About Family Accommodation
Family accommodation (FA) in obsessive-compulsive disorder (OCD) refers to family members’ or significant others’ participation in or facilitation of patients’ rituals and/or avoidance. Common examples of FA include providing reassurance to the patient, directly participating in the patient’s compulsions such as helping the patient with washing or checking, or modifying family routines to make it possible for the patient to engage in compulsions. See Table 1 for more examples of FA. Studies show that FA is common in families of individuals with OCD. It is estimated that FA occurs in 60-97% of these families, with the majority accommodating on a daily basis. Some OCD symptoms, such as cleaning rituals/contamination fears, have been associated with more frequent FA. Notably, FA occurs even though over 80% of family members believe that the obsessions and compulsions are unreasonable and 66% do not believe that FA alleviates OCD symptoms.
Examples of Family Accommodation
- Providing reassurance regarding the OCD concern
- Waiting for patient to complete compulsions
- Directly participating in compulsions (e.g., doing repeated washing or checking at patient’s request)
- Providing items needed to do compulsions (e.g., purchasing cleaning products for patient)
- Taking on patient’s family or household responsibilities that he/she can’t complete due to OCD
- Modifying the family’s routine because of the patient’s OCD
- Aiding in avoiding anxiety-provoking situations that trigger OC symptoms
The Role of Family Accommodation in Maintaining OCD Symptoms
Accommodating behaviors function as compulsions, immediately but temporarily reducing patients’ distress, preventing patients from developing tolerance or habituating to the anxiety associated with their OCD triggers, and preventing them from developing more adaptive ways of coping with their distress. More information is below.
Family accommodation (FA) is believed to maintain OCD symptoms by disallowing patients to face their feared situation. More specifically, accommodating behaviors function like compulsions in that they immediately but temporarily reduce patients’ distress, preventing patients from developing tolerance or habituating to the anxiety associated to their OCD triggers and preventing them from developing more adaptive ways of coping with their distress. According to this cognitive-behavioral model of OCD, patients will repeatedly seek or request FA because of the associated immediate (yet fleeting) relief of anxiety. In this way, FA results in a negative reinforcement cycle and contributes to poorer patient functioning, greater OCD symptom severity, and increased family distress/disharmony.
Family accommodation is assessed by the Family Accommodation Scale for Obsessive-Compulsive Disorder (FAS). The FAS:
- Identifies the types of accommodations that family members may make in response to the patients’ OCD.
- Measures how often theses accommodations occur.
The FAS was developed in English and is now available in several languages. Two versions of the scale are designed to be administered to family members of patients with OCD, an interviewer-rated version (FAS-IR) and a self-rated version (FAS-SR). There is also a version designed to be administered to patients to report on their relatives’ effort to accommodate the patient (FAS-PV).
The scale in English and several other languages is available here.
- Identifies the types of accommodations that family members may make in response to the patients’ OCD.
- Clinicians can use the FAS to monitor family accommodation in patient and/or family treatment.
- Researchers can use the FAS to assess family accommodation in treatment and other studies.
Please see the list below for articles describing the development of FAS:
- Pilot version of the FAS administered to family members (1995): Calvocoressi L, Lewis B, Harris M, Goodman WK, Trufan SJ, McDougle, CJ, Price LH. Family accommodation in obsessive-compulsive disorder. American Journal of Psychiatry 1995;152:44-443.
- Interviewer-rated FAS administered to family members (FAS-IR) (1999): Calvocoressi L, Mazure CM, Kasl SV, Skolnick J, Fisk D, Vegso SJ, Van Noppen BL, Price LH. Family accommodation of obsessive-compulsive symptoms: Instrument development and assessment of family behavior. The Journal of Nervous and Mental Disease 1999;187:636-642.
- Self-rated FAS administered to family members (FAS-SR) (2013): Pinto A, Van Noppen B, Calvocoressi L. Development and preliminary psychometric evaluation of a self-rated version of the Family Accommodation Scale for Obsessive-Compulsive Disorder. Journal of Obsessive-Compulsive and Related Disorders 2013; 2(4):457-65.
- Self-rated version administered to patients to report on their relatives’ accommodation of patients (FAS-PV) (2016).Wu MS, Pinto A, Horng B, Phares V, McGuire JF, Dedrick R., Van Noppen B, Calvocoressi L, Storch EA. Psychometric properties of the Family Accommodation Scale for Obsessive-Compulsive Disorder – Patient Version. Psychological Assessment 2016 Mar;28(3):251-62.
Family accommodation (FA) runs counter to exposure and response prevention (ERP) by facilitating and maintaining OCD symptoms and disrupting family and individual functioning. A family-based technique to target and reduce accommodating behaviors is called behavioral contracting. This serves as a platform for families to move towards normalizing the household and individual functioning. Since FA has been identified as a predictor of poorer treatment outcome both in adults and children/adolescents, there is growing interest in applying family-based cognitive behavioral interventions for OCD that are aimed at reducing FA as a means of improving patient outcomes. In fact, preliminary studies indicate that family-based interventions may lead to more durable symptom improvement than individual CBT.
Behavioral contracting begins with using the Family Accommodation Scale to list in more detail the specific situations in which accommodation takes place. How family will change their responses to demands to open doors, buy supplies, provide reassurance, avoid certain words, wash hands and so forth is carefully negotiated with the individual with OCD and family members. Withdrawing accommodation is a gradual process, similar to ERP. Fears about not accommodating and consequences for not completing the contract are discussed. Contracts can be modified and altered as the treatment progresses.
- Calvocoressi, L., Lewis, B., Harris, M., Trufan, B. S., Goodman, W. K., McDougle, C. J., & Price, L. H. (1995). Family accommodation in obsessive compulsive disorder. American Journal of Psychiatry, 152, 441-443.
- Calvocoressi, L., Mazure, C. M., Kasl, S. V., Skolnick, J., Fisk, D., Vegso, S. J., Van Noppen, B. L., & Price, L. H. (1999). Family accommodation of obsessive-compulsive symptoms: instrument development and assessment of family behavior. J Nerv Ment Dis, 187(10), 636-642.
- Albert, U., Baffa, A., & Maina, G. (2017). Family accommodation in adult obsessive-compulsive disorder: Clinical perspectives. Psychology Research and Behavior Management, 10, 293-304.
- 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.
- Albert, U., Baffa, A., & Maina, G. (2017). Family accommodation in adult obsessive-compulsive disorder: Clinical perspectives. Psychology Research and Behavior Management, 10, 293-304.
- 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.
- Steketee G, Van Noppen B. Family approaches to treatment for obsessive compulsive disorder. Rev Bras Psiquiatr. 2003 Mar;25(1):43-50.
- Steketee, G. & Van Noppen, B. (2003). Family approaches to treatment for obsessive compulsive disorder. Journal of Family Psychotherapy, 14 (4), 55-71.