Family Accommodation In OCD

Family accommodation in OCD refers to the adjustments or changes family members make to assist or avoid conflict with a relative suffering from obsessive-compulsive disorder. This can include participating in or facilitating rituals, providing reassurance, or avoiding certain triggers. While intended to help, accommodation can inadvertently reinforce OCD symptoms and hinder treatment progress.

Brownings, S., Hale, L., Simonds, L. M., & Jassi, A. (2023). Exploring the experiences and responses of siblings living with a brother or sister with obsessive compulsive disorder. Psychology and Psychotherapy: Theory, Research and Practice, 96(2), 464-479. https://doi.org/10.1111/papt.12454

Key Points

• The study explored the experiences of 8 siblings aged 12-20 years old who were living with a brother or sister diagnosed with obsessive-compulsive disorder (OCD).
• Two main themes emerged from the interpretative phenomenological analysis:
  • OCD as a dangerous dictator: OCD created a dictatorial environment characterized by loss, helplessness, and adjustment. Siblings felt the home was tense and fragile.
  • Unifying/polarizing impact on relationships: OCD either pushed siblings to the periphery or unified the family against a common threat.
• All siblings reported accommodating OCD symptoms, like avoiding triggers or providing reassurance. Many experienced disruption to routines, social life, and family activities.
• Siblings described feelings of loss, frustration, distress, isolation, and helplessness. Some felt “trapped” by OCD or like a hostage.
• For some siblings, OCD brought the family closer together with a shared purpose. Others felt marginalized and overlooked as parents focused on the child with OCD.
• The study had a small, homogeneous sample. Longitudinal and mixed methods research is needed on larger groups of siblings.

Rationale

Obsessive-compulsive disorder (OCD) affects 0.25-2% of children and adolescents and causes significant disruption to family routines (Stewart et al., 2017).

Family accommodation of OCD symptoms is common, with 60-96% of relatives reporting involvement in rituals or avoidance (Lebowitz et al., 2016).

However, most research focuses on parents, not siblings. Siblings play a unique, lifelong role, so their experiences require direct study rather than generalization from parents (Orsmond & Seltzer, 2007).

Prior work found siblings have high distress and accommodation, but quantitative measures provided limited insight into the impacts on siblings’ lives (Barrett et al., 2000).

This study aimed to explore siblings’ first-hand experiences of living with youth diagnosed with OCD using qualitative methods.

Method

• Design: Qualitative interpretative phenomenological analysis (IPA)
• Participants: 8 siblings (12-20 years old, 4 male/4 female) living with a brother/sister diagnosed with OCD at a specialist NHS clinic.
• Materials: Semi-structured interview lasting ~1 hour. Questions explored the sibling experience, coping, accommodation, impact on functioning and relationships.
• Procedure: Siblings were recruited from families who had attended multi-family therapy. Interviews were conducted via telephone and audio-recorded.
• Qualitative Analysis: Transcripts were analyzed using IPA to understand siblings’ perspectives and meaning-making about their experiences co-habiting with a brother or sister with OCD. Themes were extracted from detailed coding and interpretation.

Sample:

• 6 adolescents ages 13-17 with mild to severe depression at baseline, 3 no longer depressed after treatment
• 5 parents, mostly mothers
• 5 therapists delivering BA with different backgrounds and NHS bands
• Most adolescents had 8 BA sessions, ranging 2-8 sessions over 4-13 weeks

Results

Two main themes were identified: OCD as a dangerous dictator, and unifying/polarizing impact on relationships

1. OCD as dictator:

• Loss and Adjustment: All siblings described needing to make adjustments to cope with OCD at home, like avoiding certain rooms or triggers.
  
  This caused a sense of loss – losing shared experiences and quality time with their sibling and family. Some resented OCD for missing out.
  

  Participant 5: Yeah, it does like some days, you look at X (OCD sufferer), “oh, that’s a nice day,” and then other days you look back and like that day was ruined because of his OCD.

• Control and Power: OCD ruthlessly controlled family life. Rituals constantly interrupted activities, forcing them to be abandoned.
  
  Siblings felt they had to “walk on eggshells” and described the home environment as tense and fragile.
  

  Participant 4: Because obviously, we didn’t really go many places with X (OCD sufferer) because of all that – the contamination and germs.

• Threat and Helplessness: OCD created a looming sense of danger and anxiety for siblings. Some felt “trapped” and “hostage” to OCD.
  
  Siblings felt helpless against OCD’s authority and unable to challenge it. This only eased with professional help.
  

  Participant 5: I’ve kind of been exposed into it unwillingly and I was like I don’t feel comfortable doing this (accommodating) but I know I have to do it.

2. Unifying/polarizing

• Marginalization: Some siblings distanced themselves from family by isolating themselves in their room, hiding distress, or burying themselves in school/hobbies as an “escape”.
  
  They felt overlooked from family attention, which was dominated by an OCD sibling.
  

  Participant 3: I just feel quite left out because we’ve been talking about it (OCD) a lot and maybe going toa lot of meetings and yeah, I just felt like the whole world revolved around OCD and then I just wasn’t really part of that.

• Unifying Influence: Other siblings felt OCD unified the family against a common enemy. Working together to overcome OCD strengthened family relationships and resilience.

All siblings tried to reduce suffering by accommodating OCD symptoms, despite feeling distressed. Accommodation caused guilt, frustration, and anxiety.


Participant 1: I think it gave us […] the whole family, it brought us closer, something to work on erm, and and like, a reason for us to not be arguing and stuff but to be like all with the same purpose and the same goal.

Implications

• Supports incorporating siblings into OCD treatment plans to address accommodation and distress.
• Suggests the need for support options for at-risk siblings like education, counseling, or youth groups.
• Family environments with OCD are challenging. Open communication, empathy, and externalizing OCD as the problem may help.
• Marginalization of siblings could have long-term mental health effects warranting monitoring.
• Overall, critical and accommodating behaviors from close others, which are often targets of family-based treatments, may be associated with greater concerns about the loved one starting therapy. Addressing these concerns early on may improve treatment outcomes.

Strengths & Limitations

The study had many methodological strengths, including:

• In-depth qualitative design allowed a nuanced understanding of siblings’ perspectives.
• Homogeneous sample that had undergone specialist family therapy for OCD.
• Comprehensive themes extracted using rigorous IPA process.
• Study addresses a significant gap, as siblings are understudied.

However, this interpretative phenomenological analysis was limited in a few ways:

• Small, homogeneous sample limits generalizability.
• Cross-sectional design provides limited snapshot.
• Did not include siblings with mental health issues.

Conclusion

This exploratory study provides initial valuable insights into the lived experience of siblings of youth with OCD using qualitative methods.

The emotive home environment and shifts in family dynamics had significant impacts. Further research with diverse samples is critically needed to understand this vulnerable group’s needs and experiences over time.

Findings suggest siblings should be involved in OCD treatment plans and supported, as they face distress and accommodation demands akin to parents.

References

Primary Paper

Brownings, S., Hale, L., Simonds, L. M., & Jassi, A. (2023). Exploring the experiences and responses of siblings living with a brother or sister with obsessive compulsive disorder. Psychology and Psychotherapy: Theory, Research and Practice, 96(2), 464-479. https://doi.org/10.1111/papt.12454

Other References

Barrett, P. M., Rasmussen, P. J., & Healy, L. (2000). The effect of obsessive-compulsive disorder on sibling relationships in late childhood and early adolescence: Preliminary findings. Bulletin of the Australian Educational and Developmental Psychologist, 17(2), 82-102.

Lebowitz, E. R., Panza, K. E., & Bloch, M. H. (2016). Family accommodation in obsessive-compulsive and anxiety disorders: A five-year update. Expert Review of Neurotherapeutics, 16(1), 45-53.

Orsmond, G. I., & Seltzer, M. M. (2007). Siblings of individuals with autism spectrum disorders across the life course. Mental Retardation and Developmental Disabilities Research Reviews, 13, 313–320.

Stewart, S. E., Hu, Y. P., Leung, A., Chan, E., Hezel, D. M., Lin, S. Y., Belschner, L., Walsh, C., Geller, D. A., & Pauls, D. L. (2017). A multisite study of family functioning impairment in pediatric obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 56(3), 241-249.

Further Information

• Family Accommodation in Obsessive-Compulsive Disorder
• Albert, U., Baffa, A., & Maina, G. (2017). Family accommodation in adult obsessive-compulsive disorder: Clinical perspectives. Psychology Research and Behavior Management, 10, 293-304.
• Gomes, J. B., Van Noppen, B., Pato, M., Braga, D. T., Meyer, E., Bortoncello, C. F., & Cordioli, A. V. (2014). Patient and family factors associated with family accommodation in obsessive–compulsive disorder. Psychiatry and clinical neurosciences, 68(8), 621-630.
• Lebowitz, E. R., Panza, K. E., & Bloch, M. H. (2016). Family accommodation in obsessive-compulsive and anxiety disorders: a five-year update. Expert review of neurotherapeutics, 16(1), 45-53.
• Merritt, O. A., Rowa, K., & Purdon, C. L. (2023). Criticism and accommodation are associated with treatment concerns in close others to those with anxiety. British Journal of Clinical Psychology, 62(1), 146-157.
• Shimshoni, Y., Shrinivasa, B., Cherian, A. V., & Lebowitz, E. R. (2019). Family accommodation in psychopathology: A synthesized review. Indian Journal of Psychiatry, 61(Suppl 1), S93.
• Strauss, C., Hale, L., & Stobie, B. (2015). A meta-analytic review of the relationship between family accommodation and OCD symptom severity. Journal of Anxiety Disorders, 33, 95-102.
• Thompson-Hollands, J., Abramovitch, A., Tompson, M. C., & Barlow, D. H. (2015). A randomized clinical trial of a brief family intervention to reduce accommodation in obsessive-compulsive disorder: a preliminary study. Behavior Therapy, 46(2), 218-229.

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