?
- [02:48]
A
Yeah. We're always looking for explanations. And I think it's one of those things that can be not easily done but considered or thought of or looked into. If you know you're in a relationship and you really like the person, but there's doubts coming up, like, as you said, is so normal. Oh my God. Like in the 10 years that I've been married, I mean, I might. I say this all the time. I mean, I could have been divorced 100 times by now.
- [03:15]
B
Well, no, I agree. Because, yeah, I actually think that the checking in is actually a really healthy part of a relationship. Right. Like, are my relationship needs still being met? I mean, I've been married only a little bit longer than you, but our relationship now is quite different to what it was when we first began. Like, it goes through all of these beautiful evolutions. I mean, for people who don't know Esther Perel, she's a world famous couples therapist who has an incredible podcast and has published beautiful books and she has these incredible seminars. But she talks about how people have multiple marriages or relationships in life and often those are still with the same person. She's reflecting on is how relationships evolve. And so the relationship you have when you've been married for 10 years is different to when you've been married for one year. And you know, so anyway, I digress. But what I'm talking about is that checking in the thoughts we have is actually, I think, a really healthy function. The problem is when we judge ourselves.
- [04:14]
A
Yes, exactly.
- [04:15]
B
Having those thoughts.
- [04:16]
A
Right. Or be really black and white about it. Like we are conditioned from such a young age to think, oh, you got to live happily ever after. And the happily ever after is daisies and roses and whatever and no arguments and everything's bliss and you're skipping down the street holding hands.
- [04:36]
B
And I'm thinking about all the Disney films I watched when I was growing up.
- [04:39]
A
Yeah, same.
- [04:39]
B
But they also only ever got to the wedding. Like they didn't show us.
- [04:42]
A
No one showed you after what happened is they didn't want to. They knew. No, I'm joking.
- [04:53]
B
Yeah, I was thinking the Shrek. Shrek showed what happened next in Happily Ever After.
- [04:58]
A
But that came so much later. Yeah, it did.
- [05:01]
B
Right. Like that was. I was an adult when Shrek came out.
- [05:03]
A
Yeah, Like Shrek was one of those earlier cooler looking cartoons, like, where it was more, I think, carried a lot more adult humor and stuff like that in there too. Like there were different layers of the movie it was. Was, I think, one of the earliest sets of those sorts of movies, which are so beautifully done now.
- [05:23]
B
Yeah. Agree.
- [05:24]
A
Yeah, absolutely. We didn't get to see after the wedding. Oh, my God. But, yeah, I mean, these are the things. But also, you know, even in today, you see things posted on social media and people show us what they want to show us, and then, you know, you hear about separations or whatever else happening, and we get surprised or shocked or even when we hear about celebrities, you know, it seems like a certain way. And then you hear about them separating, and you're like, oh, wow, I would never have thought that. But it's like, hang on a minute. Yeah.
- [05:59]
B
Well, you know what I just watched at your recommendation? The Fall of Ruby, Frankie. Oh, yes, right. Speaking of a story about what's publicly presented versus what's actually happening behind the scenes.
- [06:11]
A
So devastating and awful.
- [06:13]
B
Terrible story. Absolutely terrible story. But you're so right to the world. At first, the public presentation of this relationship and the relationship with kids was family life was one of hard work, but it was perfection. And it was actually. It was a lie.
- [06:32]
A
Yeah, it's really full on, definitely. But, you know, it just kind of goes to our brain, tries to gather all this evidence and it tries to delve into looking for reasons and whatever when things start coming up for us and we start comparing comparisons of the Thief of Joy. But, you know, we're very much social beings and, well, a lot of people, if we think about for ourselves what's normal in inverted commas, you know, in terms of what's expected, what's acceptable, all that sort of stuff, we look out to the rest of the world to help guide us, gather that information so we can make decisions. Right. So I think when it's skewed in particular ways, we're not getting a full representation. So I guess the point of this episode, from what you and I, I think, want to hit home with today, is it's make room for the doubt. It's not black and white. It's okay to have doubt in relationships, and it might not be relationship OCD that you're dealing with. So when you've got a client in front of you who is saying, I think I've got rocd going, okay, let's actually explore what is going on here. Let's put the OCD diagnosis aside for a second. Tell me about your relationship. How did you meet? What's happening right now? What are your doubts? What are your concerns? How is that impacting on your life? What are you doing to manage the thoughts that are creeping in, the doubt that's creeping in. What does that picture look like? And I think when we explore relationships and the nature and the context of the relationship in that way, because we're coming in objectively, we can very much go, oh, actually I don't think this is rocd. I think there's genuine doubt in this relationship. And fair enough, because guess what?
- [08:15]
B
People with OCD can have normal doubts too. Normal doubts too. Right. OCD is not about having doubts or not having doubts.
- [08:24]
A
No, not at all. It's not black and white in that way. People with OCD also have normal human experiences.
- [08:30]
B
Absolutely. Because one of the reasons we wanted to talk about this was this question of is everyone kind of hamming up? I mean, doubts are normal. Everyone's kind of going, oh, I've got doubts, therefore I have rocd. What does it actually look like when someone actually has rocd? So maybe if we talk about that, because then we can use that as a point of reference for distinguishing ROCD from regular relationship doubts and how clinicians might be able to tease that apart. Because I don't want clinicians just going, oh, everyone thinks they've got rocd. You're probably not right. Well, let's look at what those parameters are. Like the clinical guide for how you would discern what is and what isn't.
- [09:07]
A
Yeah, like, we don't want to be dismissive. You don't want to invalidate your client. You want to be able to go, okay, let's. Let's explore that together and see where it lands. Right. If we kind of think about OCD in general, because the DSM doesn't have a whole list of subtypes. Like, it's literally just a general. This is what OCD is. And the content of the obsessions, I think, is what people over the years have started to go. Okay, if the content is more harm related or relationship related or health related or incest related or whatever it is, then the extra acronyms have kind of come along, but they're not in the dsm. So if we think about the DSM in and of itself, it talks about obsessions being present. So intrusive, unwanted obsessions about a particular topic that take up a fair amount of the day, which then creates significant amounts of distress because they are ego dystonic, inconsistent with our values and beliefs, followed by compulsions. Whether the compulsions can be mental compulsions, such as ruminating, scanning over events in your mind, mental comparisons, checking, etc. Or they can be Observable, like reassurance seeking, instance of things like contamination and harm. It could be like physical checking, hand washing, et cetera. In the case of relationships, more specifically, what that might look like is experiencing really significant ego dystonic intrusive obsessions around a relationship. But the relationship can be not just intimate relationships. It could be about caregivers, parents, if you're a younger person, or if your client's younger. Teenagers with friends can also experience these intrusive thoughts, et cetera. So the relationship can be any form of relationship. It could even be a work relationship as opposed to just the classic intimate ones followed by intense distress and then things done to alleviate it. And those things could be things like monitoring and checking feelings like, do I feel love? Am I looking at other relationships? What's my partner like compared to that person's partner? And thoughts. So like, do I have critical thoughts about my partner? Am I experiencing doubts in this relationship? Other things that could be done is trying to recall good experiences with the partner to check that they still love them. You might be intimate with your partner and you know, during sex might be like, okay, well, am I turned on? Am I really loving this moment? Is this setting me on fire? Or whatever it is. Other things could be, like I mentioned before, seeking reassurance sometimes concerns consulting with friends. So like, lots of, oh my God, he did this. What do you guys think? And trying to get lots of opinions from other people or your family or therapists, sometimes even fortune tellers and psychics about their relationship for reassurance and confirmation. Testing your partner could be another compulsion to see whether they are intelligent enough or whether they are still in love with you, you know, or you know how we think. They should know what I need for my birthday, or they should know where I want to go for dinner for date night, or whatever it is. Attempting to correct the partner to fit the obsession or need. So engaging in those just right behaviors. Now, everything I've listed is something everyone can relate to at some point in a relationship, right? The problem here is, I think when it cross, what we can consider is, is it crossing over into OCD territory if the behavior is causing you distress where you're like, I need to know. Or if we think about the ego dystonic, there's an element of deep down, I know I have no doubt in my relationship, I know this is uncalled for, I know I love my partner or I feel secure in my relationship, but it's just these thoughts and doubts that keep coming in that are really frustrating. For me, or causing me a lot of doubt. The other thing to think about is how much of the day is it taking up? Like, how excess is it? I always think about functional impact. How much is this behavior impacting someone's life? And if it's taking up at least more than an hour of the day, then we're bordering on. We're now probably looking at relationship type ocd. Having said that, though, we still have to think about the context of the relationship, because that's the first question I always ask. Tell me about your relationship. Tell me about what it looks like. How do you navigate conflict? Because sometimes times of conflict can also bring up these moments, so, you know, other doubts, episodic rather than ongoing, and so on and so forth. And so again, if there's genuine doubt in the relationship, but it's still causing distress and taking up time, I would likely think there's a preoccupation here because there's something that's uncomfortable going on for this client. And I probably wouldn't think that it's relationship ocd.
- [14:10]
B
Yeah. Because if I think about times where I've had friends go through significant relationship conflict, they have been really preoccupied, they have been wanting to talk about it, they have been seeking reassurance, they have been doing. Checking with their partner, and it has been really stressful, uncomfortable time. But relative to the reality of the situation at the time, it fits, given the conflict that's being experienced. Your mention of context is so important because, yes, I would argue in those times, functionally quite disabling because they can't stop thinking about the relationship. They're distracted at work, on the phone, night and day, talking to people about. Because when we're in crisis, that's what we do.
- [14:51]
A
That's what we do.
- [14:52]
B
Yeah, but we're not talking about those situations, are we?
- [14:56]
A
No, I agree. So I think that in and of itself, like in with. When it comes to relationship type ocd, I think, yes, we've got the criteria for the dsm, but we really need to consider context.
- [15:08]
B
Yes. And I think actually people with OCD are actually pretty good. I mean, they know, like, they know when it doesn't fit. Right. When they're like, I know that it's fine, but I just can't stop thinking about it. You know, they can really discern, I think, what is contextually appropriate.
- [15:24]
A
Yes.
- [15:24]
B
And what isn't.
- [15:25]
A
And if clients are coming at us with. But how do I know if it's OCD or not? That's part of OCD as well.
- [15:32]
B
So True.
- [15:32]
A
It's part of reassurance seeking. It's a way to elicit reassurance. So that's part of that picture too, because it comes up quite a lot. And had clients over the years with OCD and with other subtypes come to me going, I now think I have rocd, but really it's a genuine doubt in the relationship. And I say that. I'm like, look, this is not your first rodeo with OCD themes, right? Like, you know what it looks and feels like. Does this feel like OCD doubt or genuine doubt? And then they'll look and they're like, it feels like genuine doubt. And then you can see like the drop in the shoulders, the like almost shame creeping in because they feel bad for feeling that way. Especially when someone has scrupulosity as a trigger. Oh, whoa. Like, if someone has scrupulosity as a trigger, feeling doubts in their relationship and even having thoughts of breaking up with someone or ending the relationship and then being the bad guy in inverted commas is so painful.
- [16:29]
B
Yeah. I've had young people I've worked with who have had doubts in their relationship with their parents as they're going through adolescence and. And it causes them so much shame during that process of individuation because they feel like they should be devoted to their parents and love them unconditionally. And they find the process of stepping away, building their own mind, having their own thoughts and belief systems really torturous. And they become really preoccupied with, am I harming the relationship? And doing lots of compulsions to try to make sure that the relationship is intact.
- [17:00]
A
Individuation is expected. It's a normal developmental milestone to reach. And so absolutely, like there are all of these, all of these things we need to be mindful of to help us determine is this proper ROCD or not.
- [17:16]
B
And I think the truth is, is that the compulsions are really disabling. And I do think that when someone's in the room with you and they're engaging those compulsions, I think, and if you've asked the questions and being curious and open minded about both possibilities, I think it actually often is quite. I think you can see it. I think one of the things that I wonder about for clinicians, I know that one of the broader debates for psychologists and I suppose clinicians more generally, is when to diagnose, when not to diagnose. And I think that there is a real resistance to labeling everything. And I do get that. And I also agree with this, that we don't have to label everything. The human experience is extremely complex, and diagnostic labels can be helpful. They can be harmful. And I think we have to use our clinical intuition, as well as a really collaborative approach with our clients to decide when it is worth really, truly kind of labeling something or not. But what I worry happens for clinicians when it comes to the subtypes of OCD is that I sometimes feel that maybe there's a bit of resistance, like, oh, God, not another label. Like, stop with the labels already. Like, so with labels. And in some instances, that might be true. But I think that there are a lot of people with OCD who find identifying the type of OCD very useful because it relieves them of a sense of guilt. I think it gives them direction, it helps them contain, it helps them to focus their exposure work, and I think it can be really useful. But I do know that in the broader community, it's like, I'm not another one, really. Do you really have to also have rocd? Do you have to have all of them? And I think we can be, as a group, kind of judgy about clients when they want to use these terms. And I think we have to be really careful because it's not respectful, it's not kind, it's not collaborative. Talk to our clients about it. Ask what that motivation is, what it does for them, what the meaning is, what the purpose is. Go down that garden path. But I think I just wonder if that is part of the discussion here. The resistance to using the ROCD term is it's like, guys, you don't have all the things like, just calm down. You just, you know, just have some doubts.
- [19:30]
A
That's definitely kind of coming off the. You know, we've had, Tori and I have had in the last month, probably a few people come up to us and ask us, is ROCD really a thing with clinicians? And so, yeah, exactly. It's one of those things where 100%, it's so helpful for a lot of people. I'm always surprised at how much or how often clinicians sometimes will hold back from having transparent discussions with their clients. And like you said, it's just showing a genuine curiosity, like, we can have conversations with our clients. We're being respectful and curious. We're not being, like, patronizing or anything. It's just, tell me what this. You know, exactly what you said. You said it so beautifully, so respectful. And I think it's something that we can definitely do with our clients. I'm with you on that 100%. So. So if we have hopefully shed some light in terms of what it is and what it isn't. What do we do then with it? How would we treat it? So, as Troy mentioned, if someone is dealing with ROCD and we're having these open, curious discussions with them, we've always said the theme doesn't matter. But it does matter in a sense that from a treatment perspective, the protocol is very similar. But from a content perspective it's important because you need to know what the content is to kind of weave into your exposure tasks. But also, again, like you said, some people find it really helpful to understand this theme that they're dealing with and it gives them a sense of autonomy, I would say, and understanding. So what do we do with it? Hey, Tori.
- [21:13]
B
Hi, Celine.
- [21:15]
A
Did you know that we run our own courses here at Melbourne Wellbeing Group?
- [21:18]
B
I did know that. In fact, it's one of my favourite things we do here because it's a great way to help psychologists and other clinicians learn more about ocd, which means.
- [21:28]
A
We get to help more people. So if you're a clinician who works in mental health and you're interested in learning from us, then get in touch.
- [21:36]
B
For more information, head to www.melbournewellbeinggroup.com and click on the webinars and Books tab.
- [21:44]
A
Alrighty, back to the show. Go.
- [21:49]
B
Treating ROCD is really the same as any other subtype of ocd. You do an assessment, you identify the obsessions, so those intrusive thoughts, you identify the triggers, so the situations, the people, the circumstances, the memories, the smells, whatever it happens to be that seems to be setting things off, you identify the worry beliefs, so those sort of secondary, like, what ifs, you know, what does this mean? If I think this thing, does it make me a bad person? Does it mean that the relationship's going to fail? Does it? You know, whatever those worry beliefs happen to be, you identify those, you identify the compulsions, so the things that you want to start resisting. And you build your exposure plan, be that a menu or a hierarchy, depending on what style you and your client prefer to use, and then you work systematically through it and you apply all the usual techniques. So mindfulness based interventions, because of course we want to do that rather than distraction. So we want to be noticing and sitting with rather than trying to avoid. We want to be actively exposing ourselves to circumstances where we're going to be triggered and then practicing urge surfing, practicing delay, practicing body regulation, so breathing, grounding and, and reminding ourselves that we're capable, we're capable of Moving through this, you know that these feelings will pass, that we can handle. Whatever the hard thing is, if the worst case scenario happens, so be it. We will deal with it. We're practicing all of those, and then we're moving through each of the triggers, each of the compulsions, until it gets easier and easier to deal with.
- [23:34]
A
One thing I want to add, if I can, is what happens when your client comes to you, where, you know, you're dealing with other themes and stuff, and then they're like, I think I have rocd. And then you talk about it, and they have genuine doubt in these instances, Something I'm always really mindful of. And you can tell me about your experience. Tell us about your experience as well. Tori is just making sure that ocd, which is already present in other themes, doesn't turn that genuine doubt into a thing, which actually, then, for me, we're dealing with scrupulosity. Because what happens in that instance is the not wanting to be the bad person or feeling guilty for having those thoughts and feelings, or feeling shameful or whatever it is triggers the scrupulosity, which then looks similar in a sense where it's, is this the right person for me? Am I in the right relationship? Or is this friendship meeting my needs? Is my friend available for me all the time? Or whatever it is, whatever. The context is so similar sorts of thoughts and feelings, but really it's stemming from that guilt and shame tied in with scrupulosity. Because deep down, the thought is, I think I need to exit this friendship, or it's unhealthy for me, or I think I need to end this relationship or whatever else, or have more separation from my parents and set boundaries in place. And, yes, so I think in those moments, we really like the nuances of going, what are we actually dealing with here? Is really important. And making sure that we're addressing those and really kind of going, okay, again, similar to what Tori was describing. What are the compulsions look like here? What does the avoidance look like? Is there rumination happening, et cetera? And what kind of skills and tools can we have in place to help our client pull this back in order to help them stay in that discomfort and keep moving through it, to help then make those decisions as opposed to getting stuck in the ruminating or the obsessing and not having decision paralysis, really?
- [25:43]
B
And I think it reminds me of that, that idea about responding, not reacting.
- [25:47]
A
Yes.
- [25:48]
B
And it could feel, as a clinician, and I have no doubt as a client, really challenging to try to discern the origins of these thoughts. And I think as clinicians we can sometimes feel an enormous sense of responsibility to be able to do that for our clients, to be able to know exactly the source. Like is it scrupulous, is it rocd? And you know, what we can't know and we can only know also what our clients know, what they present to us. We're not magicians, we're not psychics, but what we can do is be patient, not feel like you've got to jump to and say this is exactly what's going on. You can be curious. And this is where some sort of act based principles and mindfulness really kind of come in, which is just be an observer, just be a nonjudgmental observer because there's no harm that is coming to someone who just says, look, I'm just going to. I've got an urge to sort of to stay with or to break up with this person or whatever. It's like, okay, we don't have to decide today whether we are saying that, you know, what you need to do here. Like let's just observe, let's just see and just spend some time being curious and open minded and non judgmental and see where it comes to and, and help sort of with. And I don't think that's inconsistent with an ERP approach. It's not the same as going, well, let's see what the symbolism and the meaning is. Let's deep dive, deep dive, deep dive. And getting caught in sort of the mental ritual of having to go over and over and over. It's still very consistent with ERP to just do non judgmental observation and just wait and see and just take a responsive approach as opposed to a reactive approach.
- [27:19]
A
Agreed. Because those conversations and that space of curiosity is painfully uncomfortable. So that in and of itself is an exposure task because you're exposing the client to their uncomfortable doubts and thoughts and experiences. You're helping them hold that space by sitting with them in the doubt and uncertainty and being curious about it and reflective. And then when you notice reassurance seeking creeping in or doubt creeping in in that way, it's okay to go. I think let's come back to that discomfort. Let's lean into this and keep exploring it together as opposed to giving in to whatever's going on. So that's your erp. You know, in a sense of. It might not look traditional, but we're choosing discomfort and leading into doubt and uncertainty without the rumination and all the rest of it that comes with it. Especially I think more so when there's genuine doubt in a relationship.
- [28:19]
B
And this is the part of treating OCD which might be about the person more than the specifics of applying ERP to a symptom and a diagnosis. This is where we sit in a space and we hold our clients and we just help them walk through life because it happens.
- [28:36]
A
And like we said earlier, people with OCD who have an already existing diagnosis, they're not immune to normal doubts and experiences of life.
- [28:44]
B
Agreed.
- [28:45]
A
Well, that's it for our skills episode for today. Thank you Tori.
- [28:48]
B
Thank you, Celine. It's been great as always.
- [28:50]
A
Hopefully it's helped provide a little bit of clarity for our listeners, but also raised some really interesting points of discussion. So thank you everyone so much for listening. As always, we will catch you next time you've been listening to Breaking the Rules, a show for mental health professionals designed to help you build confidence in treating obsessive Compulsive Disorder.
- [29:14]
B
This podcast is brought to you by Melbourne Wellbeing Group, a psychological practice based in Melbourne with a special focus on treating OCD. To find out more, head to our website, melbournewellbeinggroup.comau all one word, that's melbournewellbeinggroup dot com this podcast was made with.
- [29:32]
A
Strategy and production support from Wavelength Creative. To make sure you don't miss an episode of Breaking the Rules, be sure to subscribe to or follow the show in your podcast app. And while you're there, leave us a five star review. It really helps others find the show. I'm Celine Galgett.
- [29:49]
B
And I'm Tori Miller.
- [29:51]
A
And we'll be back next episode with more reasons to convince you to get messy, have fun and break the Rules.