How to treat obsession in relationships?

Treatment of Obsession in Relationships

If the obsession involves intrusive, unwanted doubts about one's partner or relationship that cause marked distress and are accompanied by compulsive checking, reassurance-seeking, or avoidance behaviors, this represents Relationship Obsessive-Compulsive Disorder (R-OCD) and should be treated with exposure and response prevention (ERP) therapy as the first-line intervention. 1

Critical Diagnostic Distinction

Before initiating treatment, you must differentiate between two distinct presentations:

• Sexual Orientation OCD (SO-OCD): Intrusive, unwanted thoughts about one's sexual orientation that cause distress because they are ego-dystonic (inconsistent with one's actual identity), accompanied by compulsive checking behaviors, reassurance-seeking, and avoidance 1
• Relationship OCD (R-OCD): Obsessive preoccupation with doubts about whether one's partner is "right," whether one truly loves them, or excessive focus on perceived partner flaws, accompanied by relationship-focused compulsions 2, 3

Common pitfall: SO-OCD is misdiagnosed as a "sexual identity crisis" approximately 50-84.6% of the time by clinicians, leading to inappropriate treatment 1. The key distinguishing feature is that SO-OCD thoughts are unwanted and distressing because they contradict the person's actual orientation, not because they represent genuine questioning 1.

First-Line Treatment: Exposure and Response Prevention (ERP)

ERP is the gold-standard behavioral treatment for all OCD presentations, including relationship-focused obsessions. 1

Core ERP Components for Relationship Obsessions:

For R-OCD specifically:

• Identify feared scenarios (e.g., "What if I don't really love my partner?") and catastrophic beliefs 3
• Create graded exposure hierarchy targeting relationship doubts 3
• Practice exposure to uncertainty without performing compulsions (checking, comparing, reassurance-seeking) 3
• Target covert rituals including mental compulsions and reassurance-seeking, which are particularly prominent in sexual and relationship obsessions 1

For SO-OCD specifically:

• Use controlled graded exposure to sexual imagery that triggers obsessions 1
• Employ imaginal exposure focusing on perceived negative consequences (not physical encounters) 1
• Address three key areas: (a) LGBTQ+-affirming psychoeducation to correct misinformation, (b) neutral or positive exposures using pride flags or neutral media, and (c) exposures targeting core fears using the downward arrow technique 1

Critical treatment consideration: Never use exposures that target identity-based anxiety or reinforce stereotypes; only use such exposures upon client request and in a sensitive, collaborative manner 1

Evidence for ERP Efficacy:

A case study demonstrated dramatic improvement in SO-OCD symptoms: Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores decreased from 24 at intake to 3 at post-treatment and 4 at 6-week follow-up after 17 sessions of ERP 1. This represents a shift from moderate symptoms to minimal symptoms.

Couple-Based Cognitive-Behavioral Therapy

For patients in romantic relationships, couple-based CBT enhances treatment outcomes beyond individual therapy alone. 4

A 16-session couple-based CBT program should include:

• Partner-assisted ERP exercises 4
• Techniques targeting symptom accommodation (when partners enable compulsions) 4
• Addressing non-OCD relationship stressors 4

This approach produced substantial improvements in OCD symptoms, relationship functioning, and depression that were maintained at 12-month follow-up 4. This is particularly important because R-OCD symptoms are linked with decreased relational and sexual functioning even after controlling for other OCD symptoms. 2

Cognitive Interventions

Target specific maladaptive beliefs that maintain relationship obsessions:

For R-OCD:

• Challenge perfectionism about relationships and partners 2, 5
• Address beliefs about needing certainty in relationships 2
• Target OCD-related beliefs (overestimation of threat, inflated responsibility) 2

For SO-OCD:

• Address contamination-based disgust coupled with responsibility/threat overestimation beliefs, which uniquely predict sexual orientation obsessions 1
• Challenge rigid beliefs about homosexuality, identity concerns, and implications of "incorrect" feelings 1
• Target "feared self" beliefs that significantly relate to SO-OCD 1

Pharmacological Considerations

Sertraline is FDA-approved for OCD treatment and should be considered as adjunctive therapy, particularly for patients with severe symptoms or comorbid depression. 6

• Sertraline has demonstrated efficacy in maintaining OCD response for up to 52 weeks 6
• Evidence for SSRIs in sexual obsessions specifically shows mixed results 1
• Important caveat: Medication alone is insufficient; combine with ERP for optimal outcomes 1

Special Population Considerations

LGB individuals with relationship obsessions:

• Report greater doubt regarding partner's love, more negative affect, antagonism, and perfectionism compared to heterosexual individuals 5
• Require personalized interventions acknowledging minority stress 5
• May experience SO-OCD regardless of actual sexual orientation (not limited to heterosexual individuals) 1, 7

Gender differences:

• Males are twice as likely to experience SO-OCD, but females report higher distress levels 1
• 91% of those with SO-OCD report distress ranging from "much" to "suicidal" 1

Treatment Pitfalls to Avoid

1. Do not provide reassurance about relationship doubts or sexual orientation—this maintains the OCD cycle 1
2. Do not recommend "testing" arousal through pornography viewing—this is a compulsion that provides only transient relief 1
3. Do not confuse SO-OCD with genuine sexual identity exploration—the distress in SO-OCD comes from thoughts being ego-dystonic 1
4. Do not ignore covert rituals like mental reviewing, self-reassurance, or internet searching 1
5. Do not use exposures that tokenize LGBTQ+ individuals or play on stereotypes when treating SO-OCD 1

Monitoring and Maintenance

• Reassess severity using Y-BOCS at regular intervals 1
• Monitor for depression, which is common in both R-OCD and SO-OCD 1, 2
• Periodically re-evaluate long-term medication need if using SSRIs 6
• Address impact on family members and partners, as excessive reassurance-seeking adversely affects relationships 1