Managing Relationship Conflict Part III: When Helping Becomes Harmful

This is the third post in our relationship series on managing relationship conflict. In today’s post, we provide some general education on how to help manage a partner’s mental health issues, how to recognize what is helpful versus harmful, and where to find more information and resources.

The family environment has long been studied among psychologists as an important factor in the development, maintenance, and treatment of psychological disorders. In particular, researchers have studied “accommodation” behaviors, broadly defined as “changes that individuals (e.g., parents, partners, siblings, and children) make to their own behavior, to help their relative who is dealing with a psychiatric and/or psychological disorder(s), avoid or alleviate distress related to the disorder.”[1] In other words, accommodation refers to any learned behavior to help loved ones avoid or alleviate distress related to their disorder.

In the alcoholism literature, the terms “enabling” and “co-dependency” have been promoted in self-help and Alcoholics Anonymous circles. More recent formulations of alcohol dependence argue that “co-dependency” is an unhelpful term entirely, as it conveys negative connotations about the family members of addicts as having disturbed personalities or being to blame for the alcoholic’s disordered drinking behavior.[2]

Rather, recent research aims to identify accommodation behaviors that may start out with an intention to alleviate the alcoholic’s distress in the short-term, but ultimately maintains or even exacerbates the problem in the long-term. These behaviors become negatively reinforced to avoid conflict with the loved one, who, in turn, also comes to rely on the accommodation. For example, some of the most frequently reported accommodation behaviors reported by the spouses of alcohol addicts include the following[3]:

• Lying or making excuses to family/friends to hide loved one's drinking/drugging
• Taking over loved one's neglected chores/because s/he was drinking/drugging
• Threatening loved one with separation because of the drinking/drug use but later didn’t follow through with it
• Drank/using drugs with loved one or in loved one’s presence
• Making excuses to others for loved one's impaired behavior when s/he was drinking or high

There has been a separate literature on accommodation behaviors in obsessive-compulsive disorder (OCD), and other anxiety disorders.[1] Up to 90% of family members accommodate symptoms to some degree, and family accommodation has been shown to be positively correlated with OCD symptom severity and impairment.[1] Some examples of family accommodation behaviors in anxiety disorders include:

• Avoiding having guests over the house to alleviate distress for a partner with social anxiety disorder
• Sleeping next to a child with separation anxiety disorder
• Providing excessive reassurance to a partner with generalized anxiety disorder or OCD

There have been some reports that family members experience coercion by patients with OCD, who impose accommodation behaviors.[4] Coercive behaviors may involve badgering family members until accommodation is done, or accusing family members of not loving or caring if they do not accommodate.[4] This can place significant caregiver burden on the part of spouses and other family members. Partners need to educate themselves about the problem, learn to set appropriate boundaries with their loved one, and seek out resources for their own self-care.

I focus here on accommodation in addiction and anxiety disorders because they are the most well-studied, but accommodation behaviors can be harmful to patients suffering from other problems as well, such as depression, other mood disorders, eating disorders, and suicide.

The most obvious accommodation behavior is facilitating avoidance. This can come in many forms, including avoiding talking about the problem, letting partners cancel plans due to their disorder, or letting them modify plans because of their disorder.

To learn more about how to effectively help a partner who is struggling with mental health issues, see the following online resources, or consult a professional for guidance.

• General information for partners on how to help a loved one, from the Anxiety and Depression Association of America:
   
• Information for partners on how to help a loved one with suicidal thoughts or behaviors, from the American Foundation for Suicide Prevention
   
• Specific help for alcohol abuse, from the Association for Behavioral and Cognitive Therapies
   
• Specific help for OCD, from the International OCD Foundation

References
[1] Lebowitz, E. R., Panza, K. E., & Bloch, M. H. (2016). Family accommodation in obsessive-compulsive and anxiety disorders: a five-year update. Expert Review of Neurotherapeutics, 16, 45-53.
[2] Rotunda, R. J., & Doman, K. (2001). Partner enabling of substance use disorders: Critical review and future directions. The American Journal of Family Therapy, 29, 257-270.
[3] Rotunda, R. J., West, L., & O’Farrell, T. J. (2004). Enabling behavior in a clinical sample of alcohol-dependent clients and their partners. Journal of Substance Abuse Treatment, 26, 269-276.
[4] Lebowitz, E. R., Vitulano, L. A., & Omer, H. (2011). Coercive and disruptive behaviors in pediatric obsessive compulsive disorder: a qualitative analysis. Psychiatry, 74, 362-371. 

By Angela Fang, Ph.D. - Expert Psychologist