Some families accommodate an individual’s avoidance and compulsions; some are overprotective, aggressive or sarcastic; they may minimise the problem or avoid the individual as much as possible. Sometimes the behaviours associated with the OCD restrict the activities of family members (such as gaining access to the bathroom) or their freedom to use certain rooms in the home because of hoarding.

People with OCD may react with aggression when their compulsions are not adhered to by their family. Frequently, family members have different coping mechanisms, leading to further discord when they disagree over the best way of dealing with the situation.

Assessment should focus on how different members of the family cope and their attitudes to treatment. The goals of CBT include helping family members to be consistent and emotionally supportive, without accommodating the OCD. They may be encouraged to assist in exposure tasks and behavioural experiments if these would facilitate recovery from OCD.

OCD in children and adolescents
Chronic, severe OCD can be particularly disabling in young people, who often have little insight into their condition and are not ready to change. Using the Mental Health Act is usually unhelpful unless for a trial of medication, for reasons of physical health or because there is a need to remove the patient from their family and home environment.

It is preferable to try to engage young patients in understanding the cognitive–behavioural model of OCD and to help them follow their valued directions in life despite the disorder. If the OCD is so severe that it prevents the individual from coping without supervision, the parents may make their child homeless and ask for the child to be rehoused, as this may motivate the individual to change.

David Veale
David Veale is an honorary senior lecturer at the Institute of Psychiatry, King’s College London and a consultant psychiatrist in cognitive–behavioural therapy at the South London and Maudsley Trust (Centre for Anxiety Disorders and Trauma, The Maudsley Hospital, 99 Denmark Hill, London SE5 8AF. Email: .(JavaScript must be enabled to view this email address); website: http://www. veale.co.uk) and the Priory Hospital North London. He is President of the British Association of Behavioural and Cognitive Psychotherapies, was a member of the National Institute for Health and Clinical Excellence group that produced guidelines on treating obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD) and runs a national specialist unit at the Bethlem Royal Hospital for refractory OCD and BDD.

References
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Frost, R. O, & Hartl, T. L. (1996) A cognitive–behavioural model of compulsive hoarding. Behaviour Research and Therapy, 34, 341–50.

Goodman, W. K., Price, L. H., Rasmussen, S. A., et al (1989) The Yale-Brown Obsessive Compulsive Scale. I: development, use and reliability. Archives of General Psychiatry, 46, 1006–1011.

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National Collaborating Centre for Mental Health (2005) Obsessive–Compulsive Disorder: Core Interventions in the Treatment of Obsessive–Compulsive Disorder and Body Dysmorphic Disorder (Clinical guideline CG31). British Psychological Society & Royal College of Psychiatrists.