As you already know, when your child has OCD, the entire household is affected. Siblings and parents, alike may have their routines interrupted or feel pressured to accommodate your child with OCD by taking part in rituals. But more than anything, it is important that your child with OCD feel loved and supported, even when that means using “tough love” to enforce homework and exercises assigned by your child’s therapist.
In an effort to strengthen relationships between individuals with OCD and their family members and to promote understanding and cooperation within households, we have developed the following list of useful guidelines for family members to be tailored for individual situations. If you are unsure how to employ or implement some of these guidelines, don’t be afraid to ask your child’s OCD therapist for help — your therapist should be accustomed to working with the entire family when necessary.
1. Recognize signals
This first guideline stresses that family members learn to recognize the “early warning signs” of OCD symptoms. Your child may seem fine from the outside but may suddenly experience a wave of intrusive thoughts, so watch for subtle behavior changes. Remember that these changes can be gradual but overall different from how your child or teen has generally behaved in the past.
Signals to watch for include, but are not limited to:
- Large blocks of unexplained time that your child or teen is spending alone (in the bathroom, getting dressed, doing homework, etc.)
- Doing things again and again (repetitive behaviors)
- Constant questioning of self-judgment; excessive need for reassurance
- Simple tasks taking longer than usual
- Perpetual tardiness
- Increased concern for minor things and details
- Severe and extreme emotional reactions to small things
- Inability to sleep properly
- Staying up late to get things done
- Significant change in eating habits
- Daily life becomes a struggle
- Increased irritability and indecisiveness
People with OCD usually report that their symptoms get worse the more they are criticized or blamed because these emotions generate more anxiety. It is essential, then, that you learn to view these behaviors as signals of OCD and not as personality traits. This way, you can help your child to combat the symptoms, rather than encouraging your child to hide the symptoms out of shame or fear.
2. Modify expectations
People with OCD consistently report that change of any kind, even positive change, can be experienced as stressful. It is often during these times that OCD symptoms tend to flare up; however, you can help to moderate stress by modifying your expectations during these times of transition. Family conflict only fuels the fire and promotes symptom escalation (“Just snap out of it!’). Instead, a statement such as: “No wonder your symptoms are worse — look at the changes you are going through,” is validating, supportive, and encouraging. Remind yourself the impact of change will also change; that is, the person with OCD has survived many ups and downs, and setbacks are not permanent.
3. Remember that people get better at different rates
There is a wide variation in the severity of OCD symptoms between individuals. Remember to measure progress according to your child’s own level of functioning, not to that of others. You should encourage your child to push him/herself and to function at the highest level possible; yet, if the pressure to function “perfectly” is greater than a person’s actual ability, it creates more stress which leads to more symptoms. Just as there is a wide variation between individuals regarding the severity of their OCD symptoms, there is also wide variation in how rapidly individuals respond to treatment. Be patient. Slow, gradual improvement may be better in the end if relapses are to be prevented.
4. Avoid day-to-day comparisons
You might hear your child say he or she feels like they are “back at the start” during symptomatic times. Or, you might be making the mistake of comparing your child’s progress (or lack thereof) with how he/she functioned before developing OCD. It is important to look at overall changes since treatment began. Day-to-day comparisons are misleading because they don’t represent the bigger picture. When you see “slips,” a gentle reminder that “tomorrow is another day to try” can combat your child or teen’s possible desire to self-destructively label him or herself as a “failure,” “imperfect,” or “out of control,” which could result in a worsening of symptoms!
You can make a difference with reminders of how much progress has been made since the worst episode and since beginning treatment. Consider occasionally using a rating scale to have an objective measure of progress that both you and your child can refer back to. For example, ask your child to rate his or her symptoms using a simple 1–10 rating. You can ask things such as, “How would you rate yourself when OCD was at it’s worst? When was that? How is it today? Let’s think about this again in a week.”
5. Recognize “small” improvements
People with OCD often complain that family members don’t understand what it takes to accomplish something such as cutting down a shower by five minutes or resisting asking for reassurance one more time. While these gains may seem insignificant to other family members, it is a very big step for your child. Acknowledgment of these seemingly small accomplishments is a powerful tool that encourages him or her to keep trying. This lets your child know that his or her hard work to get better is being recognized, and can be a powerful motivator.
6. Create a supportive environment
The more you can avoid personal criticism, the better — remember that it is the OCD that gets on everyone’s nerves. Try to learn as much about OCD as you can. Your child still needs your encouragement and your acceptance as a person, but remember that acceptance and support does not mean ignoring the OCD behaviors. Do your best to not participate in compulsions or rituals. In an even tone of voice explain that the compulsions are symptoms of OCD and that you will not assist in carrying them out because you want him or her to resist as well. Gang up on the OCD, not on each other!
7. Set limits, but be sensitive to mood (refer to #14 below)
With the goal of working together to decrease compulsions, family members may find that they have to be firm about:
- Prior agreements regarding assisting with compulsions
- How much time is spent discussing OCD
- How much reassurance is given
- How much the compulsions infringe upon others’ lives
It is commonly reported by individuals with OCD that mood dictates the degree to which they are able to divert obsessions and resist compulsions. Likewise, family members have commented that they can tell when someone with OCD is “having a bad day.” Those are the times when family may need to “back off,” unless there is potential for a life-threatening or violent situation. On “good days” individuals should be encouraged to resist compulsions as much as possible. Limit setting works best when these expectations are discussed ahead of time and not in the middle of a conflict. It is critical to minimize family accommodation to OCD.
8. Support taking medication as prescribed
Be sure to follow the medication instructions that have been prescribed. Do not make any changes to your child’s dosage without consulting the prescribing physician. If you notice serious side effects and have concerns, tell you doctor immediately. Only trained professionals will know the implications of changing medication dosages or what might happen if medications are stopped abruptly.
9. Keep communication clear and simple
Avoid lengthy rationales and debates when your child or teen is seeking reassurance or asking for accommodation. This is often easier said than done because most people with OCD constantly ask those around them for reassurance: “Are you sure I locked the door?” or “Did I really clean well enough?” You have probably found that the more you try to prove that your child does need not worry, the more he or she disproves you. Even the most sophisticated explanations won’t work. There is always that lingering, “What if?”
Tolerating this uncertainty is an exposure (which your child should have learned how to manage in their ERP therapy) that may be tough for your child. Recognize that your child is triggered by doubt and label the problem as one of trying to gain total certainty about something that cannot be provided — this is the essence of OCD, and the goal is to accept uncertainty in life — and move on.
10. Separate time is important
Family members often have the natural tendency to feel like they should protect an individual with OCD by being with him or her all of the time. This can be destructive because family members need their private time, as do people with OCD — even children!
Make age-appropriate determinations about how much freedom and independence your child or teen should reasonably have, and give him/her the message that he or she can be left alone and can care for themselves sometimes. OCD cannot run everybody’s life; you have other responsibilities and interests, and your other children and your spouse likely need your attention as well. This not only keeps you and the rest of the family from resenting the OCD. It is also a example to your child or teen with OCD that there is more to life than anxiety. Again, this is a great topic to address with your child’s therapist.
11. It has become all about the OCD!
Whether it is about asking and providing reassurance to the child with OCD or talking about the desperation and anxiety that the illness causes, families struggle with the challenge of engaging in conversations that are “OCD free,” an experience that feels liberating when achieved. We have found that it is often difficult for family members to stop engaging in conversations around the anxiety because it has become a habit and such a central part of their life. It is okay not to ask, ”How is your OCD today?” Some limits on talking about OCD and various worries is an important part of establishing a more normative routine. It also makes a statement that OCD is not allowed to run the household.
12. Keep your family routine “normal”
Often families ask how to undo all of the effects of months or years of going along with OCD symptoms and accommodations. For example, to avoid a tantrum, parents may allow their daughter’s contamination fear to dictate who can enter the home, and they may decide to prohibit their other children from inviting any friends over.
While this avoids an initial meltdown, it is also likely to create resentment and animosity, and also establishes the idea that the parents will cave to other OCD demands in the future. How do you break this cycle?
Through negotiation and limit setting, family life and routines can be preserved. Remember, it is in your child’s best interest to tolerate exposure to their fears and to be reminded of their siblings’ and other family member’s needs.
13. Be aware of family accommodation behaviors (refer to #14 below)
First, there must be an agreement between all parties that it is in everyone’s best interest for family members to not participate in rituals or accommodate OCD demands. However, in this effort to help your loved one reduce OCD behaviors, you may be easily perceived as being mean or uncompassionate, even though you are trying to be helpful. It may seem obvious that all family members and your child with OCD are working toward the common goal of symptom reduction, but the ways in which people do this varies. Attending a family educational support group for OCD or seeing a family therapist with expertise in OCD often helps improve family communication and understanding.
14. Consider using a family contract
The primary objective of a family contract is to get all family members (including your child with OCD) to work together to develop realistic plans for managing the OCD symptoms in behavioral terms. Creating goals as a team reduces conflict, preserves the household, and provides a platform for families to begin to “take back” the household in situations where most routines and activities have been dictated by an individual’s OCD.
By improving communication and developing a greater understanding of each other’s perspectives, it is easier for your child to have family members help him or her reduce OCD symptoms instead of enable them. It is essential that all goals are clearly defined, understood, and agreed upon by any family members involved with carrying out the tasks in the contract. Families who decide to enforce rules without discussing it with the child with OCD first find that their plans tend to backfire. Some families are able to develop a contract by themselves, while most need some professional guidance and instruction. Be sure to reach out for professional assistance if you think you could benefit from it.
Adapted from guidelines developed by Barbara Livingston Van Noppen, PhD, & Michele Tortora Pato, MD, Keck School of Medicine, University of Southern California.