What cause would you donate $50,000 to? Faced with this dilemma, most people would probably choose to aid cancer research, help Syrian orphans or establish a shelter for animals. But when Leonardo, a multimillionaire American tech entrepreneur, took out his wallet, he chose to inject $50,000 into development of a website that would help people experiencing with a controversial form of a wily psychological disorder that plays havoc with romantic relationships. An exceptional decision of that scale can only be made in exceptional circumstances. And such, indeed, were the circumstances of Leonardo’s love life.
“We had been dating for four years before we got engaged, and were obviously very much in love. I was really thinking that this was going to be my life partner,” Leonardo says, recalling what ended up being the most traumatic relationship of his life. (The names of the interviewees for whom only the first name is given have been changed to protect their privacy.)
“As soon as I got engaged,” he continues, “the anxiety started and then it went through the roof. It was about crazy things that make no sense. You worry about: Is she tall enough? Is her hair long enough? What if she believes in different things than I do – will that ruin our kids? [I was afraid that] I would be miserable because of certain of my partner’s traits and would therefore break off the relationship, which would hurt her, so maybe it would be best to break off already now.
“At first I would have these thoughts dozens of times a day, and afterward hundreds of times. It sort of progressively becomes the elephant sitting on your head, and then it gets worse. I would wake up at night with the same panicky feeling. You can’t function. For a while I was afraid to leave the house, because other people would see me in this debilitated state. You are like a walking zombie.”
Leonardo was in his 40s at the time, educated and very successful, well known and highly regarded in certain circles. But this time his money and his connections didn’t help. It was him against himself, and the adversary was about to win. Two psychiatrists who had been recommended to him for therapy only made matters worse.
“It was 2013,” he relates. “The therapeutic community in the United States had no real understanding of my problem. They told me, ‘Respect your feelings, trust your feelings.’”
Leonardo laughs bitterly on the Zoom screen: “The more you are coached by professionals to think about why you might not be compatible, it has the opposite effect: You have more anxiety and are more confused.”
Leonardo and his partner went on suffering for another year and a half, and then broke up. The wedding they had planned was canceled; he remained alone. His disquiet dissipated within a few weeks, and this, in retrospect, seemed to justify his apprehension about making the relationship permanent. But something continued to bother him. In 2017 he entered therapy again, with a third professional.
It just kind of snowballed, it became worse and worse to the point where it was like 24/7 with all these doubts – horrible, horrible doubts.
“I wanted to get a perspective on what had happened, because obviously it was very painful. He told me it might be something new he’d read about, called ROCD.” What followed was an explanation that Leonardo could relate to.
“If only somebody had told me that at the beginning,” he says. “My experience was that it ruined my life, blew it up. It should not have ended the relationship.” His voice suddenly trembles. “It was unfair that it ended.”
ROCD – relationship obsessive-compulsive disorder – is a relatively new phenomenon, which first appeared on the mental-health map eight years ago. The concept was formulated by two clinical psychologists, Prof. Guy Doron from the Baruch Ivcher School of Psychology at the Interdisciplinary Center, Herzliya, and Dr. Danny Derby from the Israeli Center for Cognitive Behavioral Therapy, while discussing similar problems that they had diagnosed in their patients.
ROCD is stirring increasing interest today in academic circles. While it does not yet appear in the diagnostic manual of the American Psychiatric Association, it is already being taught in university courses, according to Doron. Three years ago a chapter the two Israeli researchers wrote about the disorder appeared in the thick “Wiley Handbook of Obsessive Compulsive Disorders” – one of the most influential publications in the field.
The phenomenon has also been covered in the media, but remains largely unknown, even among professionals, because of its confusing character. Still, some light has been shed on the subject by a series of studies conducted in Israel and abroad in the past few years. One study revealed, for example, that ROCD can be accompanied by pathological jealousy, as it is liable to lead to an obsessive occupation with the degree of trust you have in your partner.
Another study found that intensive use of dating apps is associated with an increase in obsessive symptoms. Yet a third research project discovered a clear connection between one partner’s obsessive feelings about a relationship, and an increase in the level of stress and depression of the other, “healthy” partner. Yet another form of the disorder was uncovered by a study that revealed the degree of distress felt by parents who obsess over their children’s flaws.
But above all else, Derby, Doron and their colleagues are currently engaged with the issue of treatment. On the assumption that the problem is widespread but underdiagnosed and undertreated, is it possible to assist people who suffer from ROCD by means of inexpensive, accessible internet methods, and thus spare them mental anguish and perhaps also avert some unnecessary breakups?
This is where Leonardo and his bank account entered the picture. His intense suffering was converted into a check, and the check is now being translated into an internet site that is due to go online in August.
“I remember clearly the first time I had a bit of a weird thought,” says Anita, 27, who is originally from Latin America but has been living in England for the past decade. “I was doing yoga in my room, and suddenly this thought came into my head: ‘What if you’re not in the right relationship? How do you know if this is right?’ I remember opening my eyes and thinking, like, ‘Where the hell did that come from?’”
It was in 2016 and she had been in a relationship for five years with an American man her age. Until that moment it had been successful and satisfactory for both sides. As happens in many cases of ROCD, however, their conversations about the future were a trigger for something else.
“It just kind of snowballed, it became worse and worse to the point where it was like 24/7 with all these doubts – horrible, horrible doubts. I talked about it all the time, even with my partner: ‘I don’t love you, I love you, I don’t how I feel about you. But I don’t want to break up with you, because that doesn’t feel right’” – Anita’s rapid-fire speech reflects the cruel loops she shared with her boyfriend.
He bore it heroically, but in such cases both partners are frequently hurt.
“In classic OCD, people wash their hands [repeatedly]; the tragedy with ROCD is that the couple are the ‘hands,’” says Gideon Fain, a psychologist and the director of an OCD clinic in Ramat Gan. “You are constantly checking whether the other person is ‘clean’ – meaning smart and good-looking enough – and whether you love them enough. If you’re apprehensive that you don’t, you start ‘washing’; in other words, trying to reassure yourself through a solution to the problem.”
In difficult cases, ROCD sufferers may encourage their partners to seek more education, to make them smarter, or to have plastic surgery, to make them better looking.
“I lost a lot of weight because I couldn’t eat from having so much anxiety,” Anita recalls. “Sex was really difficult at that time as well, because all I thought was, ‘I don’t know if I love you,’ ‘how do I know if I love you,’ ‘what does it mean if I don’t feel anything?’”
Sometimes she would hold her boyfriend’s hand just to check if she felt fireworks. So powerful did her distress become, that she started thinking about suicide: “I don’t know if I would have actually attempted something, but I had a lot of ideas about it. Never like a solid plan. More like… death would be so calm and sweet, and I wouldn’t have to listen to all this shit in my head, 24/7.”
If, for example, I don’t know how much I love my partner, I will count the number of times I called her today. That’s easier for me than looking within myself and understanding what I feel.
Anita pestered friends and family about their relationships: How did they know it’s the real deal? The answers were usually along the lines of, “It’s normal to have doubts occasionally,” but lukewarm phraseology of that order does not cool the core of the nuclear reactor of obsessiveness when it is on the verge of meltdown. What does “normal” mean? Or “occasionally”? And if I feel doubts all the time, what does that say about the nature of my relationship?
Still, and also characteristically, deep in her heart Anita had a vague feeling that these thoughts had somehow attacked her from outside, and that she did indeed love her partner. It’s an elusive feeling like a slithery eel in a sea of emotions, but it’s there.
Anita: “I remember feeling this dissonance – of like, being in crisis mode all the time with these questions, and when I was with my partner I was still in distress because I was having these thoughts, but I was sort of certain about my feelings for him. Does that make sense?”
‘Better off with the ex’
Anita’s paradoxical feelings make very good sense to researchers from the School of Psychological Sciences at Tel Aviv University, who have been developing a new model for OCD in recent years. According to the classic explanation, the disorder is based on the connection between anxiety and how it is relieved. Studies show that everyone is subject to intrusive thoughts, disturbing images, unsettling feelings and shocking impulses. But if a thought of that sort – for example, “Maybe I would have been better off with my ex” – leaves you deeply anxious; you might cope with it compulsively, by means of obsessive behavior. This could manifest itself in concrete behavior (such as repeatedly viewing your wedding video and analyzing your facial expressions), or it could be mental (counting the number of times you felt love for your partner in the past week).
That old model is still very much present, but it raises a number of questions. Such as, why does one person move on from disturbing thoughts like that, while another gets mired in them? The reason for this, according to the new model propounded by TAU Profs. Nira Liberman and Reuven Dar, and Dr. Amit Lazarov, lies in the difficulty some people have in accessing their true internal feelings – a situation that generates a desperate attempt to cling to the external representations of those feelings. This hypothesis, confirmed in the past decades by dozens of experiments, offers an explanation for subjects’ deep doubts, which arise from the constant need for external confirmation, and from a tendency to monitor their feelings. The monitoring itself, as studies also show, has a deleterious effect on the feelings being monitored.
“If during sex you examine how erect your organ is, or what your heartbeat is, in order to know how loving you are – you feel less,” Guy Doron says, when we met as the first wave of the coronavirus epidemic was receding, on a small patch of grass in Rabin Square in Tel Aviv. “You do not fully get the experience of the passion, because you are busy deconstructing it.”
The new model being developed in Israel is called SPIS (seeking proxies for internal states). According to Lazarov, who wrote his doctoral thesis on the subject, one of the first experiments involving SPIS dealt not with emotions but with muscle tension. The researchers compared the performances of subjects with and without OCD by means of an easy task: flexing the forearm muscle when asked to, at varying intensities. The subjects were found to have greater difficulty regulating their muscle tension. When given a biofeedback device that displayed the degree of tension they exerted on a screen, they performed well. But when the device was taken away, they were again “all over the place,” in Lazarov’s words. In other words, the problem seemed to lie not in the ability to control the muscle, but in sensing it.
Since then the Israeli scientists and their counterparts abroad have demonstrated this difficulty in relation to a range of internal conditions, including understanding and emotions. About two months ago, for example, Lazarov and his colleagues published the results of a study showing that obsessive people are far less precise than the average in rating pictures according to the degree of positive emotions they arouse.
“No one can tell you how hungry you are, or how tired, or how much you love,” Lazarov explains. “When one’s inner feelings are vague, there is an incessant process of casting doubt, and in order to get rid of the doubt you look for a substitute in external indices. If, for example, I don’t know how much I love my partner, I will count the number of times I called her today. That’s easier for me than looking within myself and understanding what I feel. This is a model with a lot of compassion. A person does not have obsessions for no reason; he has a real problem accessing internal states.”
The idea that a connection exists between difficulties with physical sensation and impaired access to emotions may sound odd. But psychologists who treat people with OCD are not surprised to hear, for example, that they decide what to wear according to the room temperature indicated by the air-conditioner remote control, or that they have a hard time choosing the right size when buying a new pair of shoes, because they’re not sure whether they are tight or not. This is evidence of common ground between physical pressure and mental pressure, between awareness of the body and awareness of the psyche.
Furthermore, when the researchers undermined the confidence of “healthy” subjects’ ability to access their emotions, the results obtained were similar to those of the obsessive subjects in the experiment. The implication is that one can render a person obsessive in laboratory conditions by implanting doubt in him. It stands to reason that a person who was obsessive to begin with, is liable to become even more obsessive if the little confidence he has in his emotions is further undermined. Accordingly, people who have symptoms of ROCD are likely to suffer acutely from therapy that encourages them to dig into their emotions, and it may even intensify their indecisiveness.
Thus, the first thing Doron and Derby do with patients in romantic distress is to get them to decide to postpone a decision about their partner for half a year.
“Indecision is not a strategy for solving problems,” Derby says. “It’s a ceremony. In ROCD, indecisiveness is the meta-obsession hovering above all the compulsions.”
Washing to excess
Epidemiological studies show that about 1 percent of the population suffers from OCD in a given year, and some 2.5 percent will experience it at some stage of their life. Currently, there are several tens of thousands of people in Israel who meet the criteria set out in DSM-5, the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: obsessions and/or compulsions that take up at least one hour a day, impair everyday functioning or cause significant distress.
People who have symptoms of ROCD are likely to suffer acutely from therapy that encourages them to dig into their emotions, and it may even intensify their indecisiveness.
Doron emphasizes that ROCD is not a “lite” or friendly version of OCD, but that at the very least, it meets the same criteria.
How many OCD sufferers are actually suffering from ROCD? In a Zoom conversation with Haaretz, Prof. Jonathan Abramowitz, from the University of North Carolina at Chapel Hill, a coeditor of the Wiley Handbook of OCD, estimated that among 5 percent of people with OCD, the focus is on relationships, as compared with the 75 percent who suffer from the disorder in its classic sense – what’s known in the professional jargon as “washing and checking.” These people are coping with symptoms associated with OCD in popular culture, such as washing hands, organizing objects and repeatedly checking whether the gas is turned off. The remaining 20 percent suffer from other, “esoteric” forms of OCD, such as harboring obsessive doubts about one’s sexual inclinations.
Usually a few years go by after the first symptoms arise until OCD is diagnosed, if at all. But cases of ROCD are particularly complicated, because we are all occupied in evaluating our interpersonal relations to one degree or another. There are two boundaries that are blurred here: The first relates to quantity, namely, how much is considered too much. Doron suggests a rule of thumb: If you’re occupied by thinking about it for more than two-three hours a day, there is a good chance there’s a problem that needs to be addressed. The diagnostic criterion mentions one hour, but due to the widespread preoccupation with this subject, he thinks otherwise.
The second, and even more complicated, boundary relates to the question of essence. A person who washes his hands 80 times a day is undoubtedly overdoing it, unless he’s a sanitation worker in a coronavirus ward. But perhaps I am actually harping on my relationship because the relationship is screwed up – and not me? Doron admits that this is not a simple distinction, especially when there is an evolving dynamic of destruction: An obsessive occupation with the relationship is liable to harm it, in which case a problem that originated in your mind morphs into a real problem. No one wants to hear that her partner is constantly thinking about flaws in her skin, for example.
Prof. Jonathan Huppert, an expert in OCD in the psychology department of the Hebrew University of Jerusalem, is not fully convinced that a sharp and clear distinction can be drawn between “healthy” doubts and doubts that spring from OCD. At the same time, he is certain that those who have a tendency toward OCD are liable to express it also in their romantic relationships.
In the background, there will of course be one’s social and cultural climate. The connection between romance and obsession is likely to be particularly strong in a society that emphasizes the “rightness” of the choice of one’s partner, and how “precise for me” the person is. Huppert likens this to OCD associated with the observance of religious commandments. “The ultra-Orthodox don’t have OCD more than others,” he says. “But when they do have OCD, it usually manifests in matters relating to religion. Similarly, in a culture that attaches supreme importance to the romantic link, it’s a reasonable assumption that OCD will be given expression more in connection with relationships.”
Gideon Fain treats ultra-Orthodox, secular people and members of his own religious-Zionist community suffering from ROCD. His impression (which is not scientific) is that the religious-Zionist community in particular suffers from ROCD, because of a distinctive combination of a desire to achieve perfect accord between the two partners, and a deep fear of divorce.
“Among the Haredim, there are [only] a few meetings before the wedding, so they don’t have high expectations of a perfect romance,” he says. “Secular people do have high expectations, but they also have a more flexible attitude toward divorce. Among the ‘knitted skullcap’ population there is, on the one hand, insane idealization of the spousal relationship, a search for spiritual harmony together with romantic harmony – which is a lethal cocktail – and on the other hand, they see marriage as the holy of holies and consider divorce to be the end of the world.”
Despite the complexities, practitioners in the field believe there is a way to distinguish between normal doubts and obsessive indecisiveness. They have adopted a few key sentences to help them explain the difference to patients. Anita, for example, relates that in one of the sessions she and her partner attended, the therapist asked him, “Do you feel that you love her at this moment?” He replied that he did not.
“I didn’t know that it was possible to know that I love someone and not feel it all the time,” Anita says. “I was stunned by what the therapist asked me: ‘Do you feel burning love for your mother nonstop? Then why should you feel it for your partner?’”
Like a broken-down car
The ROCD diagnosis is vulnerable to attack from several directions. Some students of OCD maintain that there is no need for it: OCD is OCD, period. Devotees of polyamory will claim that monogamy is to blame for everything, that if there is no absolutely unequivocal commitment between partners, there are also no anxieties. Practitioners of dynamic psychology who base themselves on abstract models of the psyche will say that such a diagnosis reflects a reduction of the human experience, and that in any case people should not be treated by way of a series of repairs, like a broken-down car.
But it’s hard to argue with the tremendous sense of relief felt by people who have experienced the symptoms of ROCD when they hear that diagnosis. In many cases they suspected that they had a problem, but went through a whole series of therapists who failed to identify the obsessive element in their romantic ties and instead focused on less relevant aspects of their personality or their past.
Aharon, who was worn out from examining obsessively the most minute nuances of his fiancée’s behavior – afterward, she became his wife – went through absolute hell in an attempt to get help. After consulting a well-known therapist who only aggravated his condition, and meeting with several psychologists who didn’t help, he finally met with an elderly psychologist with a highly developed sense for OCD, who made the diagnosis within a minute. “‘You have OCD, you know,’ he told me, and it was one of the happiest days of my life,” Aharon recalls.
When Anita found out about ROCD online, she cried for sheer joy. She couldn’t find suitable therapy in London, so she is being treated to this day by an Israeli therapist via the web.
The difficulty in obtaining reliable information about the diagnosis and treatment of the disorder is one of the motives behind the new website that Doron and Derby are working on now, with their team. The site will take the form of interactive courseware, based on the main points of the treatment protocol for the disorder, which is itself currently being formulated. The site includes questionnaires for diagnosis and follow-up, written explanations, video-clips and worksheets. The method also uses cognitive behavioral therapy (CBT), which is the most proven treatment for OCD, and for the specific problems of ROCD.
As part of the cognitive component, patients are required to challenge and grapple with their extreme beliefs, such as, “If the relationship is not completely harmonious, it’s apparently not true love.” On the behavioral side, patients are urged to refrain from indulging in characteristic compulsions, such as turning to Google with abstract searches like “I’m not sure of my feelings,” or avoid watching romantic comedies. A considerable portion of the process is devoted to exposure and response prevention (ERP), a tool from behavioral therapy that is considered to be a key element in the effective treatment of OCD.
“It can be brutal,” Anita says, relating how she was sent to record herself describing in tremendous detail the horrific scenario of the disintegration of her relationship, and to listen to it for an hour every day.
What, then, is the website? A tool to support therapy, or therapy itself? That depends on whom you ask. Doron considers it to be a base that in the future will develop into a system that will enable a patient to help himself – with human supervision and support. The method is known as “guided self-help,” and in recent years, he says, an increasing number of studies support it as effective treatment for OCD.
In general, Doron is a great advocate of treatment by technological means. He and his friend Gur Ilany, a children’s author, have developed an application called GG Self Care & CBT Journey, which is intended to assist people suffering from several types of mental difficulties by means of a game that takes three minutes a day. The app’s ostensible superficiality is liable to make the user uncomfortable, however. With its ROCD platform, for example, the user is asked react by means of touching the screen to statements like “My ambivalence dominates me.” Those who are laughing may find themselves less amused when they hear that an experiment has shown that the app has succeeded in causing significant improvement regarding ROCD symptoms in about half the subjects. An article about the experiment is forthcoming in the well-regarded Journal of Affective Disorders.
OCD experts Huppert and Abramowitz express a certain skepticism about treating the disorder by digital means.
“Doron’s work is interesting, but it is preliminary,” Huppert says. “I am developing therapy programs via computer for disorders of panic, social anxiety, even depression. But OCD demands the personal tailoring of the therapy to the specific behaviors of the patient, and that is far more difficult to do via a tool that is general in character and internet-based.”
Derby and Doron believe that solutions of this type are compatible with the proper use of resources existing in the mental health system. The wisdom, as is clear to everyone, lies in identifying those simple cases that can be aided by treatment of the kind they suggest, and leaving the costly hours of the therapist for the more complicated cases. A may concern – which Doron is trying to deal with – is related to the “burnout” of patients who were not helped by therapy in its “lite” version. Even though they were only treated via computer, they are liable to think that they have already tried psychological treatment and will refuse other attempts, though they may help them.
What does Leonardo think about the site that’s being built with his money, in order to address a problem that changed the course of his life?
“I would love to see it as a stand-alone tool,” he says. “I think that ROCD is such a nasty, pernicious condition that you’re going to need your hand held very firmly [during therapy]. Because in therapy you have to live your worst fears. And nobody is going to do that on their own, just because the computer tells them to!” he laughs. All in all, he adds, the site offers both patient and therapist tools that will help them in the process.
Leonardo is once again involved in a serious relationship and is readying himself for the possibility that the obsessing will “unpack again.” That won’t be easy to deal with, he admits, “but at least at this time I will have a framework for anticipating these attacks, and coping with them.”