January, 2022. In this issue of the Journal, La Buissonnière-Ariza and colleagues report on the use of a patient version of a Family Accommodation Scale (FAS-PV), aimed to help patients with obsessive-compulsive disorder (OCD) and their families. It is well-established that families of patients with OCD adjust their own behavior to accommodate the family member’s OCD-driven pathologic behavior, in their attempt to help, and to “keep the peace.” However, the effects of such accommodating efforts, however well-intended, are often not recognized or understood—especially when the family accommodations contribute to perpetuation or worsening of the pathologic behavior. An interviewer-rated version of the Family Accommodation Scale (FAS-IR) was first developed to assess these family dynamics,1 but it is time-consuming, and families are not always available. More recently, a patient version of the FAS was developed (FAS-PV), showing promising results with adult patients with OCD.2 In the study presented in this issue of the Journal, La Buissonnière-Ariza and colleagues used the FAS-PV with a large group of adult patients with OCD to evaluate the following 4 types of family accommodation: (1) participation in symptoms, (2) avoidance of OCD triggers, (3) taking on responsibilities, and (4) modifying responsibilities. They found that “family accommodation was positively correlated with OCD symptom severity and with functional disability,” confirming similar earlier findings utilizing the FAS-IR. The authors add that future research “should examine possible treatment-related changes in FAS-PV scores, as well as associations between FAS-PV scores and posttreatment changes in OCD symptoms.”
But let’s step back a minute and put on our mentalizing hats, to beam ourselves into some of these family living rooms and imagine what it’s like. What’s a family member to do? Isn’t it natural to try and reason with the patient, to explain the irrationality of the thinking and behavior? To reassure the patient that nothing terrible will happen if he or she doesn’t check the locks every hour all night? Sure, it’s natural, but it doesn’t work. What about the opposite, try to prevent the behavior? All hell breaks loose. It must seem like a no-win situation, and the stress and burden just multiply for everybody in the house.
And aren’t there similar dilemmas for families of patients with other illnesses, such as attention-deficit/hyperactivity disorder, posttraumatic stress disorder, substance use disorders, other addictive behaviors, personality disorders, mood disorders, and the list goes on. Telling the difference between being supportive and being enabling or accommodating is not easy. If there’s a bottom-line message here, it’s that treatment for conditions like these, and certainly for severe OCD, should involve the family when possible. In a relatively recent review by Albert et al3 of clinical perspectives regarding family accommodation in adult OCD, the authors thoughtfully stressed the importance of addressing nontherapeutic family accommodation, while appreciating the family’s efforts to help. They recommended family participation in treatment, stating in particular that clinicians “should be aware that family-based cognitive-behavior therapy incorporating modules to target family accommodation is more effective in reducing OC symptoms.”
Also in this issue of the Journal, Phillips and colleagues review suicidal behavior in transgender youth, providing 5 brief case vignettes illustrating the complex challenges these young people face. Here again, the crucial role of the family is at the forefront, since a family’s attitude toward the transgender behavior of a child is critical. And here again, how the family figures out what will be helpful and supportive or what might be, even if well-intended, distancing and discouraging, is no easy matter.
JOHN M. OLDHAM, MD Editor
1. Calvocoressi L, Mazure CM, Kasl SV, et al. Family accommodation of obsessive-compulsive symptoms: instrument development and assessment of family behavior. J Nerv Ment Dis. 1999;187:636–642.
2. Wu MS, Pinto A, Horng B, et al. Psychometric properties of the Family Accommodation Scale for Obsessive-Compulsive Disorder-Patient Version. Psychol Assess. 2016;28:251–262.
3. Albert U, Baffa A, Maina G. Family accommodation in adult obsessive-compulsive disorder: clinical perspectives. Psychol Res Behav Manag. 2017;10:293–304.