When treating a patient with OCD or an Anxiety Disorder, you are rarely going to be working with just the patient. The OCD monster will do its best to drag the ones closest to the patient into its vicious cycle, and if you or the parents of your patients are not aware, this can set up treatment to be a failure. In this blog post, I will be defining family accommodation (FA), ways to identify it, and ways to stop it from fueling the vicious OCD cycle.
Regarding parenting, FA is defined as any behavior a parent engages in that helps facilitate the patients’ rituals and avoidance of feared stimuli. FA serves the same function as a compulsion in the OCD cycle, which is to provide quick and temporary relief to the sufferer and the family engaging in the behaviors. One of the main reasons FA occurs is that it is challenging to watch someone you care about struggle, so our instinct is to do whatever is needed to end that suffering. For example, if every time a child has an intrusive thought about whatever their OCD theme is and starts getting triggered, the child’s parents will most likely reassure the child or help them calm down as quickly as possible. While this does provide temporary relief for both the child and the parents, it only serves to reinforce and support the OCD while at the same time increasing the long-term suffering of the child. Additionally, FA does not allow the child to habituate to the fear and learn that they do not have to listen to their OCD Monster to feel better. Additionally, the amount of FA that is required will grow as the OCD grows. Examples of FA are as follows:
- Providing reassurance about whatever your child’s fears are (i.e., telling your child that nothing bad will happen if they don’t pray a certain number of times)
- Waiting for your child to complete their compulsions
- Engaging in compulsions with the patient (i.e., helping your child keep their room exactly right or helping them wash until they feel clean enough)
- Doing tasks around the house that your child refuses to do due to their OCD (i.e., changing the cat litter, cleaning the bathroom, doing the laundry, etc…)
- Completing school work for your child due to it being too triggering
- Avoiding discussing specific topics in the home that may trigger your child
Research suggests that FA occurs in 60-97% of families that have a member with OCD (Calvocoressi et al., 1995). Therefore, it is critical in treatment to identify when FA is occurring as the presence of FA is directly linked to increased OCD symptom severity, decreased patient functioning, and increased family distress and dysfunction (Albert, Baffa, & Maina, 2017). The most effective way to assess for FA is to use the Family Accommodation Scale for Obsessive-Compulsive Disorder (FAS) (Calvocoressi et al., 1995). This scale helps clinicians identify the types of FA occurring as well as the frequency of the FA. Once it is determined what FA is happening, the clinician, patient, and family can address it systematically. The clinician should manage FA similarly to exposures in Exposure and Response Prevention (ERP), the evidence-based treatment for OCD and Anxiety Disorders. In ERP, you gradually expose your patients to their OCD fears while having them refrain from engaging in their compulsions. This process helps rewire their fight or flight response to go off when there is danger, not just when the OCD says there is. ERP is done in a gradual process to help build the patients’ confidence and removing FA should be tackled in the same manner. The clinician should use behavioral contracting to assist both the patient and the family in deciding what FAs they are ready to remove. For example, a lower-level accommodation to remove for a child with contamination OCD may be for the parents not to open the child’s bedroom door for them. This process is continued until all FAs are removed. As treatment progresses, it is appropriate to modify and alter the contract as needed. It is suggested that removing all FAs while also engaging the child in ERP can lead to more significant improvement than individual ERP alone (Steketee & Van Noppen, 2003).
If you want to learn more about FA and how to manage it with your patients, go to IOCDF.org or check out any of the references below.
Albert U, Baffa A, Maina G. Family accommodation in adult obsessive-compulsive disorder:
clinical perspectives. Psychol Res Behav Manag. 2017 Sep 20;10:293-304. doi: 10.2147/PRBM.S124359. PMID: 29033617; PMCID: PMC5614765.
Calvocoressi L, Lewis B, Harris M, Trufan SJ, Goodman WK, McDougle CJ, Price LH. Family
accommodation in obsessive-compulsive disorder. Am J Psychiatry. 1995 Mar;152(3):441-3. doi: 10.1176/ajp.152.3.441. PMID: 7864273.
Steketee G, Van Noppen B. Family approaches to treatment for obsessive compulsive disorder.
Braz J Psychiatry. 2003 Mar;25(1):43-50. doi: 10.1590/s1516-44462003000100009. PMID: 12975679.