Author: Hemendinger, Emily

Accommodation and Obsessive Compulsive Disorder: Recognizing and Addressing Accommodation in Therapy

Accommodation is when you actively and directly participate in and/or facilitate a loved one’s compulsions or avoidance

Accommodation...
Reinforces the OCD and makes it stronger
Gets in the way of Exposure Response Prevention and treatment
Impairs individual and family functioning
Only provides temporary relief
Does not allow the client to increase their distress tolerance, habituate, utilize healthy coping skills, or relate to their distress in an adaptive way

If accommodation is not addressed in an individual’s treatment, it will interfere with ERP done in session and perpetuate the OCD

Accommodation and Obsessive Compulsive Disorder: Recognizing and Addressing Accommodation in Therapy

*Buying supplies for compulsions (e.g. soap, cleaning products, etc.) or paying for compulsions/avoidance

*Overly assisting in daily activities

*Providing reassurance

*Avoiding using triggering words, watching triggering media, listening to triggering songs, etc.

*Waiting for a loved one to complete a ritual

*Assisting a loved one in a compulsion or allowing them to use you in a compulsion

*Making decisions for loved ones

*Letting loved one create unusual conditions in the home

*Making changes in routines

Note: As a provider, you may feel the urge to reassure your client as a means of soothing them. However, with OCD this can oftentimes be reinforcing the obsessive-compulsive need for reassurance, thus perpetuating the OCD cycle.
Validation and support are different from reassurance!

Accommodation and Obsessive Compulsive Disorder: Recognizing and Addressing Accommodation in Therapy

Everyone deserves a reality check and to know what is going on, however constant questioning/asking the question in different ways , known as reassurance seeking, is a type of compulsion used to seek certainty
Assurance and Reassurance are different!

Assurance is to provide truth and helps someone to feel more secure; give confidence/inspire
Giving someone the facts/what’s happening/evidence and they judge for themselves if all is well
Reassurance is done to lessen anxiety or help someone worry less by assuring them again; to free from fear and terror; restore confidence
Telling someone all is well

If accommodation is not addressed in an individual’s treatment, it will interfere with ERP done in session and perpetuate the OCD

Accommodation and Obsessive Compulsive Disorder: Recognizing and Addressing Accommodation in Therapy

How to involve family and start to address accommodation

Make sure you take time to educate the individual about accommodation and find out from them, as well as their support system, how their OCD is being accommodated
Assess using clinical interviews and the Family Accommodation Scale (FAS)

Team approach
The caregivers/support system, the individual, and the therapist are a team
A team approach is needed to tackle the OCD and accommodation

Accommodation and Obsessive Compulsive Disorder: Recognizing and Addressing Accommodation in Therapy

Educate caregivers and support system
Provide psychoeducation on OCD and accommodation (and why accommodation does not work)
Teach the team about ERP, identifying triggers, setbacks being normal, and distress tolerance
Guide support system in recognizing traps such as:
* Having too high of expectations
*Circular arguments
*Not staying in the present tense (what ifs and yeah buts)
*Being defensive
*Getting caught up in the details (the less words you use, the better)
Help caregivers and support system set boundaries, hold boundaries, and help loved one sit with uncertainty

Make a plan with the team
Remember that you are all on the same team
Help the support system and their loved one recognize the accommodations that are happening and support them in choosing which accommodation they want to address first
Help the team work on creating a contract for decreasing and eliminating the chosen accommodation
Having this written up as a contract can be helpful for all those involved

Accommodation and Obsessive Compulsive Disorder: Recognizing and Addressing Accommodation in Therapy

Modalities to look into and utilize:

Emotion Focused Family Therapy
A great modality for working directly with caregivers created by Adele Lafrance
Gives tools for caregivers to use, that help them support their loved one in an effective and not accommodating way

Validation
Help caregivers work towards meeting their loved one’s emotional needs instead of the practical need
Validate instead of trying to fix

Accommodation and Obsessive Compulsive Disorder: Recognizing and Addressing Accommodation in Therapy

Modalities to look into and utilize:

Emotion Focused Family Therapy (continued)
Addressing fears
Work with caregivers on addressing their own fears when it comes to challenging the OCD and doing exposures
Help them to recognize these fears as another piece that is reinforcing and maintaining the OCD
Validate them and work with them to build their distress tolerance around seeing their loved one in distress

Common fears of support system:
Afraid of doing exposures because it will make the OCD/anxiety/distress worse
Afraid reducing accommodation will tear the family apart
Afraid that their loved one will hate them/be mad at them/their relationship will be ruined if they hold boundaries around accommodation

Accommodation and Obsessive Compulsive Disorder: Recognizing and Addressing Accommodation in Therapy

Modalities to look into and utilize:

Supportive Parenting for Anxious Childhood Emotions (SPACE)
SPACE was created by Eli Lebowitz as an intervention to help parents focus on changing their behavior vs. changing their child’s behavior
Parents learn how to respond to their children in a more supportive way and focus on reducing accommodations

References:
Hershfield, J. (2015). When a family member has OCD. California: New Harbinger Publications.
Lafrance, A., Henderson, K. A., & Mayman, S. (2019). Emotion-focused family therapy: A transdiagnostic model for caregiver-focused interventions. American Psychological Association.
Lebowitz, E. R., Panza, K. E., Su, J., & Bloch, M. H. (2012). Family accommodation in obsessive-compulsive disorder. Expert Review of Neurotherapeutics, 12, 229-238.
Lebowitz E. R. (2021). Breaking free of childhood anxiety: A scientifically proven program for parents. Oxford University Press.

Hemendinger 2021