If you have a child, significant other, or friend who has OCD, you likely know the suffering it can create. Or maybe you don’t; that’s okay. The unfortunate reality for most clients once they appear in my office is that OCD has culminated in tremendous levels of stress and disability. 14-17 years from the onset of OCD is the average needed to obtain evidence-based treatment. By this time, OCD is typically well-developed. Sometimes, it can function under the level of awareness, even when severe. Family members often feel guilty that they missed it for so many years. You are not alone. This article presumes basic knowledge of OCD, so if you are brand new to the topic, I recommend a primer, such as the following on my OCD Resources page: Intro brochure, ERP for OCD Presentation, and the IOCDF’s “What You Need to Know About OCD”
OCD is an extremely debilitating disorder as a whole, ranking as one of the top ten medical and mental illnesses in the world- right alongside such things as Heart Disease, Major Depression, and COPD, according to the World Health Organization. With 2 out of 3 people reporting severe impairment at some point in their lives (e.g., work, relationships, school), you can count on OCD to create an ever increasing set of problems- without effective treatment. Furthermore, around 90% have at least one comorbid mental disorder, such as Major Depression, Panic Disorder, or a Substance Use Disorder. OCD has a tendency to make sufferers “hostages"- feeling stuck in an ever-narrowing loop of behaviors and/or thoughts that usually seem nonsensical to the person themselves, which tends to drive even more shame. Families and support are collateral damage. It is crucial to identify the threat and connected suffering of OCD in order to fully address its impact- and to have the proper perspective and motivation in getting necessary treatment.
Do Your Research
Attempt to really understand your loved one’s suffering, and understand how to help, howa not to help, and how to stay healthy yourself. Finding effective support and treatment is crucial. You don’t have to have diagnosable OCD to be an incredible advocate. Myself and a majority of my OCD specialist colleague/friends do not have diagnosable OCD. Knowing treatments that are effective helps to stay grounded and focused. In short, a specific subset of CBT (Cognitive Behavioral Therapy) known as ERP (Exposure and Response Prevention) is the Gold Standard in treatment. SSRI medications (and clomipramine, a TCA) are used as the first line psychopharmacological treatments. Supportive psychotherapy is not evidence-based first-line treatment for OCD. You may love a counselor who is very supportive, but if they’re not doing some sort of exposures or behavioral experiments, and there’s not a noted clinical reason why they cannot, consider an OCD specialist, because they are not following clinical practice guidelines. Again, check out my Intro Brochure and ERP for OCD Presentation for more on the research and specifics.
Make the Unseen Seen
Taking OCD seriously involves seeing it- and you may help your loved one see it more clearly through your loving support. When it is beneficial to a client, I almost always recommend involving a supportive loved one at some point in treatment. We would consider it odd or unusual not to involve a family member in many other medical treatments. A major challenge with mental illness is making the unseen seen.
Be Realistic With Expectations
One of the roles I serve is setting expectations. Consider how a coach might observe, teach, encourage, and challenge based on a fitness or performance goal. I know OCD from the inside; you can, too. I want to prevent “injury” from occurring in clients who are overeager and might overwhelm themselves jumping in unrealistically- in order to make progress quicker than their skill and training can support. I’ve seen this occur when clients start with the hardest thing they can imagine doing without the support to do it- they usually get burned out or drop out of treatment altogether if they don’t redirect this focus into systematic, consistent, and sustainable work. Conversely, some sufferers have low motivation or may be depressed. Walking together in the trenches and valleys, I seek to boost their perspective to know there is hope when they don't feel it. You cannot “cure” / overcome core fears in OCD with a single exercise, so pushing a loved one to do something they are terrified of can backfire- reinforcing fear vs. disconfirming it; we need to consistently, systematically face fears by addressing with a strategy and a plan.
Be careful to not underestimate how much of a problem OCD can create- and in turn, how much work and growth is needed to learn to say no to all the compulsions that exist for an individual. When there are additional treatment factors (comorbidity and severity, among others, negatively influence outcomes), they can complicate the learning and growth process . Probably the most common error I see in practice is an underestimation of how much treatment and work is needed to accomplish clients' and families' goals (e.g., in terms of number of sessions, practices at home). We also want to be realistic about outcomes, i.e., getting better. Though the treatments for OCD are highly efficacious for most and can be life-changing in a short amount of time for some, practicing patience in your individual situation is key. No one case is exactly alike. You as a family member can help spell out hope or chaos in expectation-setting- helping your loved one in staying the course without being overly idealistic or nihilistic in their views of getting better.
Facilitate buy-in by reinforcing the principles of what it takes to get better. Validate growth- and always validate the person's value and importance, no matter how much they struggle. Remember to encourage yourself, too!
Support: Don't Accommodate or be Emotionally Explosive
Support needs to strike a balance between being overly-accommodating and overly-emotionally expressive (outbursts, hostility, negativity, etc.). The well-researched terms we use to describe these are Family Accommodation (FA) and Emotional Expression (EE). Break the Cycle!! Don’t Do Compulsions for them (by proxy). Begin (with a plan) to minimize your accommodation. Typically in therapy, I help to incrementally get rid of accommodation altogether without “pulling the rug out” too fast (i.e., in one day). Therapeutically, all client rituals must ideally be terminated to maximize outcomes. Helping a loved one ritualize only feeds the cycle. Don’t Give Reassurance. To do this well, you often need to be involved in the prior steps this article elucidates. It can be tricky to know what is reassurance and what is not. Ask questions of your loved one. If they are not open to sharing, you may have to do your best to set your own boundaries, make an informed guess, and base your limits on your own personal boundaries until they're willing to communicate further. Part of feeding obsessions involves engaging the content of obsessions with logic, emotion, and reactions. The person with OCD must learn to live their goals and values without following the content of obsessions. Be careful not to get pulled in, either through accommodation or emotionality. Offer to go to therapy with your loved one if they are willing. You can also gain much support by doing your own therapy, as well! Part of support may be helping covering costs of therapy. Just to be clear- you get to have your own emotions, whatever they are! But EE refers to when these emotions are expressed in harmful ways.
Make Space for your Own Growth and Boundaries
You are a person with your own thoughts, feelings, life to live and decisions to make. Having healthy boundaries for yourself and family is very important. Helping does not mean loss of your own identity and responsibilities. It is not over-extending, nor is it avoidance of problems. Review the chart above. Your situation is your situation; there is a lot of similarity and variety (homogenous and heterogenous) to stories around OCD. You will likely be encouraged at how others feel similarly; but you also have unique factors that make your story your own- be careful not to compare unnecessarily. For goal and boundary setting, Contingency/Behavioral Contracts might be helpful, especially if you are responsible for someone with OCD (i.e., a child), or if you just need clear guidelines of involvement (how and when to discuss obsessions, financial support, reinforcements and privileges, etc.). Your own support and therapy can help you with you own growth and boundaries. Refer to the IOCDF’s excellent tool to “Find Help.”
You can be a crucial source of ongoing recovery, similar to how a coach or trainer might help. We all need reminders, especially in dealing with a consistent need (exercise, diet, and chronic disorders). You can be part of the team surrounding a sufferer to help them be aware of any new compulsions or problems that may arise. You may want to communicate with them in advance about how to best bring up concerns when they are observed. You can be part of the team that cheers them on and helps with motivation! Remind them of their values and why they want to grow (i.e., to go to school, work, not be controlled by OCD, feel better, enjoy life, help others, grow as a person, etc.).
Practical Tools for You
I often have my parents and significant others complete several documents and incorporate various tools. Each situation will vary, but commonly I use:
If you have made it this far to read this article, you are quite likely a key support of someone who has OCD. It is then very likely that you care and want to make a difference. You rock. Keep up the good work.
Calvocoressi, L., Lewis, B., Harris, M., Trufan, B. S., Goodman, W. K., McDougle, C. J., & Price, L. H. (1995). Family accommodation in obsessive compulsive disorder. American Journal of Psychiatry, 152, 441-443.
Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD. Journal of obsessive-compulsive and related disorders, 1(4), 251-257.
What You Need To Know About Obsessive Compulsive Disorder. (n.d.). Retrieved February 2, 2020, from https://iocdf.org/wp-content/uploads/2014/10/What- You-Need-To-Know-About-OCD.pdf
Thanks to Jonathan Hoxmark on Unsplash for this beauty!
Perfectionism and OCD
What is perfectionism? Oxford dictionary defines it as “refusal to accept any standard short of perfection.” That’s automatically problematic. Perfectionism leads to a circumscribed focus, stress, and suffering for not only individuals, but for loved ones nearby who feel the weight of being perfect.
Is this the same as OCD? Nope. OCD and perfectionism often get confused. They both can affect and drive distress in one another, but they are separate. OCD involves unwanted (intrusive) thoughts, urges, and impulses that cause distress; furthermore, compulsions are repetitive behaviors or thoughts that attempt to reduce distress or prevent something bad from happening. Perfectionistic manifestations of OCD, often referred to as “just right / not just right” fit this categorization. Separately, in Perfectionism, someone pursues “perfect” thought, behavior, or action initially out of interest or enjoyment (rather than to suppress an intrusive thought/urge/impulse, like in OCD). There are typically problems that go with this, however. So a difference between the two is that OCD is ego-dystonic and Perfectionism is typically ego-syntonic (you can check out my video here explaining the difference).
Examples of perfectionistic thoughts and behaviors[4,5]:
I am a "recovering" perfectionist. And it’s a problem when I’m not, well, “recovering” from it. One of the mechanisms that keeps perfectionism going is the belief that it is helpful (this is a “Positive Belief” about perfectionism, and it is a cognitive distortion). When I succeed at a task- and especially if I get a lot of praise, it is a natural reinforcer that I must be doing well. However, if I spent 8 hours researching, writing, and proofing this blog today, that is problematic for me at this point in life (and I easily can spend that much time). What is a problem or not sometimes depends on the person and their situation- maybe a journalist would spend that much time or even more, but I am a full-time clinician with a family, church, volunteer involvements, and hobbies. If I make this post “perfect,” in my perfectionism, I will seriously miss out on other things.
This pursuit of perfection doesn't stop with one blog post. It will always generalize if allowed. So if I let it, the pressure of perfection will continue (and does, at times) to move on to other things like caring for my home, caring for people in my life, my relationship with others, my diet, exercise, my spiritual walk, my car, money, and so on. And being honest with you, these things are tied up in anxiety and simultaneously selfishness- attempting to control these things rather than to engage with them/others in a meaningful way by learning to lean into the fear and live based on what is valuable.
Parenting is probably the single biggest event that pressed me with the realization I need really challenge my perfectionism. There are two stark realities to me in life: I can either do my work/relationships/home life/etc. “perfectly” and end up in an ever narrowing scope of anxious overwhelm trying to keep all the balls in the air, OR learn to tolerate the distress that comes doing things "not just right" and focus on the big picture, growing towards what I love and value. And the reality usually is that in time, this fear habituates when not engaging in avoidance, rituals, or control strategies.
Whether in therapy or personal life, to change how I behave and think and respond in life, I need to be aware/monitor what it is that needs to change (good therapy, support, and resources such as on my website can help). Even if I know what needs to be done, if I can’t effectively observe and catch it when it occurs, I will not be able to change it. Next, I will need tools and strategies to effectively grow and mature. In therapy, some of these are Exposure Therapy, Cognitive Restructuring, and more. In essence, at the point of the problem I must be able to insert the solution- and consistently. Lastly, I want to continue to monitor and gain feedback to incorporate learning and solidify growth. I don’t want to oversimplify this- if you are having a problem with any of the areas I have discussed, please reach out to a competent trusted person and/or therapist.
Today I gave myself the time limit of 3 hours- start to finish- to research, write, upload and post. And it’s simultaneously stressful and joyous at the same time. I’m going to do a behavioral experiment and keep doing it- “testing” whether or not my choice(s) in leaning into my fear of failure a) doesn’t end up as bad as it feels like it will, and/or b) I was able to handle or face it anyway. We’ll have to see- I'm leaning in!!!
Justin K. Hughes
 First of all, it’s a whole mess to even get into a truly perfect standard- if I make and continue to make mistakes, I am not perfect. I cannot even begin to conceive what perfect is, then, since I would make a mistake in defining “perfect.”
 The Diagnosis of Obsessive Compulsive Personality Disorder (OCPD) may apply when a person pursues perfectionistic behavior to pathologically disordered levels.
 Grayson, J. (2014). Freedom from obsessive-compulsive disorder: a personalized recovery program for living with uncertainty. New York: Berkley Books.
 Minirth, F. B., & Meier, P. D. (2015). Happiness is a choice: enhance joy and meaning in your life. Grand Rapids, MI: Spire.
This post was originally published on 04/19/2015 on my wordpress and is newly updated.
In Latin, Quid Pro Quo means, “something for something.” You scratch my back; I scratch yours. Tit for tat. It’s how the world runs.
Or is it?
In the business world, this often works. Social psychology calls it “reciprocity.” In relationships, well, this is where it gets fuzzy. Relationships require sacrifice regularly; they require that you stick around, presuming it’s reasonable to do so. In business, if someone doesn’t offer you a good deal, you can move on. If you keep doing this with relationships, you will bankrupt your heart and anyone close to you quicker than ever thought possible.
Relationships involve the molding and holding of hearts. Business involves the flow of money.
I want to call to the table that many principles that work for business DON’T in relationships, which is partly why someone can be extraordinarily successful in the business world but trade in relationships as often as changing underwear. The concept of reciprocity is fascinating, and I regularly utilize it in respectful ways when I consider how to engage in business, such as when I “add value” to interactions with businessmen and women by offering helpful counseling materials. This, in turn, increases my odds of getting a favorable response. Nothing wrong with it. I attempt to not do it ONLY for this reason. However, when I expect a certain response- demand it, even- I am not respecting a person’s freedom, uniqueness, or spontaneity. And this is precisely the problem when quid pro quo is present as a foundation in relationships.
Everyone from Hendrix to Gottman to Eggerichs (see references below) point out the necessity of proactive initiative in love- an active, intentional doing what’s best for another, choosing love over “balancing the budget.” In fact, the eminent researcher Dr. John Gottman states the myth of quid pro quo in The Seven Principles for Making Marriage Work (2002): “But it’s really the unhappy marriage where this quid pro quo operates, where each feels the need to keep a running tally of who has done what for whom” (p. 15).
Isn’t this the definition of selfishness? And it tears relationships apart. I don’t know of anyone who says, “Yes, being completely selfish is good; I want to live by the principles of selfishness and teach my kids to do the same.” No one really debates this. How quickly it takes over, though! My role as counselor isn’t to point a finger; it’s to help uncover what’s holding people back. Consider how you might be “losing while winning,” holding grudges, keeping a record of wrongs. These things are the opposite of contentment- and love. "Love keeps no record of wrongs," (1 Corinthians 13:5d) as is often quoted at weddings.
Don’t wait for a person to do good to you. That’s the whole importance of the Golden Rule and the Greatest Commandment. If you wait around for the other person to “play by the rules” in loving you, prepare to be unsatisfied. There will come a time (in EVERY relationship) when loving another becomes hard: when the "high" of newness wears off, when the attractiveness of another becomes the norm, when that little quirk that you thought was wonderful turns out to annoy the heck out of you. If it’s left up to reciprocity, we’re screwed. In friendships, romantic relationships- ANY relationship.
If a relationship fundamentally relies on quid pro quo, it will prove an unhappy ending. Find out how to love others despite what they bring to the table, and reap the overflowing results. If one person brings a feast to the table, just because the other doesn't bring one won't mean you can’t enjoy yours- and just maybe win them over in love.
For more information:
Business Networking That Works...It's Called Quid Pro Quo (Forbes)
Getting the Love You Want (Drs. Harville Hendrix and Helen LaKelly Hunt)
Influence and Persuasion (Robert Cialdini)
Love and Respect (Dr. Emerson Eggerichs)
The Seven Principles for Making Marriage Work (Psych Central summary)
A Psychotherapists' thoughts on healthy living.
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