At Melbourne Wellbeing Group we work with a lot of people with obsessive compulsive disorder, and predominantly the treatment that people are looking for is individual exposure response prevention (ERP), therapy that specifically targets their OCD. This is fantastic because as most people know ERP is considered the gold standard treatment for OCD. However, OCD doesn’t just impact the person with OCD. Often loved ones and family members have been pulled into the rituals and compulsions, accommodating OCD, and when this is occurring it is much harder for the individual engaging in treatment to effectively treat their OCD. Research into family accommodation and OCD effectiveness has clearly demonstrated that the presence of family accommodation is correlated with more severe OCD symptoms and a greater impact of these symptoms. As such, family accommodation is an important aspect of OCD that needs attending to.
So, what exactly is family accommodation. We know that when triggered, individuals with OCD can experience uncomfortable and unwanted intrusive thoughts and that this can lead to very high levels of anxiety and distress. To manage this experience, it is normal for people with OCD to try to manage their environment by trying to remove triggers (such as insisting that no one wears their shoes inside) or by accessing reassurance through the behaviours of others (such as having someone wash something again or reassure them their hands are clean). When family members participate in these compulsions or say yes to these requests, we call it family accommodation.
There are a few reasons why family accommodation is unhelpful.
· First takes away an opportunity for the individual with OCD to practice using more helpful coping mechanisms such as distress tolerance skills. When their distress and discomfort is taken away quickly by others (even when they ask for it) via a compulsion or the provision of reassurance, they are missing an important therapeutic opportunity.
· Additionally, if in family accommodation triggers are being minimised by family members, the person with OCD is being set up to fail – they are being taught to rely on life around them being tightly controlled which isn’t something that is sustainable. Outcomes are better when the individual with OCD is given the opportunity to practice managing the distress that comes with being triggered, so that over time their coping can strengthen.
· Further, when families engage in the compulsions and rituals, it is inadvertently (even if not intentionally) saying to their loved one with OCD that they don’t believe they can cope with their distress, and it’s best if they step in to reduce it.
It is entirely understandable that families and loved ones get pulled into rituals and compulsions. Seeing someone you love in distress is a very painful and challenging experience and most of us would do anything to take that distress away. And in many instances, providing reassurance (“nothing bad will happen if you catch the bus”) or a specific and certain answer (“yes, the chicken is cooked”) are of no consequence and are just a part of everyday life. As such, it makes sense that family members and loved ones follow their instincts and provide such reassurance only to later find themselves stuck in unhelpful patterns they wish they could reverse.
It is useful to see a specialist trained in ERP for guidance through this process, particularly if family accommodation is highly disruptive to family life, and especially if the person with OCD in the family is not engaged or wanting treatment. Here is an overview of what intervention to address family accommodation typically looks like.
1. Just like in individual treatment, families/parents/partners are asked to develop a list of ways in which the family accommodates. These could be compulsions such as double washing vegetables, providing reassurance, repeating sentences, avoiding saying certain words, not sitting in certain places, purchasing extra soap, cooking or serving food a certain way.
2. The family/parents/partner then choose a target to reduce and with support, slowly reduce their engagement in that behaviour. They are asked to continue doing this, even if it triggers distress in their loved one. New ways of supporting their loved one with distress are taught and practiced.
3. When that target is no longer a trigger or a requested behaviour, they can move onto a new target.
The process, while simple on paper, can feel complicated and challenging in real life, which is why we suggest accessing additional support for the process. This way families/partners can fine tune their process and have the support they need to attend to obstacles as they arise. ERP informed family therapy, ERP informed child focused parent therapy or time with their loved one’s individual therapist are all good options for accessing direct support. There are also good books on how to address family accommodation that are readily available through online retailers and at all good bookstores (we’ve referenced a couple of our favourites below). Additionally, at Melbourne Wellbeing Group we have a webinar available to purchase through our website - Treating OCD: Breaking the Rules at Home, a guide for parents of children with OCD; the link is below.
If you would like to link in with someone for support with family accommodation, please feel free to contact our administration team at The Melbourne Wellbeing Group by calling 9882 8874 or by visiting our website at melbournewellbeinggroup.com.au.
Books on managing family accommodation:
The Family Guide to Getting Over OCD (2021) by Jonathan Abramowitz, PhD.
Breaking Free of Child Anxiety and OCD: A Scientifically Proven Program for Parents (2021) by Eli Lebowitz.
Webinar on family accommodation run by Dr Celin Gelgec and Dr Victoria Miller: