“Should I check that for you?” When the family accommodates OCD
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When family members become involved in rituals or organise everyday life around the symptoms, this is known as family accommodation in OCD. Family accommodation includes actions intended to prevent or ease the person’s anxiety, as well as actions that keep the family’s daily routines functioning. Such help may therefore be an attempt both to support the person with OCD and to keep everyday life running.
Family accommodation is common among families of people with OCD. In a 2012 study of parents of children and young people with OCD, the most common daily forms of family accommodation were:
In the same study, almost one in four parents reported that family or work routines were interrupted or changed as a result of this involvement.
Direct and indirect family accommodation
Family accommodation may be direct or indirect. Direct accommodation may involve, for example, parents helping a child wash their hands or wearing sterile gloves when preparing the child’s food.
Reassurance seeking is another example. When doubt or anxiety arises, the person with OCD may repeatedly seek reassurance or confirmation from family members. A young girl with OCD may, for example, ask her parents whether the front door was definitely locked before the family left home. The need for an answer is often intense, so this form of accommodation is common in both direct and indirect forms.
Indirect accommodation is often less visible but can significantly alter the family’s daily life. Family members may, for example, begin avoiding certain areas of the home – so-called zones – so that they do not “contaminate” them.
Why does family accommodation occur?
Family accommodation is not limited to parents of children with OCD. Siblings, partners and spouses can be drawn into the pattern in the same way. A sibling may open doors, switch lights on and off, or answer the same questions many times. The help may have become the family’s way of easing anxiety and avoiding intense reactions.
It is difficult to see your child, partner, brother or sister trapped in doubt and intense anxiety. It is therefore natural to turn to whatever brings calm: helping with rituals, avoiding things or situations that may trigger anxiety, or providing reassurance.
Accommodation may also be an attempt to avoid angry reactions or shorten a compulsion.
How does family accommodation affect treatment?
Family accommodation is common when OCD symptoms are severe and daily life is under considerable strain. The more OCD comes to dominate daily life, the more the family is typically drawn in. Help that brings calm in the moment may also maintain avoidance and rituals. When the person with OCD or a family member performs the compulsion, this often brings short-term relief. The person then has fewer opportunities to experience that distress can be tolerated and can subside without the ritual.
The family’s role is therefore addressed as part of treatment. In exposure and response prevention, the person with OCD practises facing anxiety, doubt or distress without performing the usual compulsion. If the family takes over the ritual or removes the uncertainty, it takes over the very challenge the person needs to practise facing. Instead, family members can support the person in treatment without resolving the doubt or performing the ritual.
How does family accommodation affect family members?
The strain affects the whole family. Higher levels of accommodation are associated with poorer family functioning, greater distress among individual family members and more strained relationships. Studies also report higher stress levels among parents of children with OCD, as well as anxiety and depression among family members of adults with OCD.
How can family accommodation be changed?
The first step is to identify how family accommodation has shaped daily life. A clearly defined level of accommodation can be kept stable while the family and clinician prepare the next step. Calm and predictability create room for change, and the plan sets out when the next step will be taken.
From this starting point, one thing is changed at a time. Each step is agreed in advance: What will the family continue to do, what will change now and which steps will come later? Particularly at the beginning, it may be necessary to stay with the same small step for one or two weeks. This gives the person with OCD time to prepare and prevents the family from changing approach in the middle of a pressured situation.
Many family members have experienced intense anger, very harsh language or prolonged distress in response to previous attempts to change the help. Such experiences can make even small changes feel unsafe. New boundaries should therefore not be introduced spontaneously in the middle of a situation dominated by OCD. The agreements are made at a calm time, while the treatment plan sets the direction and pace.
The agreements can be brought together in a family agreement. It describes the accommodation that will continue, the next small step and the support the family will provide when the pressure rises. The agreement creates a shared direction and must not be used as a way of pressuring the person with OCD. The family needs to be able to stand together against OCD.
Care continues even as accommodation is reduced. A meal, a walk, a jigsaw puzzle or other shared activities can preserve closeness and create room for a family life that is not governed by OCD. Time together has value in its own right and is not a reward for completing a particular step in treatment.
In this way, the family can gradually let go of the rituals without letting go of the person.
More support and information for family and friends
Supporting someone with OCD
Get an overview of support, strain, roles, boundaries and gradual change.
Family accommodation
Read the encyclopedia explanation, see the difference between support and accommodation, and learn how family accommodation can be mapped and changed.
Exposure and response prevention
Read about the treatment method and about facing distress without carrying out the usual compulsion.
30 practical recommendations
Find practical guidance on supporting someone without becoming part of the OCD pattern while also protecting the relationship and your own life.