Supporting Your Loved One With OCD

If you have a child, significant other, or friend who has OCD, you likely know the suffering it can create. Or maybe you don’t; that’s okay. The unfortunate reality for most clients once they appear in my office is that OCD has culminated in tremendous levels of stress and disability. 14-17 years from the onset of OCD is the average needed to obtain evidence-based treatment. By this time, OCD is typically well-developed. Sometimes, it can function under the level of awareness, even when severe. Family members often feel guilty that they missed it for so many years. You are not alone. This article presumes basic knowledge of OCD, so if you are brand new to the topic, I recommend a primer, such as the following on my OCD Resources page: Intro brochure, ERP for OCD Presentation, and the IOCDF’s “What You Need to Know About OCD”

OCD is an extremely debilitating disorder as a whole, ranking as one of the top ten medical and mental illnesses in the world- right alongside such things as Heart Disease, Major Depression, and COPD, according to the World Health Organization. With 2 out of 3 people reporting severe impairment at some point in their lives (e.g., work, relationships, school), you can count on OCD to create an ever increasing set of problems- without effective treatment. Furthermore, around 90% have at least one comorbid mental disorder, such as Major Depression, Panic Disorder, or a Substance Use Disorder. OCD has a tendency to make sufferers “hostages”- feeling stuck in an ever-narrowing loop of behaviors and/or thoughts that usually seem nonsensical to the person themselves, which tends to drive even more shame. Families and support are collateral damage. It is crucial to identify the threat and connected suffering of OCD in order to fully address its impact- and to have the proper perspective and motivation in getting necessary treatment. ​

Attempt to really understand your loved one’s suffering, and understand how to help, howa not to help, and how to stay healthy yourself. Finding effective support and treatment is crucial. You don’t have to have diagnosable OCD to be an incredible advocate. Myself and a majority of my OCD specialist colleague/friends do not have diagnosable OCD. Knowing treatments that are effective helps to stay grounded and focused. In short, a specific subset of CBT (Cognitive Behavioral Therapy) known as ERP (Exposure and Response Prevention) is the Gold Standard in treatment. SSRI medications (and clomipramine, a TCA) are used as the first line psychopharmacological treatments.  Supportive psychotherapy is not evidence-based first-line treatment for OCD. You may love a counselor who is very supportive, but if they’re not doing some sort of exposures or behavioral experiments, and there’s not a noted clinical reason why they cannot, consider an OCD specialist, because they are not following clinical practice guidelines. Again, check out my Intro Brochure​ and ERP for OCD Presentation for more on the research and specifics.

Taking OCD seriously involves seeing it- and you may help your loved one see it more clearly through your loving support. When it is beneficial to a client, I almost always recommend involving a supportive loved one at some point in treatment. We would consider it odd or unusual not to involve a family member in many other medical treatments. A major challenge with mental illness is making the unseen seen.  ​

One of the roles I serve is setting expectations. Consider how a coach might observe, teach, encourage, and challenge based on a fitness or performance goal. I know OCD from the inside; you can, too. I want to prevent “injury” from occurring in clients who are overeager and might overwhelm themselves jumping in unrealistically- in order to make progress quicker than their skill and training can support. I’ve seen this occur when clients start with the hardest thing they can imagine doing without the support to do it- they usually get burned out or drop out of treatment altogether if they don’t redirect this focus into systematic, consistent, and sustainable work. Conversely, some sufferers have low motivation or may be depressed. Walking together in the trenches and valleys, I seek to boost their perspective to know there is hope when they don’t feel it. 
You cannot “cure” / overcome core fears in OCD with a single exercise, so pushing a loved one to do something they are terrified of can backfire- reinforcing fear vs. disconfirming it; we need to consistently, systematically face fears by addressing with a strategy and a plan.​Be careful to not underestimate how much of a problem OCD can create- and in turn, how much work and growth is needed to learn to say no to all the compulsions that exist for an individual. When there are additional treatment factors (comorbidity and severity, among others, negatively influence outcomes), they can complicate the learning and growth process . Probably the most common error I see in practice is an underestimation of how much treatment and work is needed to accomplish clients’ and families’ goals (e.g., in terms of number of sessions, practices at home). We also want to be realistic about outcomes, i.e., getting better. Though the treatments for OCD are highly efficacious for most and can be life-changing in a short amount of time for some, practicing patience in your individual situation is key. No one case is exactly alike. 
You as a family member can help spell out hope or chaos in expectation-setting- helping your loved one in staying the course without being overly idealistic or nihilistic in their views of getting better.

Facilitate buy-in by reinforcing the principles of what it takes to get better. Validate growth- and always validate the person’s value and importance, no matter how much they struggle. Remember to encourage yourself, too!

Support needs to strike a balance between being overly-accommodating and overly-emotionally expressive (outbursts, hostility, negativity, etc.). The well-researched terms we use to describe these are Family Accommodation (FA) and Emotional Expression (EE). Break the Cycle!! Don’t Do Compulsions for them (by proxy). Begin (with a plan) to minimize your accommodation. Typically in therapy, I help to incrementally get rid of accommodation altogether without “pulling the rug out” too fast (i.e., in one day). Therapeutically, all client rituals must ideally be terminated to maximize outcomes. Helping a loved one ritualize only feeds the cycle. Don’t Give Reassurance. To do this well, you often need to be involved in the prior steps this article elucidates. It can be tricky to know what is reassurance and what is not. Ask questions of your loved one. If they are not open to sharing, you may have to do your best to set your own boundaries, make an informed guess, and base your limits on your own personal boundaries until they’re willing to communicate further. Part of feeding obsessions involves engaging the content of obsessions with logic, emotion, and reactions. The person with OCD must learn to live their goals and values without following the content of obsessions. Be careful not to get pulled in, either through accommodation or emotionality. Offer to go to therapy with your loved one if they are willing. You can also gain much support by doing your own therapy, as well! Part of support may be helping covering costs of therapy. Just to be clear- you get to have your own emotions, whatever they are! But EE refers to when these emotions are expressed in harmful ways.

You are a person with your own thoughts, feelings, life to live and decisions to make. Having healthy boundaries for yourself and family is very important. Helping does not mean loss of your own identity and responsibilities. It is not over-extending, nor is it avoidance of problems. Review the chart above. Your situation is your situation; there is a lot of similarity and variety (homogenous and heterogenous) to stories around OCD. You will likely be encouraged at how others feel similarly; but you also have unique factors that make your story your own- be careful not to compare unnecessarily. For goal and boundary setting, Contingency/Behavioral Contracts might be helpful, especially if you are responsible for someone with OCD (i.e., a child), or if you just need clear guidelines of involvement (how and when to discuss obsessions, financial support, reinforcements and privileges, etc.). Your own support and therapy can help you with you own growth and boundaries. Refer to the IOCDF’s excellent tool to “Find Help.”

You can be a crucial source of ongoing recovery, similar to how a coach or trainer might help. We all need reminders, especially in dealing with a consistent need (exercise, diet, and chronic disorders). You can be part of the team surrounding a sufferer to help them be aware of any new compulsions or problems that may arise. You may want to communicate with them in advance about how to best bring up concerns when they are observed. You can be part of the team that cheers them on and helps with motivation! Remind them of their values and why they want to grow (i.e., to go to school, work, not be controlled by OCD, feel better, enjoy life, help others, grow as a person, etc.).

I often have my parents and significant others complete several documents and incorporate various tools. Each situation will vary, but commonly I use:

• Family Accommodation Scale (FAS)
  
• Hierarchy– Filling out a Hierarchy based on how difficult you think it would be for your loved one to accomplish said task without compulsion. Communicating with them and clarifying expectations and needs can really help in being realistic.
  
• Log
  
  • Track/Monitor your observations:
    
    • ​O-C Log
      
    • Functional Assessment
      
• ​Support Group / Therapy
  
• Some of my favorite stories, tools, and resources can be found on my ever-expanding page for OCD.

If you have made it this far to read this article, you are quite likely a key support of someone who has OCD. It is then very likely that you care and want to make a difference. You rock. Keep up the good work.

References:
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.

Depression and Other Common Mental Disorders: Global Health Estimates. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.

Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E., & Foa, E. B. (2012). Common Pitfalls in Exposure and Response Prevention (EX/RP) for OCD. Journal of obsessive-compulsive and related disorders, 1(4), 251-257.

​What You Need To Know About Obsessive Compulsive Disorder. (n.d.). Retrieved February 2, 2020, from https://iocdf.org/wp-content/uploads/2014/10/What- You-Need-To-Know-About-OCD.pdf