Quand aider devient nuire : une compréhension des implications de l’accommodation familiale sur l’efficacité des interventions psychologiques dans le TOC

Abstract

The objective of this article is to present a review of current knowledge of the consequences and determinants of family accommodation in adults, children and adolescents. Family accommodation can be defined as the changes in behavior adopted by family members of a relative suffering from a mental disorder in order to reduce the associated suffering and distress (e.g., participating in OCD rituals or helping with avoidance). This phenomenon is particularly frequent since it is observed in from 70 to 97% of the relatives interviewed in the studies, whether the patients are adults or children. To present this mechanism, this article will discuss the underlying theoretical models in obsessive-compulsive disorder (OCD) as well as outline the epidemiology, consequences and maintaining factors of family accommodation. The second part of this article will deal with the principal programs and methods of treatment of family accommodation. To this end, a review of the literature regarding family accommodation was conducted using the following databases: PubMed, Google Scholar, ScienceDirect, and PsycINFO, without date limitation. Sixty-seven articles were selected to explore the question of family accommodation in OCD, both in child and adult populations. The data in the literature clearly show that family accommodation is an important factor in the perpetuation of OCD and anxiety symptomatology. Indeed, this accommodation would seem to impede attempts to learn new functional behavior by not allowing the person to perceive the negative consequences of his or her symptomatic behavior or by preventing him or her from experiencing habituation to anxiety-provoking stimuli. In addition, several studies have shown a moderate correlation between the intensity of OCD and family accommodation, as well as the negative effects on the quality of the relationship in couples, or an increase in the perceived burden for the relative. Another finding that seems relevant to clinical practice is that family accommodation is negatively associated with the effectiveness of psychotherapeutic interventions. Indeed, it has been shown that a high level of family accommodation is positively correlated with a low response to psychotherapeutic and pharmacological treatments. Family accommodation has been shown to be a factor in the failure of psychotherapies by distorting the learning achieved in therapy, as well as by leading to greater functional deterioration in the patient. This accommodation is also a predictor of non-spontaneous recovery. These data, therefore, indicate the importance of considering this mechanism in the treatment of patients suffering from OCD, regardless of their age or sex. In the second part of the article, we discuss many proposals for interventions, based on CBT models, which have emerged in recent years in order to maximize the effectiveness of therapies for OCD and anxiety disorders. Their aim is to integrate the family member into the therapy so that he or she can understand the interest in changing his or her reinforcing behavior. In addition to understanding the importance of change, they can be helped by the therapist. Most of these programs are for children only, but some do exist for relatives of adult patients. These propositions for the treatment of family accommodation seem to demonstrate interesting evidence in favor of their effectiveness. However, considering the small number of existing programs, and the small sample sizes that have led to their validation, further research is needed on this topic in order to highlight key interventions that can lead to a decrease in family accommodation. In conclusion, despite an acceleration of research during the last decade, family accommodation remains relatively insufficiently studied, particularly in adults. Recently, family accommodation has been demonstrated in cases of depression, all anxiety disorders, autism spectrum disorders, eating disorders and in chronic pain. There is still a lack of evidence for the existence of this process in certain disorders such as schizophrenia or bipolarity, but it is easy to hypothesize that a change in behavior can be found in the relatives of people suffering from these types of pathologies. In consideration of these results and of the negative impact of family accommodation on the treatment of mental pathologies, a better understanding of family accommodation and its consideration in all psychiatric pathologies seems essential in the future in order to increase the effectiveness of treatment proposals.