Are we really offering a helping hand?

“Can you please help me to hold the door?”

“Would you please tell me if that was okay?”

One of the many challenges in addressing obsessive compulsive disorder (OCD) is the presence of family accommodation. The term family accommodation (FA) describes changes that individuals (e.g. parents, partners, siblings, and children) make to their own behaviour, usually well intended to assist their affected relative avoid or alleviate distress related to the disorder.

FA may take several forms, ranging from engaging in excessive hand washing to helping to reduce contamination fears experienced by a loved one, listening to repeated confessions of a relative who feels the need to constantly confess, providing excessive reassurance, as well as removing knives to reduce or alleviate the distress of a relative with aggressive or suicidal obsessions. The below table listed some examples of FA in OCD.

Table 1. Examples of family accommodation in obsessive-compulsive disorder organised by obsessive-compulsive disorder symptom dimension and type of accommodation

Forbidden thoughts and checkingSymmetry and orderingContamination and cleaning
Avoidance of OCD triggersCutting food for patient because of the fear of knivesRefrain from moving furniture or making changes in the homeOpen doors for patient
Improvement in compulsionsListening to patient’s confessionsTouching both sides of the patient (e.g. kissing both cheeks)Buy special/extra soap

FA is common. In fact, researchers reported that 96.9% of the relatives of patients with OCD engaged in accommodative behaviour, with the degree of accommodation ranging from mild to extreme.

What can be so bad about these FA behaviours? Well, research informed that FA predicts symptom severity and functional impairment with more accommodation being associated with worse clinical presentation and poorer treatment outcomes.

With a close examination of the behaviours, we can notice that FA functions in the same manner as a ritual, in that obsessive-compulsive distress is reduced, thereby negatively reinforcing further symptom engagement. The accommodation of symptoms conflicts with the primary goals of cognitive-behavioural therapy (which is an effective and recommended treatment for many with OCD) for OCD and can be an obstacle to positive outcomes.

Furthermore, FA has various negative impact on the ‘helping’ individuals. Research highlighted that increased FA was found to be linked to poorer caregiver health, lower quality of life and increased caregiver burden.

Are we really offering a helping hand?

As highlighted earlier, FA is common and you are not alone in this struggle. If you notice that you are carrying out some family accommodation behaviours, have a discussion with your therapist to explore how you can be more effective in providing a helping hand in your love one’s recovery, as well as caring for your well-being in the process.

Written by:

Adrian Toh

Clinical Psychologist

M.Psychology (Clinical) (Singapore)

MSPS, Registered Psychologist

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