Family Accommodation Worsens Anxiety, OCD

A recent study from Harvard Medical School and McLean Hospital reveals that family members routinely change their own behavior to help loved ones avoid anxiety or obsessive-compulsive disorder triggers. This pattern, known as family accommodation, is prevalent across all age groups and is linked to more severe symptoms, but targeted treatment can overcome its negative effects.

While well-intentioned, these accommodating actions reinforce the patient's fears. By helping a loved one avoid temporary distress, families inadvertently confirm the idea that the feared situation is dangerous and unmanageable. This prevents corrective learning. The individual never discovers they can tolerate anxiety alone.

Lead researcher Jacqueline Sperling, a clinical psychologist, explained the study's origins. "This topic was inspired by a collaborative discussion among science practitioners at intensive treatment programs for youth and adults," she said. "We recognized that both the pediatric and adult research worlds can be separate, and we wanted to bridge that research gap by exploring patterns across the lifespan."

Study Scope and Methods

The research examined 67 children and adolescents aged 8 to 19, and 131 adults aged 18 to 76. All were receiving intensive or residential treatment at a single academic medical center. The youth attended an intensive outpatient program several afternoons a week. Adults were in a partial hospital or residential program with an average stay of about two months.

At the start and end of treatment, patients and family members completed questionnaires. These measured symptom severity, functional impairment, and the frequency of family accommodation. In the youth program, parents reported on their own behavior. For adults, parents, spouses, partners, or siblings reported.

Treatment involved cognitive-behavioral therapy with gradual exposure to feared situations. Clinicians met regularly with families to teach them how to systematically reduce accommodating behaviors. For example, parents learned to gradually reduce the time spent walking an anxious child into school or to cut back on answering repetitive reassurance-seeking calls.

Prevalence and Impact of Accommodation

The study found family accommodation was nearly universal in these intensive settings. At admission, 100% of child/parent pairs and 95% of adult patient/family member pairs reported some form of accommodation. Specific behaviors like providing verbal reassurance, allowing avoidance of responsibilities, and changing family routines occurred at high rates.

"Family accommodation is incredibly common across the lifespan, and that makes a lot of sense given that one’s instincts are to try to support family members," Sperling said. "The key distinction, however, is that the support is for the anxiety and OCD and not the family members."

Accommodation was more frequent among families of children. Family members across both groups generally reported more accommodating behaviors than the patients themselves perceived. Higher initial accommodation levels were associated with more severe symptoms and greater daily impairment.

Treatment Outcomes and Limitations

Despite its strong link to symptom severity at the start, the initial level of family accommodation did not predict how much patients improved by discharge. Patients achieved symptom reduction regardless. "It was pleasantly surprising that family accommodation levels at the beginning of treatment did not predict less treatment progress by the end of treatment," Sperling noted. "This finding highlights how working to reduce family accommodation in treatment could help families yield treatment gains."

The researchers caution that this positive outcome is specific to the intensive treatment context, where programs actively trained families to stop accommodating. In standard therapy where these habits are ignored, accommodation likely remains a barrier.

The study has limitations. Participants were from resource-intensive programs, resulting in a relatively homogeneous sample where most identified as white. The research relied on self-reported surveys, which can be influenced by a desire to present family dynamics positively. The treatment programs and some assessment measures differed between youth and adults, preventing direct comparison.

Sperling pointed out, "The treatment programs are not exactly the same, so there could not be a direct comparison of pediatric and adult treatment." Future research could assess accommodation weekly to track how changes in family behavior align with patient improvement over time.