For the 2016 Annual OCD Conference

1. Working With Frustrated Families
Perrie T. Merlin, MSW, LICSW
Ben Eckstein, MSW, LICSW

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

27. Questions