2. Who are frustrated families?
Treatment is not working
Severity of symptoms
Lack of effort
Lack of interest
Comorbidity
Lack of resources
Therapist/psychiatrist shopping
Lack of insight
3. Who are frustrated families?
Often have previously tried OCD and/or family therapy
Family in crisis
Failure to launch
Police involvement
Inability to keep job/stay in school
In-home hostility
Financial burden
4. Assessment
Inventory of OCD symptoms and their effects
Even 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
5. Assessment
Assess family accommodation
Family Accommodation Scale (FAS)
5-Point Likert scale assessing frequency of accommodations
Example “I put up with unusual conditions in my home due to my
relative’s OCD” & “I provided my relatives with items s/he needed to
perform rituals or compulsions
Types of accommodation: providing reassurance, waiting for
ritual completion, avoiding OCD triggers,
facilitating/participating in rituals, rearranging routines
Accommodation is bad for BOTH OCD and family functioning
6. Assessment
Assess family functioning
Quality of interactions
Impact on relationships
Ability to fulfill roles (mother/father, spouse, sibling)
Consider developmental stages
Elicit family’s description of last “normal” functioning
7. Defining the Work
Goal is to increase level of functioning of family/parents
What about individual treatment for the sufferer?
Use of treatment team, when possible
Managing expectations
Chronic nature of OCD
Potentially slow pace of OCD treatment
“tough love” is hard!
Therapist cannot be working harder than the family
8. The Work
Individual vs Family Treatment for OCD
What are the parallels?
Individual Family
Treatment can be uncomfortable ERP Withholding reassurance and/or
accommodation
Guilt Obsessive guilt (excessive
sense of responsibility), feelings
about imposition on loved ones
Feelings about contributing to
illness, inability to help sufferer
Focus on minutiae rather than
bigger picture
Focus on symptoms, anxiety,
rather than values, etc.
Focus on progress of loved one,
rather than continuing to live
meaningful life
Hierarchy Used for ERP Used to eliminate
accommodation and resume
“normalized” familial roles and
patterns
Defensiveness Fusion with OCD Difficulty seeing behaviors as
disorder
9. Goals of Family Therapy for OCD
Learn to stay in the present tense
Psychoeducation, experiential work
OCD primarily lives in past and future – behavior is in the
present
Important tool for both the individual and the family
Eliminate circular arguments
Become flexible with “baggage” of past experiences,
disappointments, failures, etc.
10. Goals of Family Therapy for OCD
Boundaries/Return to Appropriate Roles
Assessment, psychoeducation, behavioral tasks
With or without the inclusion of the OCD sufferer
Focus on helping family members to thrive in their various
roles (mother/father, sister/brothers, husband/wife,
son/daughter)
11. Goals of Family Therapy for OCD
Example 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.
12. Goals of Family Therapy for OCD
Resume “Normal” Family Functioning
Assessment, psychoeducation, behavioral tasks
Focus on day-to-day tasks, responsibilities, activities
Goal is to minimize impact of the OCD on overall family
functioning
13. Goals of Family Therapy for OCD
Example 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 Lucy’s 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.
14. Goals of Family Therapy for OCD
Values
Assessment, psychoeducation, behavioral tasks
Clarifying family values can take place organically over time
or via specific exercises
Values can both strengthen and undermine work
15. Goals of Family Therapy for OCD
Example 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.
16. Goals of Family Therapy for OCD
Behavioral Work Targeting:
Family functioning
Use assessment to determine which areas to prioritize
Hierarchy of developmentally appropriate behaviors
Consider age and development in setting realistic and appropriate
goals
Individual vs. treatment team approach
Allows sufferer own space, separate from family
Allows therapist consultation and collaboration
Adds weight to treatment recommendations
Minimizes therapist fatigue
17. Progression of Treatment
“Finally, somebody who gets us!”
Manage expectations
Begin to build Skills to enable family to stay in the present
Begin working on Hierarchy
Start small – build family confidence, not threatening to
sufferer
Utilize societal and community norms
Manage family expectations
18. Progression of Treatment
Begin to increase difficulty
Housebound person vs join community at large
Sufferers’ unrealistic expectiations; entitlement of youth
Values of individual and values of the family
OCD vs. OCPD
19. Progression of Treatment
Expect to be fired…
Often toughest stage for family
Feeling in crisis again & need assistance holding the line
Help family follow through with boundaries & expectations
At this time, may need to do some dynamic work to bring family closer
Example 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.
20. Progression of Treatment
…And Re-Hired
Opportunity to negotiate with sufferer while holding the
boundary
21. Progression of Treatment
Progress
Lighter interactions/communications
Moving toward diffusion – everybody less defensive
Developmental stages/Boundaries moving back into
alignment
22. Progression of Treatment
Expect backslides
Family expectations of sufferer too high and too fast
Family not ready for sufferer to be more independent
23. Differences Between Ages
Differences between Children, Young Adult and Adult
Sufferers
Consider development, not just chronological age
If working with family over larger periods of time, allow for
reassessment and reconceptualization based on
developmental criteria
24. Differences Between Ages
Children
Must utilize extended network of systems (school, clergy,
community, etc)
Consistency and continuity are important
Parent assume more responsibility for treatment
25. Differences Between Ages
Young Adult
Autonomy/dependence
Be careful with assumptions about symptomatic bx
Example: isolation, avoidance, moodiness, etc.
More evenly shared responsibility for treatment
Adult
Emphasis on ability to fulfill roles and responsibilities
26. Complications
Willingness (or lack thereof) to “do what it takes”
Unreasonable expectations
Additional family members with mental health problems
“Normalized” compulsive behavior; fusion with OCD
Each developmental age brings unique complications
