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When Helping is Hurting:Understanding the Role of Family
Accommodation in OCD
E M I LY B E R N E R , L M F T ( M F T 8 1 5 3 3 )
International OCD Awareness Day, October 2017
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• What is family accommodation?
• Why is it harmful?
• Why do we do it?
• How do we stop it?
Overview
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OCD Model
OCD Trigger / Obsession
Anxiety
Compulsion/ Ritual Relief
Fear reinforced; need for
compulsionsstrengthened
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The way families act to reduce symptoms of distress and anxiety in their loved one (engaging in the OCD cycle)
Two main types:
1. Participating in symptoms (compulsions/rituals) and modifying family routine
2. Providing reassurance and facilitating avoidance (most common)
Family Accommodation defined
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• Hiding or removing potential triggers
• Taking responsibility for something so your child doesn't have to (e.g. being the last one to lock up, go to bed, throw away trash)
• Allowing extra time for ritual completion
• Not making appointments/demands during certain times of the day
• Purchasing supplies that will help with rituals
• Not disciplining behaviors you otherwise would
Examples
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“Is it safe?”“Did you wash it?”
“I’m sorry”“Say it again”
“Is that poisonous?”“I love you”
“What if it touched something?”“ARE YOU SURE?”
And the big one…REASSURANCE
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So…what’s the big deal?
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• Family accommodation is linked to:• Greater symptom severity • Poorer response to treatment • More impairment in functioning (social, academic,
family)• Poorer quality of life for relatives• Lower insight about the disorder (fear is
normalized)
So…what’s the big deal?
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The Family Accommodation Cycle
Anxiety
Demand for FA
Family eventually gives in
Relief
Request for more FA
Resentment/ Discord
Defiance; child sides with OCD
More OCD
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• It’s instinctive
• It’s easier in the short term
• It’s an attempt to minimize distress:• For the sufferer• For the family members*
• It might seem harmless
Why do families accommodate?
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• Characteristics of the child:• Anger/rage• Aggression• Defiance/strong-willed
• Characteristics of the parent:• Anxious (transgenerational nature of anxiety)• Low coping/emotion regulation skills• Low tolerance for distress*• Over-protective parenting style
Factors linked to higher accommodation
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#1: Know how to spot it!
• What things do you do that you wouldn’t do if your family member didn’t have OCD?
• What do you do to avoid conflict with your family member?
• How much time do you spend on reducing your family member’s anxiety?
• Do you make decisions or complete tasks for your family member (because these create anxiety for him/her)?
Tackling Accommodation
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#2: Be collaborative
• Help your family member understand that accommodation is harmful
• Change your language when discussing OCD so it’s clear OCD is the bully and you’re both on the same team against it
• Make sure to collaborate with other family members too! Avoid the good cop/bad cop dynamic and be consistent with your approach
Tackling Accommodation
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#3: Make a specific plan
• Define the problem (a specific accommodation)
• Set the goal (for eliminating accommodation)
• Make a plan (let the child decide what language the family should use in the moment)
• Include rewards when appropriate
Tackling Accommodation
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Problem: Parents lay with their child each night until she falls asleep because she is afraid something bad will happen if she falls asleep without her parents in her room. This routine lasts up to 60 minutes per night.
Goal: Child falls asleep by herself
Plan: Parents and child agree that parents will stay in her room for 20 minutes per night for one week, then 15 minutes the following week, and so on until they no longer stay in her room. Child identifies a bedtime coping plan and tools she can use to soothe herself after her parents leave the room. Child asks parents to remind her that she is making OCD weaker and that they are on her team. She also puts up pictures of the reward she will earn.
Reward: When child meets the goal each night, she will earn a reward of her choice the following morning. Once she is able to fall asleep on her own, she earns a big bonus reward
Tackling Accommodation: Example
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#4: Give encouragement and support
• Pay more attention to brave behaviors and less attention to anxious behaviors
• Model brave behaviors (“we can do hard things”) and take risks yourself (quality of life over safety and certainty)
• Zoom out to gain perspective and help yourself not be reactive to triggers
Tackling Accommodation
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Don’t drink the kool-aid
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• “I’m so sorry OCD is making you so anxious right now”
• “I’m not going to do anything to make you sicker”
• “I won’t let OCD boss me around in order to hurt you”
• “I know this is hard, but we agreed I’m not going to answer that”
• “That sounds like you’re asking for reassurance”
• “I know you can handle this”
How to respond compassionately to requests for accommodation
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"Ray" movie clip
Video Clip
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• How can I tell if it’s a request for accommodation or just a reasonable, “normal” request?
• What if my family member is not on board?
• Gradual step-down or “cold turkey”?
Common questions
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• You and your partner are not on the same page about how to respond to accommodation requests
• You don’t know how to handle your child’s response to limits, and/or they are violent or aggressive
• You don’t know where to start or how to make a plan
• You feel like nothing is working
When to seek extra support
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Emily Berner, LMFTSan Francisco Bay Area Center for Cognitive Therapy
5435 College Ave. Suite 105 Oakland, CA 94618510.652.4455 [email protected]
Please visit our website for tools and resources about family accommodation
Thank You!