Family Culture Matters


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How I Treat OCD: Family Culture Matters

by Lee Fitzgibbons, PhD, and Gordon Street, PhD of Anxiety Solutions

from OCD Newsletter, Spring 2004, Volume 18, Number 2 - If you would like learn more about the OCD Newsletter and/or read more of its articles, click here.

In our work, we have noticed on numerous occasions that treatment comes more easily to some families than to others. Because of this, we think family culture matters. So despite the fact that there is not a lot of research on family factors in treatment, we pay attention to the family unit for all our patients (both adults and children). In fact, we now offer this family factor focus not only in our standard OCD treatment, but also in our newly developed intensive outpatient program which we designed to better reproduce and generalize to the patient's home environment. This article will not discuss our program in its entirety, but it will focus on issues relevant to family culture. 

Foremost, our approach includes attention to over-involvement with, enabling of, and hostility towards the family member with OCD. It is probably no great surprise that research suggests most family members feel burdened by the OCD sufferer. Also, sufferers with hostile families fare worse than sufferers with supportive families. We focus on increasing awareness of hostile behaviors and on helping families find alternative behaviors to engage in, an important first step towards building a positive family culture.

We also attempt to promote three attitudes in family members that we think are important in hopes that the family members will then help sup­port these attitudes in the person with OCD. The first attitude is to "embrace uncertainty" and accept the reality that there is no real cer­tainty, no real control, no perfection, and that THAT IS A GOOD THING. All anyone can do is one's best right now. That means there is no perfect/right decision because all the possible information is never available right now. You don't get to know how bad (or good) your choice is until later. We try to help families to accept and even enjoy the act of choosing to live right now, to be blissfully ignorant of the conse­quences that might catch up with them later.

The second attitude is to "let go of normal" and accept that for now, like diabetes, OCD is not curable. Instead, living with OCD means developing a "healthy" lifestyle that makes possi­ble approximating "normal." Making "normal" behavior the goal often leads patients (and fami­lies) to reject the most effective exposure exercis­es. That occurs because the behaviors involved often stretch beyond "normal" and into the unusual, which patients (and families) can erroneously perceive as unnecessarily risky. Also, using "normal" as a yardstick does not provide the person with OCD with the right strategies, tools, and attitudes during the maintenance phase, often setting the stage for relapse. For these reasons, we encourage families to drop this longing for "normal" early on and instead focus on developing a family culture that promotes "healthy" and distress-free functioning.

The third attitude that we try to teach is that, contrary to what people usually think, anxiety is and needs to be treated as your friend. Anxiety serves an essential purpose: it keeps you alert and improves functioning in potentially difficult or dangerous situations. But for OCD sufferers, anxiety has become something to avoid at all costs. One should do whatever one can to avoid it or escape from it. We teach OC sufferers and their families instead to view anxiety as an opportunity or a challenge or an actual chance "to go for it." When families start to view anxious moments as potentially strength­ening, it becomes easier to resist colluding with OCD by enabling OC behaviors. In turn, family members' willingness to approach anxiety-laden situations helps the person with OCD choose to approach his/her triggers instead of avoiding them. Eventually, anxiety will trigger alertness instead of persistent distress.

After helping the family to develop the right attitudes, we look at the actual family culture itself, the family's belief pattern and way of doing things. We believe that OCD can sometimes exploit family cultures. In effect, some family beliefs can provide sheltered ground for symptoms to take root and flourish. In such cases families and patients are actually putting energy and attention into maintaining practices that work against treatment.

For example, it will be critical to recovery for an OC sufferer who fears serious illnesses, who avoids contact with potentially germy sur­faces and who also compulsively utilizes vitamins and/or herbal supplements, both to risk touching such surfaces and to stop taking vitamins and sup­plements (at least for a while). But if that OC sufferer comes from a family that strongly sup­ports taking vitamins and supplements, the family as well as the sufferer may balk at the idea of not taking the vitamins and supplements, insisting that they are essential for good health. Similarly, if an OC sufferer fears that making a mistake or simply not exerting enough effort will make them fail or become "a slacker," the treatment may call for intentionally "slacking off" and/or making mistakes. But a family that values high achieve­ment, for example, may object if grades or perfor­mance start to fall or seem at risk of doing so. Another example is an OC sufferer with obses­sions of worshipping/accepting Satan that are prompted by minor mistakes or by being distract­ed when praying. For that patient, it will be cru­cial to recovery to do things that trigger the fearful obsessions and may seem to risk selling one's soul to the devil. But if that OC sufferer lives in a devoutly religious family, family members may encourage him/her to live with these symptoms rather than take such risks.

In such situations, we believe that working with the family to shift its priorities is necessary. For the time being, we tell them it is more important to help the OCD sufferer fight his/her OCD than to make sure he/she is adhering strictly to the family's pattern of beliefs and value systems. It may be necessary, for a while at least, to support the OCD sufferer's therapy even if there is a conflict between it and the values the family espouses.

One approach to this goal is to help families recognize that the patient's OCD may actually be working against or sabotaging adherence to the family values anyway. For example, for the patient with religious obsessions, it may help if the family can recognize that praying has become more about fear of Satan than love of God and that minor mistakes are being treated as more sinful than intentionally disobeying all of the Ten Commandments. For the patient afraid of failing or becoming "a slacker," it would be helpful if the family view could shift to accept that the fact that failure will be MORE likely if the patient continues to be miserable and dysfunctional. Additionally, the family may need to accept the risk that some failure may close the door to a cherished goal (perhaps NOT getting into medical school or getting an academic scholarship), but realize at the same time that if the sufferer does not take control of his OCD, it will rob him of any chance to be successful or accomplish any of his goals. Unfortunately, this is a real possibility. Some OCD sufferers have achieved their academic goal of graduating from medical school but have been unable to pursue a medical career because of their uncontrolled OCD.

In our intensive program, we often encourage (and have tried to make more financially feasi­ble) involving family members actively in treat­ment too, so that we can help modify the fam­ily culture and/or help the patient learn how to use his/her anti-OC skills and attitudes within the family culture. Hopefully, this will reduce the risk of relapse.

We hope these examples have illustrated how family culture can become a treatment impediment for some people with OCD. We encour­age families to find ways to break their own rules gradually as the sufferer moves through treatment. Often this comes down to family members being willing to do mini exposure and response prevention exercises themselves. Engaging in commensurate exercises goes a long way towards creating momentum and helping create a family culture conducive to recovery. 

from OCD Newsletter, Spring 2004, Volume 18, Number 2 - If you would like learn more about the OCD Newsletter and/or read more of its articles, click here.

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