How family accommodation impacts anxiety and OCD treatment across the lifespan

A recent study provides evidence that family members frequently change their own routines to help loved ones avoid anxiety or obsessive-compulsive triggers, a pattern seen across all age groups. When patients receive intensive treatment that specifically targets these family habits, the initial level of family involvement does not predict how much the patient will improve.

Anxiety disorders and obsessive-compulsive disorder, commonly known as OCD, can cause substantial distress and disrupt daily functioning for individuals of all ages. When a person struggles with these conditions, they often experience intense fear or discomfort in specific situations. Seeing a loved one in pain, family members often step in to help reduce their distress in the moment.

This behavior is known as family accommodation. It can take many forms, such as providing constant reassurance about a feared outcome, participating directly in an obsessive-compulsive ritual, or modifying household routines to help the patient avoid situations that trigger fear.

While well-intended and natural, family accommodation tends to make anxiety and OCD worse over time. By stepping in to help a loved one avoid temporary distress, family members inadvertently reinforce the idea that the feared situation is truly dangerous and unmanageable. This dynamic prevents the individual from experiencing corrective learning. They lose the opportunity to discover that they can tolerate anxiety and handle challenging scenarios on their own. Studies show that this cycle of reliance occurs not only with parents of anxious children but also with romantic partners, siblings, and extended relatives of adults in treatment.

Past research has documented high rates of family accommodation in both youth and adult populations. Most of this prior work looked at patients receiving standard outpatient therapy on a weekly basis, rather than those seeking higher levels of care for complex or severe symptoms. Investigating how these family dynamics operate across the lifespan helps mental health professionals understand whether specialized treatments need to address family behaviors differently for children versus adults.

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“This topic was inspired by a collaborative discussion among science practitioners at intensive treatment programs for youth and adults,” said lead researcher Jacqueline Sperling, a clinical psychologist, assistant professor at Harvard Medical School, and co-director of the McLean Anxiety Mastery Program at McLean Hospital. “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.”

Sperling, who is also the author of the book Find Your Fierce: How to Put Social Anxiety in Its Place, and her colleagues examined patients receiving intensive or residential treatment at a single academic medical center. The sample included 67 children and adolescents ranging in age from 8 to 19, along with 131 adults ranging in age from 18 to 76. The youth attended an intensive outpatient program that ran several afternoons a week. The adult participants were enrolled in a partial hospital or residential program, with an average length of stay of about two months.

At the beginning and end of their respective programs, patients and their participating family members completed a battery of questionnaires. These surveys measured the severity of anxiety, OCD symptoms, and depressive symptoms, as well as the extent of functional impairment in daily life. The researchers also measured the frequency of family accommodation using specialized scales. In the youth program, parents reported on their own accommodating behaviors. In the adult program, parents, spouses, partners, or siblings reported on how often they accommodated the adult patient’s symptoms.

During the programs, all patients engaged in cognitive-behavioral therapy that involved gradual exposure to their feared situations. Families were heavily involved in the treatment process to ensure coping skills transferred to the home environment. Clinicians met with family members regularly to teach them how to systematically reduce their accommodating behaviors. For instance, parents were taught how to gradually reduce the amount of time they spent walking an anxious child into school, or how to slowly cut back on answering repetitive phone calls from an adult patient seeking reassurance about their health.

The authors found that family accommodation was highly prevalent across all ages in these intensive treatment settings. At admission, 100 percent of the children or their parents reported some form of accommodation. Similarly, 95 percent of adult patients or their loved ones reported that family members altered their behavior to accommodate the patient’s symptoms. Specific actions, such as providing verbal reassurance, allowing the patient to avoid daily responsibilities, and changing family leisure routines, occurred at high rates for both groups.

“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 explained. “The key distinction, however, is that the support is for the anxiety and OCD and not the family members.”

“The treatment helps families recognize the difference and to offer support in a values-consistent manner instead,” she added.

Despite its presence across the lifespan, accommodating behavior was noticeably more frequent among families of children than families of adults. For example, 60 percent of parents of youth reported providing daily reassurance to their child. In comparison, 24 percent of family members of adult patients reported offering daily reassurance. Family members across both age groups generally reported engaging in more accommodating behaviors than the patients themselves perceived, suggesting that patients might not always recognize how much their families are adjusting to their needs.

When patients first entered the intensive programs, higher levels of family accommodation were associated with more severe anxiety and OCD symptoms, as well as greater impairment in daily functioning. This aligns with the idea that severe symptoms often pull for more family involvement. However, when the researchers analyzed the patients’ progress by the time they were discharged, they found that patients achieved a reduction in symptoms regardless of their initial accommodation levels.

“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.”

A reader might assume from these outcome findings that family accommodation has no negative impact on a person’s ability to recover from anxiety or OCD. This interpretation misses the specific clinical context of the study. The patients were enrolled in intensive treatment programs that actively trained families to stop accommodating the symptoms and taught them alternative ways to offer support. The findings suggest that when treatment directly and effectively addresses family behaviors, a high initial level of accommodation does not stop a patient from getting better. In standard settings where family habits are ignored, accommodation likely remains a barrier to progress.

The study has some limitations to consider when interpreting the results. The participants were drawn from intensive treatment programs that require a large time commitment and often rely on substantial financial resources. This resulted in a relatively homogeneous group of patients, the majority of whom identified as white.

A more diverse sample across different socioeconomic backgrounds might show different patterns of family involvement or face different barriers to reducing accommodation. The study also relied heavily on self-reported surveys, which can sometimes be influenced by a participant’s desire to present their family dynamics in a positive light.

The differences in how the groups were assessed present another limitation. “The treatment programs are not exactly the same, so there could not be a direct comparison of pediatric and adult treatment,” Sperling said.

“In addition, some research measures are just for either youth or adults, so not all of the questionnaires from which data were collected were exactly the same,” she added. “Analogous measures were incorporated to deduce findings.”

Future research could benefit from assessing family accommodation more frequently throughout the treatment process, such as on a weekly basis, rather than just at the beginning and end of a program. This would allow researchers to track exactly how gradual changes in family behavior align with improvements in the patient’s symptoms over time. Utilizing independent evaluators to measure family dynamics, rather than relying solely on patient and relative self-reports, could also provide a more objective understanding of how these behaviors operate and impact recovery across the lifespan.

Moving forward, the researchers want to encourage clinical integration across age boundaries. “I hope that there can be more collaboration among pediatric and adult treatment programs to support development across the lifespan,” Sperling said.

The study, “Family Accommodation of OCD and Anxiety Symptoms Across the Lifespan,” was authored by Jacqueline B. Sperling, Abigail M. Stark, Olivia Woodson, Esther S. Tung, Martha J. Falkenstein, and Jennie M. Kuckertz.