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Working With Frustrated FamiliesPerrie T. Merlin, MSW, LICSWBen Eckstein, MSW, LICSW

Who are frustrated families?Treatment is not workingSeverity of symptomsLack of effortLack of interestComorbidityLack of resourcesTherapist/psychiatrist shoppingLack of insight

Who are frustrated families?Often have previously tried OCD and/or family therapyFamily in crisisFailure to launchPolice involvementInability to keep job/stay in schoolIn-home hostilityFinancial burden

AssessmentInventory of OCD symptoms and their effectsEven though the individual is not receiving treatment for their OCD in family therapy, it will still be important to understand symptoms in order to identify where OCD may impact the family

AssessmentAssess family accommodationFamily Accommodation Scale (FAS)5-Point Likert scale assessing frequency of accommodationsExample I put up with unusual conditions in my home due to my relatives OCD & I provided my relatives with items s/he needed to perform rituals or compulsionsTypes of accommodation: providing reassurance, waiting for ritual completion, avoiding OCD triggers, facilitating/participating in rituals, rearranging routinesAccommodation is bad for BOTH OCD and family functioning

AssessmentAssess family functioningQuality of interactionsImpact on relationshipsAbility to fulfill roles (mother/father, spouse, sibling)Consider developmental stagesElicit familys description of last normal functioning

Defining the WorkGoal is to increase level of functioning of family/parentsWhat about individual treatment for the sufferer?Use of treatment team, when possibleManaging expectationsChronic nature of OCDPotentially slow pace of OCD treatmenttough love is hard!Therapist cannot be working harder than the family

The WorkIndividual vs Family Treatment for OCDWhat are the parallels?IndividualFamilyTreatment can be uncomfortableERPWithholding reassurance and/or accommodationGuiltObsessive guilt (excessive sense of responsibility), feelings about imposition on loved onesFeelings about contributing to illness, inability to help suffererFocus on minutiae rather than bigger pictureFocus on symptoms, anxiety, rather than values, etc.Focus on progress of loved one, rather than continuing to live meaningful lifeHierarchyUsed for ERPUsed to eliminate accommodation and resume normalized familial roles and patternsDefensivenessFusion with OCDDifficulty seeing behaviors as disorder

Goals of Family Therapy for OCDLearn to stay in the present tensePsychoeducation, experiential workOCD primarily lives in past and future behavior is in the presentImportant tool for both the individual and the familyEliminate circular argumentsBecome flexible with baggage of past experiences, disappointments, failures, etc.

Goals of Family Therapy for OCDBoundaries/Return to Appropriate RolesAssessment, psychoeducation, behavioral tasksWith or without the inclusion of the OCD suffererFocus on helping family members to thrive in their various roles (mother/father, sister/brothers, husband/wife, son/daughter)

Goals of Family Therapy for OCDExample 1: Lucy is 19 years old and has OCD symptoms which dictate that her mother stay with her at all times. Focus of treatment could be to see parents alone, strengthening bond as parents and spouses. Mother will eventually resume sleeping in parents bedroom, which not only eliminates accommodation and fosters growth for the individual OCD sufferer, but also takes steps towards resuming normal family roles.

Goals of Family Therapy for OCDResume Normal Family FunctioningAssessment, psychoeducation, behavioral tasksFocus on day-to-day tasks, responsibilities, activitiesGoal is to minimize impact of the OCD on overall family functioning

Goals of Family Therapy for OCDExample 2: The Beatle Family identifies that Lucy leaves clothes all over the house in specific ways not to be touched. Treatment could be that Lucy begins to allow others to touch her belongings OR that Lucy needs to keep belongings in her room. The first option eliminates accommodation by ceding control to Lucys parents, while the second option allows Lucy more agency over her progress in treatment. In both scenarios, the family is once again able to access their living room without being impeded by ritualistic clutter.

Goals of Family Therapy for OCDValuesAssessment, psychoeducation, behavioral tasksClarifying family values can take place organically over time or via specific exercisesValues can both strengthen and undermine work

Goals of Family Therapy for OCDExample 3: The Beatles value eating meals together. This value can both help and hinder treatment. Their belief that meals should be eaten together has made them steadfast in their determination to close the kitchen after meals are over, thus eliminating the accommodation of waiting for Lucy to finish ritualizing before eating. This value also means that the family experiences feeding as nurturance, which increases distress related to leaving their child hungry.

Goals of Family Therapy for OCDBehavioral Work Targeting:Family functioningUse assessment to determine which areas to prioritizeHierarchy of developmentally appropriate behaviorsConsider age and development in setting realistic and appropriate goalsIndividual vs. treatment team approachAllows sufferer own space, separate from familyAllows therapist consultation and collaborationAdds weight to treatment recommendationsMinimizes therapist fatigue

Progression of TreatmentFinally, somebody who gets us!Manage expectationsBegin to build Skills to enable family to stay in the presentBegin working on HierarchyStart small build family confidence, not threatening to suffererUtilize societal and community normsManage family expectations

Progression of TreatmentBegin to increase difficultyHousebound person vs join community at largeSufferers unrealistic expectiations; entitlement of youthValues of individual and values of the familyOCD vs. OCPD

Progression of TreatmentExpect to be firedOften toughest stage for familyFeeling in crisis again & need assistance holding the lineHelp family follow through with boundaries & expectationsAt this time, may need to do some dynamic work to bring family closerExample 4: Lucy returned home after being unable to complete her first semester at college due to OCD. She insists on living in an apartment (rather than at home), however, parents feel there should be stipulations to insure their financial commitment. Family is unable to come to an agreement and tensions in the home are high.

Progression of TreatmentAnd Re-HiredOpportunity to negotiate with sufferer while holding the boundary

Progression of TreatmentProgressLighter interactions/communicationsMoving toward diffusion everybody less defensiveDevelopmental stages/Boundaries moving back into alignment

Progression of TreatmentExpect backslidesFamily expectations of sufferer too high and too fastFamily not ready for sufferer to be more independent

Differences Between AgesDifferences between Children, Young Adult and Adult SufferersConsider development, not just chronological ageIf working with family over larger periods of time, allow for reassessment and reconceptualization based on developmental criteria

Differences Between AgesChildrenMust utilize extended network of systems (school, clergy, community, etc)Consistency and continuity are importantParent assume more responsibility for treatment

Differences Between AgesYoung AdultAutonomy/dependenceBe careful with assumptions about symptomatic bxExample: isolation, avoidance, moodiness, etc.More evenly shared responsibility for treatmentAdultEmphasis on ability to fulfill roles and responsibilities

ComplicationsWillingness (or lack thereof) to do what it takesUnreasonable expectationsAdditional family members with mental health problemsNormalized compulsive behavior; fusion with OCDEach developmental age brings unique complications

Questions