Exposure and Response prevention for anxiety and OCD can be difficult in the best of circumstances, but when a client refuses to participate or family members continue accommodation, it can feel impossible. Is there a link between treatment resistance and family accommodation?

Recently, I have begun working with a teenager who had social anxiety and OCD. In my first interaction with his mother, she told me he didn’t want to be in therapy and she didn’t think he would participate in our initial evaluation. This is not a great way to start therapy but it also creates a challenge for me-and I do love a good challenge! How can I develop a relationship with this client and provide him helpful information that will make him be curious enough to come back? What role do his parents play when he is struggling? Do they reassure him? Do they accommodate him? Do they fear something bad will happen if they push him?

CBT with ERP has trained me to be curious, not afraid. It has shown me how to climb over obstacles in therapy. I have learned to model for my clients and their families how to communicate clearly, set boundaries, work as a team together, and to identify areas where anxiety or OCD trick them. Together we develop ways to stay strong when everyone is feeling weak and exhausted. We are on this journey with our clients and often have to practice what we preach.

There are many ways to work with treatment resistance and family accommodation but always start with making sure you have spent time developing a healthy relationship with your client and their family.  Once that is secured, helping them develop motivation, identifying what they value more than being safe, and teaching them how to tolerate discomfort while moving towards valued actions are some skills that are important to use.

I remember another client that had not been to school for 2 semesters. Everyone was holding out hope that I would be the one that could help. I formed that team with the client and her parents as well as the school. We climbed over obstacles together, celebrated successes, and struggled with emotions that threatened to take everyone down. Unfortunately, the resistance and family accommodation were so significant that she started cyber school. We were all disappointed and I felt beaten. As I reviewed this case with a colleague, it became clear that the best thing I could do for this client was to get her parents specialized training around anxiety (SPACE) as well as a good family therapist. Once I switched gears and focused on the parents, they began to make headway. They are still in family therapy and my client just finished cyber school but they have made tremendous strides in understanding how anxiety was running their lives and what they can do about it.

If you would like more information about how to help anxious clients who are treatment resistance, click here