Here we're going to focus on OCD and the family. In the group, we would start out by asking the family members, and then the people who have come without support people, the same question. That is, how has OCD affected your family? And how has your family reacted to it? [Here, we go around room, hearing how families are affected, asking how each member responded to OCD by showing anger, frustration, enabling, other behaviors] We'll talk about how types of ways that families interact, patterns of behavior that are recognizable and also resolvable. We'll also talk about some of those resolutions here.

Family systems concepts. First let's talk about the family as a system. There is a whole literature on systems dynamics as it relates to the family, and we'll excerpt a bit of that. First let's look at the family structure. The family is broadly defined these days, thanks in part to Dan Quayle and Murphy Brown, and can be the nuclear family (Mom, Dad and Kids), the family of origin, living partners, or just you alone; we'll even define the family more broadly yet, to include any people in your life, be they friends, neighbors, whatever as long as they interact with you on a regular and supportive basis. Some of these people will know about your OCD, others will not. It's not crucial that everyone know everything. So the family structure includes you and everyone else. And since we're dealing with OCD here, we've already identified you as the patient. This is what has been described in the literature as the "identified patient" syndrome. This concept was originally used to describe the alcoholic family, but the dynamics are similar in many ways to those in the OCD family. This is not to say that OCD and alcoholism are in any way alike; however, the family structure ends up being similar. The identified patient is someone who is labelled by the family as the source of the problem. Then there's everyone else who ends up being resistant to the problem, supportive of the problem, aggressive toward the problem or avoidant toward the problem. And each of these people, often without knowing it, ends up contributing to the problem. So it's helpful to define the problem here as a system problem instead of as a personal problem. This may seem to fly in the face of everything we said in the last two chapters about OCD being largely biochemical and genetic. This is where we focus more on OCD and the environment, but let's be careful to define what we're talking about: the difficulties that OCD creates define a system problem. Even though one person may be the carrier of the symptoms, it becomes a dynamic system problem because everyone gets involved in one way or another, and many interactions between the OCD sufferer and the support people are disrupted.

Now families, like other systems, like finding a balancing point, or what we call homeostasis. Balance is defined in a lot of ways, and you don't have to have everyone in the family healthy in order to have balance. All you have to have is everyone involved finding ways to deal with the situation, whether they are healthy or unhealthy ways. To make this point a little clearer, we're going to use a mobile (see Figure 9). We can either imagine a mobile, or use an example like this one. I happen to use a mobile in the group that is composed of white sheep, with one of them being black. We use this family of sheep to represent your family, and we'll use the black sheep to represent the identified patient, or "IP." The IP is the person that carries the symptoms for the family, even in a case like OCD where the causes are biochemical to a large degree.

According to family systems theory, the IP also carries the shame for the family, and a lot of people with OCD report feeling a significant amount of shame around their symptoms. This is not the fault of the IP nor of the others in the family; it's part of the "family dynamic," contributed to by everyone. Now when I hold my mobile up, even though each of these members may drift around a bit in the breeze, each relationship is basically stable. Some are lower and some are higher, some are bigger and some are smaller, but everyone is in a state of balance. No one is moving, except for these little minor movements. These little movements that are caused by the room currents pretty well represent what happens in the family as well. You have little problems that come up, changing the dynamic just a little bit. For instance, you normally get along with Mom pretty well, but she won't let you have the car here and you're a bit pissed off at Mom, so you might go down a bit and Mom might go up a bit depending on how power is distributed in the family, but the movement is small and you soon return to the relationship you had before. That's homeostasis, and it happens in all systems. It's a natural behavior.

Now what happens when someone develops OCD? Let's indicate that by making that person, or sheep, heavier by pulling down on the black sheep. Now look what happens to everyone else on the mobile. They're all connected by these wires and strings, so everyone moves. Some move up, some others move down, but everyone moves to compensate for the heavier black sheep. Now what do we have here? Even though the heavy black sheep is still down, still heavy, the mobile has stopped moving again. The family has reached a new homeostasis. As long as I hold this sheep down, the family is in homeostasis - they have found a new way to adapt to the situation. Now there is a corollary to homeostasis, and that is that families tend to resist change. On the way to this homeostasis, as I pull down on this sheep, someone is going to get angry about it, someone is going to avoid talking about it, someone else is going to go out of their way to defend the person with OCD. All of this represents resistance to movement, resistance to change by all of these mechanisms. Because systems don't like change, you hear things like "can't you just not do it?" or "can't you just stop?" or "come on, just do it!" Well, that's a natural response to systems, and families, not wanting to change. So what do you do about that? Well you educate the family about the roles they are in now and the new roles you all will need to take. We'll talk more about this in a minute.

One of the other things that happens in family systems when there is an IP is called enabling. That is, learning to cope with the new situation by "helping" the person do their thing. Here, the IP is the carrier of the family problems, and family members often project their fears and concerns onto the IP, even while meaning the best for that person. Often, when someone says "can't you just..." you find out that the person really can't. In that case there is often someone who will come to the rescue, who will "help" do the ritual (like "I'll check all the doors for you") or simply to say "yes, all the doors are locked." To give reassurance that the ritual isn't needed is often enough to reduce the person's anxiety so that they can do whatever it is that you are wanting them to do. Often this is done out of frustration or anger at the situation, and sometimes this is focussed at the IP. Another version of that, when the person isn't reacting out of frustration, is something that used to be called co-dependency. This term has really gotten over used, and we try not to use it too much these days. But what we're referring to is the way some of us assist the person in either doing rituals or avoiding the consequences of the rituals, generally at their own expense and out of concern for the well-being of the IP. Let's say that someone has a ritual of checking door locks, for instance. The wife, say, who is enabling might say, "OK, I'll call your boss and tell him you'll be 30 minutes late today," or just agree to speed down the freeway to get the him to work on time after he did his checking for too long again. This is not good for him, and not good for the person who's counting on him to go to work. But it's reducing his anxiety and enabling him to do the ritual. In addition to calling this either enabling or co-dependency, sometimes we call this collusion, because what you're really doing is joining in with the plot. You're tacitly saying "I'm going to help you do this, and therefore I think it's OK even though I say differently." In reality, you're helping the OCD sufferer into helplessness, and this reassurance will have to stop. In a few minutes we will talk about how, when and what you can do differently.

Recovery from OCD. But let's look now at where you are: you've come to a new equilibrium. You're all here with your IPs, your heavy family members, down there and you don't like that. How do we know? Because if you liked it that way, you wouldn't be reading this, trying to make a change. But let's take a good look at what you're really asking for. You're asking for the person with OCD to get better, that is, to become lighter in the mobile example. But as the person with OCD gets lighter, look what happens: everybody else has to move again. Remember what we said about homeostasis? Families tend to resist change. This means, that as the IP gets better, people will find new ways to resist that change as well. Now that isn't something that we normally like to think about. We like to think, "Well, of course, if they just get better, then everything will be fine." But you all are going to have to readjust, and you may not like having to change your current ways of doing things. There may be things that you all have found beneficial about this, things like you now always have someone to blame for being late because they're often involved in their rituals. You know, if they aren't doing their rituals any more and you're still late, you won't be able to blame them. That might be difficult. You may have been able to avoid family get-togethers because so-and-so has this problem. Now you won't have that excuse any more. There are lots of examples like that. For instance, the wife that I just mentioned whose husband checks the door locks for 30 minutes in the morning. Well, she may have gotten used to having that extra half-hour to get ready in the morning. Now what will happen? He won't have his checking to do any more, and she will have to be ready a half-hour earlier. That may be uncomfortable.

That sort of enabling, when someone is there to either help you do the ritual or to reassure you that the ritual doesn't need to be done is one thing that we will help you eliminate, gradually and at the right time during recovery. And this will have to go despite the likelihood of resistance to this change. These are behaviors that we refer to as "helpful but not useful" - that is, they help reduce the person's anxiety in the short run and they get the helper's agenda taken care of, but are not useful in recovery. In fact, because they reduce anxiety about the particular stimulus, these behaviors actually retard recovery. The only way that a person can effect real recovery from OCD is that they have to take responsibility for their own recovery, to experience anxiety, live with the anxiety and come to realize that they will still be OK. That's what E & RP is all about.

So what kinds of responses are "useful," then? Let's suppose that someone came to you and asked, "Did I do this? Did I check enough? Are my hands really clean now?" You have several responses you can make. You could say, "Yes, I think so." Well, that would be enabling. You could say, "No, I don't think so." That's also enabling, because you're telling the person to go back and do the ritual again because it's not enough. You could say, "I don't know, go away and figure it out for yourself." That's probably neither helpful nor useful, might be called resistant, and would probably just upset the other person. Then, you could say, "Do you really not know, or is that just your OCD?" Here you're asking the person if they really don't know the answer to that, or if they are simply having an obsession and need some reassurance in order to reduce anxiety. In the latter case, they already know the rational answer to that question and they don't really need an answer. You're telling the person that you are there to respond if they really need an answer, but that they should look for the rational response first. Because OCD is a problem of irrational fears, most people know what the rational responses are. That's why reassurance doesn't work very well. Have you noticed that you can reassure someone until you're blue in the face and they will still want to ask you one more time? That's because irrational fears don't respond to rational reassurance. But most people with OCD know the rational answer. If you respond in this way, and the person says, "I really don't know," then it's OK to give an answer, but be alert to patterns of questions. For instance, if they ask a second time, you might respond with, "I gave a rational answer last time, do you remember what it was? Is this your OCD making you doubt yourself?" If they say, "It's just my OCD," and you know that they are working on that level of anxiety now, they will have to work out the answer for themselves. You let them know that you're not rebuffing them, but that they need to learn to be OK with the uncertainties of life. But be careful not to TELL them it's their OCD; only they know that for sure.

There are other things you can do to be useful, as well. Recognizing small improvements, even the most minuscule ones, is important. There are people who can't brush their teeth because it's not part of a ritual (or, sometimes, because it is part of one they want to avoid). You and I can brush our teeth anytime, and we may not respond to this in any way except for "It's about time!" But we need to recognize what a struggle it was for the other person and to reward that by our recognition. Instead you can say, "That was great, you did a good job!" Now note: stop there, do not add "Now what are you going to work on next?" because that invalidates the first part of what you said. Let the recognition stand alone. Remember, even though this was a small step, all journeys are made up of small steps. Recognizing small steps is a very important function of the family.

Not being too demanding is the converse of recognizing small achievements. Don't ask for too much; if this is the best they can do now, recognize that and stop there. Learn to be flexible in your routines and your expectations. And there are several more suggestions like these that are listed in a small booklet available from the OC Foundation called Learning to Live With OCD, and it's sort of a survival guide for family members.

Let's talk for a minute about resistance to change. We said that the system is going to resist change in order to stay at the same equilibrium, to maintain homeostasis. How will that happen? There are all kinds of ways the system might resist change, even if the people involved have the best of intentions. Let me start our with a medication example. "Boy, you're doing so much better on your Prozac now after three months! But you're needing 4 pills a day and they're pretty expensive. Can't you cut back to three and save the money? After all, even when you weren't taking any, we were sort of OK." Well, you might need the money for other things, but the whole reason that the person is better is because they're on the 80 mg, and shouldn't go off until recommended by the MD. Don't laugh, this happens. Here's another example: "You seem so much better now, your symptoms have calmed down so much and you seem so much less anxious. Now go out and get a job!" One of the reasons he/she is improved is that they have learned to manage their stress, and getting a job would actually serve to increase their stress. These are ways that people really think they are just responding to recovery, but in reality they are engaging in system sabotage, foiling the recovery. Why would we do this? We've learned how to operate under the other conditions, and these new conditions are foreign to us. One more example: a couple who was not very comfortable with each other may have been able to direct all of their attentions to the daughter who has OCD and not have to deal with the relationship. Now all of a sudden she is recovering, and they may be as overt as saying, "Your father and I are having problems, and we never had problems until you started going to those classes. It's all your fault." Basically, they're saying "your recovery is causing us distress," and they are resisting this change.

Sometimes the individual may sabotage his/her own recovery as well. The person may decide to go off Prozac on their own in order to save money. Or, they may realize that now that they don't have rituals to do, they may be expected to help out more around the house and not want to do that. Or they may not have the excuses for being late any more. And as much as we would like this not to be true, any of us might think, "There were some things that were good about those symptoms, I had a lot of permissions then." They might stop doing homework, stop coming to behavior therapy, etc. As the person gets better, the system will change but also the individual's position in the family will change. For instance, the older sister who is recovering may now be asked to take more responsibility for the younger brother and may not want to do that. Unconsciously, she may be feeling, "I'm not feeling that well, I won't go to the group here. And I have to stop doing the assignments, they were just making me anxious." Of course they do, that's what they are supposed to do; but here the person was uncomfortable with the change. So watch for resistances to change and for sabotage. As you spot them, bring them up and we can discuss them. Any questions about systems, change and resistance?