Family (and friends) Accommodation in OCD

If someone you love has OCD, knowing how to support them can be hard. You may struggle to understand their experiences, or feel that their obsessions and compulsions get in the way of daily life. But your support and understanding can make a big difference, and there are things you can do to help. Note: In this article, I use the term “family” to mean anyone who has a significant relationship with the person with OCD.

Education

The more you learn, the more you will be able to understand and help the person with OCD. 

Read books, join the International Obsessive Compulsive Disorder Foundation (IOCDF), attend OCD support groups, research online, etc. 

As you learn more about the disorder, you begin to feel hopeful that you can do things to help the person with OCD overcome their disorder. As your understanding increases, you will be able to view the irrational behaviors from a non-personalized perspective. Your relationships are likely to improve and the person with OCD will feel more supported. Positive relationships and feeling understood greatly enhance the therapeutic benefits of treatment.

• Visit the About OCD section on IOCDF website to learn about causes, treatments, and more.
• Read books on OCD.
• Become a member of the International OCD Foundation to receive their quarterly OCD Newsletter with information on the latest treatments and research, and to stay connected to the IOCDF community.
• Attend an OCD support group for family members. 
  • OCD Support Group for Family/Friends  – free; bi-monthly; via Zoom; facilitated by Dan Neumann, mental health professional
• Find other online research and resources

Self-care

Supporting someone with OCD can be frustrating and upsetting at times. Make sure you take time to look after yourself too. Get support and help yourself

• Seek professional advice/support for yourself from someone experienced with OCD.
• Find a family buddy (another family member going through something similar).
• Talk to other family members so you can share your feelings of anger, sadness, guilt, shame, and isolation.
• Attend a support group or find out about Multi-Family Behavior Therapy to discuss how other families handle the symptoms and get feedback about how you can deal with your family member’s OCD.
• Normalize your life as much as possible. By this I mean take steps to reduce the impact of the OCD on your life and any other participating family members and friends. This does not require the cooperation of the OCD sufferer. It does require that you stop accommodating the OCD. A family member or friend impaired by the stress of accommodating OCD is not in a state to truly help the OCD sufferer. They must first take care of their own health.

Above all, remember you also have a life and a right to that life! Self care is critical as is maintaining your work and social functioning as optimally as possible. You and other family members may need to seek advice/support/CBT from a clinician experienced in OCD. 

“Family Accommodation” – Learn to recognize and reduce

Family Accommodation behaviors are things families do that enable OCD symptoms. Families are constantly affected by the demands of OCD. Research shows that how a family responds to the OCD may help fuel OCD symptoms.

While accommodation might be helpful in temporarily getting the person to stop with the compulsions they are stuck in and possibly help them feel better in the moment, this will only reinforce the compulsion, making it more difficult to step out of the obsessive-compulsive cycle in the long term. 

The more that family members can learn about their responses to OCD, and the impact they have on the person with OCD, the more the family becomes empowered to make a difference!

Providing Reassurance

It is common for family members to provide reassurance to a loved one struggling with OCD in hopes that these reassurances will make them feel better. For example, family members may say things like:

• “Yes, I am sure you checked.”
• “Yes, I am sure you washed your hands enough.”
• “Yes, I am sure you did not make that mistake.”

Providing reassuring answers to what-if questions may seem helpful at the time, but family members ultimately end up playing into obsessive thoughts or irrational fears by trying to convince their loved one that these are false or will not occur.

When this happens, a loved one may ask the same question repeatedly or reword the question in different ways to get reassurance. The most detrimental part about these small reassurances is that family members can become part of the ritual over time, making it more difficult to resolve later on.

Therapists who specialize in OCD say that the best way to respond to these kinds of questions is to be okay leaving them unanswered. That could look like saying:  

• “I’m not sure. What do you think?”
• “Sorry, I can’t answer that for you.”
• “This sounds like reassurance-seeking. Is this really your OCD asking?

Avoidance

Family members may find themselves going through their daily routine only to suddenly stop out of fear they might trigger their loved one’s OCD. For example, they may avoid going to certain places, touching or moving specific objects, or discussing sensitive topics simply to prevent distress for their loved one.

However, avoidance ultimately reinforces the belief that triggers are dangerous and that uncertainty or anxiety cannot be tolerated. Participating in avoidance narrows the scope of your loved one’s life and creates problems of an ever-expanding magnitude. Avoidance of one place or trigger (a public bathroom, for example) can grow into avoidance of many places (all public bathrooms).

Participating in Time-Consuming Rituals

OCD can grow slowly and insidiously until rituals require significant participation by family members. Initially, a family member may start helping out with a ritual in order to make the ritual go faster, but eventually they become a necessary element of successfully completing the ritual.

When OCD is severe, it is common for a family member (or even several family members) to engage in rituals to the point that they neglect major responsibilities. For example, family members may assist with checking rituals in the morning (e.g., locks, stove burners, electrical appliances) or cleaning rituals (e.g., repeatedly washing hands or household objects).

Family members must remember that if they want to help their loved one challenge their OCD, they cannot cooperate with or participate in rituals.

Assistance With Decisions or Simple Tasks

Family members trying to help a loved one with OCD commonly report that they feel the need to take over decision-making for their loved one. They may facilitate or make decisions for their loved one to prevent cognitive gridlock, or they may agree to take over simple or complex tasks to limit time-consuming rituals.

However, as with all accommodations, assisting in decision-making undermines the goals of risk taking by guarding against the possibility that a loved one may make the “wrong” decision instead of allowing them to learn. Taking on ritual tasks also ends up enabling rather than helping and only grows worse with time.

Adjusting Responsibilities and Routines

Rituals can become involved enough that family members may make significant changes to their work, family, or social responsibilities. For example, a family member may skip social plans with friends because their loved one thinks outsiders are “contaminated,” or a family member may arrive late to work because they had to accommodate reassurance-seeking rituals.

When this happens, it is more beneficial for family members to establish that they will not adjust their responsibilities or routines to accommodate rituals. 

One small accommodation can evolve into an intricate pattern of requirements for reassurance months later.

Assuming a Loved One’s Responsibilities

OCD can reach the point where a loved one is no longer willing or able to fulfill basic responsibilities. They may find certain tasks overwhelming and opt out. For example, they may no longer go shopping, pay bills, drive, clean the house, or care for their children.

When family members step in to take care of a loved one’s responsibilities, they are furthering their loved one’s avoidance agenda and supporting the OCD. While it may be difficult to set a boundary and step out of the avoidance role in the heat of the moment, treatment requires that family members and loved ones agree to stop submitting to the OCD.

Tolerating Extreme Behaviors

As OCD progresses, a loved one may begin to engage in extreme behaviors, such as taking three-hour showers, removing all sharp objects from the home, or prohibiting guests. Eventually, these rigid rules and behaviors lead family members to face a binary decision: violate an OCD boundary and face the flood of anxiety or capitulate to the rules and support the OCD.

With ongoing support, family members will ultimately feel empowered to set boundaries and push back against OCD—the best thing they can do to help a loved one with OCD.

What to do instead

Education and an emotional understanding of what it is like to experience the symptoms of OCD should accompany the family’s efforts to intervene. Since many people with OCD are otherwise very functional it is no wonder that you may tend to see the compulsions as behaviors that are within the person’s control to initiate or cease. This is a common misunderstanding. Coming to terms with the reality that your family member has “something wrong” with him/her which requires professional attention can be a painful process. 

If you have been an “accomplice” in the OCD and now recognize this, gently withdraw and hold the line, explaining that your continual involvement (accommodation) only worsens the disorder. On the other hand, if you have refused to have anything to do with the OCD besides yelling “knock it off,” you must stop that too and learn more so that you can say the same thing, but in a way that feels more supportive and shows your understanding of the struggle the person with OCD is experiencing. In any case it is essential to be consistent. This may mean talking with other family members to ensure a unified approach, otherwise your good intentions could be undermined. For example, in one family the mother stopped doing the laundry for her 28 year old son but her husband did it instead because they did not have an agreed upon plan on how to handle the OCD symptoms.

Other things to know

Recognize Signs of OCD

Sometimes people with OCD are thinking things you don’t know about as part of the OCD, so watch for behavior changes. It is important to not dismiss significant behavioral changes as “just their personality.” Remember that these changes can be gradual, but overall different from how the person has generally behaved in the past.

Signs to watch for include, but are not limited to:

• Large blocks of unexplained time that the person is spending alone (in the bathroom, getting dressed, doing homework, etc.)
• Doing things again and again (repetitive behaviors)
• Constant questioning of self-judgment; excessive need for reassurance
• Simple tasks taking longer than usual
• Perpetual tardiness
• Increased concern for minor things and details
• Severe and extreme emotional reactions to small things
• Inability to sleep properly
• Staying up late to get things done
• Significant change in eating habits
• Daily life becomes a struggle
• Avoidance
• Increased irritability and indecisiveness

People with OCD usually report that their symptoms get worse the more they are criticized or blamed because these emotions generate more anxiety. So it’s important that you learn to view these features as signals of OCD and not as personality traits. This way you can join the person with OCD to combat the symptoms, rather than become alienated from them.

Modify your expectations

People with OCD consistently report that change of any kind, even positive change can be experienced as stressful. It is often during these times that OC symptoms tend to flare up; however, you can help to moderate stress by modifying your expectations during these times of transition. Family conflict only fuels the fire and promotes symptom escalation, (“Just snap out of it!’). Instead a statement such as “No wonder your symptoms are worse— look at the changes you are going through,” is validating, supportive and encouraging. Remind yourself the impact of change will also change; that is the person with OCD has survived many ups and downs, and setbacks are not permanent. You must adjust your expectations accordingly which does not mean to not expect something!

Remember That People Get Better at Different Rates

There is a wide variation in the severity of OC symptoms between individuals. Remember to measure progress according to the individual’s own level of functioning, not to that of others. You should encourage the person to push him/herself and to function at the highest level possible; yet if the pressure to function “perfectly” is greater than a person’s actual ability it creates more stress which leads to more symptoms. Just as there is a wide variation between individuals regarding the severity of their OC symptoms, there is also wide variation in how rapidly individuals respond to treatment. Be patient. Slow, gradual improvement may be better in the end if relapses are to be prevented.

Avoid day-to-day comparisons

You might hear your loved ones say they feel like they are “back at the start” during symptomatic times. Or you might be making the mistake of comparing your family member’s progress (or lack thereof) with how he/she functioned before developing OCD. It is important to look at overall changes since treatment began. Day-to-day comparisons are misleading because they don’t represent the bigger picture. When you see “slips” a gentle reminder of “tomorrow is another day to try” can combat self destructive labeling of “failure,“”imperfect,” or “out of control” which could result in a worsening of symptoms! You can make a difference with reminders of how much progress has been made since the worst episode and since beginning treatment. Encourage the use of questionnaires to have an objective measure of progress that both you and your loved one can refer back to (for example, the Yale Brown Obsessive Compulsive Scale). Even a 1-10 rating scale can be helpful. Ask “How would you rate yourself when OCD was at its worst? When was that? How is it today? Let’s think about this again in a week.”

Recognize small improvements

People with OCD often complain that family members don’t understand what it takes to accomplish something, such as cutting down a shower by five minutes, or resisting asking for reassurance one more time. While these gains may seem insignificant to family members, it is a very big step for your loved one. Acknowledgment of these seemingly small accomplishments is a powerful tool that encourages them to keep trying. This lets them know that their hard work to get better is being recognized and can be a powerful motivator

Create a supportive environment

The more you can avoid personal criticism the better – remember that it is the OCD that gets on everyone’s nerves. Your family member still needs your encouragement and your acceptance as a person, but remember that acceptance and support does not mean ignoring compulsive behavior. Do your best to not participate in the compulsions. In an even tone of voice explain that the compulsions are symptoms of OCD and that you will not assist in carrying them out because you want them to resist as well. Gang up on the OCD, not on each other!

Support taking medications as prescribed

Be sure to not undermine the medication instructions that have been prescribed. All medications have side effects that range in severity. Ask your family member if you could periodically attend their appointments with the prescribing physician. In this way you can ask questions learn about side effects and report any behavioral changes that you notice.

Keep communication clear and simple

Avoid lengthy explanations. This is often easier said than done because most people with OCD constantly ask those around them for reassurance. “Are you sure I locked the door?” or “Did I really clean well enough?” You have probably found that the more you try to prove that the individual need not worry the more he disproves you. Even the most sophisticated explanations won’t work. There is always that lingering “What if?” Tolerating this uncertainty is an exposure for the individual with OCD and it may be tough. Recognize that the person with OCD is triggered by doubt, label the problem as one of trying to gain total certainty about something that cannot be provided, this is the essence of OCD and the goal is to accept uncertainty in life. Avoid lengthy rationales and debates.

Separate time is important

Family members often have the natural tendency to feel like they should protect the individual with OCD by being with them all the time. This can be destructive because family members need their private time, as do people with OCD. Give them the message that they can be left alone and can care for themselves. Also, OCD cannot run everybody’s life; you have other responsibilities besides “babysitting.” You need and deserve time to pursue your interests too! This not only keeps you from resenting the OCD it is also a good role model to the person with the OCD that there is more to life than anxiety.

It has become all about the OCD

Whether it is about asking and providing reassurance to the family member with OCD or talking about the desperation and anxiety that the illness causes, families struggle with the challenge of engaging in conversations that are “symptom free,” an experience that feels liberating when achieved. We have found that it is often difficult for family members to stop engaging in conversations around anxiety because it has become a habit and such a central part of their life. It is okay not to ask ”How is your OCD today?” Some limits on talking about OCD and the various worries is an important part of establishing a more normative routine. It also makes a statement that OCD is not allowed to run the household.

By learning to accept and acknowledge your loved one’s OCD, you will significantly improve your relationship, which greatly enhances the likelihood of their gaining control over their life.

Need to talk to someone about your OCD?