Psychoeducational treatments for obsessive-compulsive disorder: A narrative review emphasizing family-based approaches

Table 1 The goals and purpose of psychoeducation

Goals/purpose	Explanation
Improving understanding of the illness	Psychoeducation aims to improve the patient’s and families’ understanding of the illness. The purpose of imparting information is to promote awareness as well as acceptance of the illness. Education about the illness paves the way for other purposes of psychoeducation including promoting empowerment, improving coping and self-management skills, enhancing treatment seeking and treatment engagement, instilling hope, reducing stress, alleviating feelings of isolation and stigma, and aiding recovery. Awareness about the illness promotes tolerance of the illness among family members, reduces family conflicts, and improves family support[17-19,29,34]
Promoting empowerment	Psychoeducation is empowering because it emphasizes the fundamental right of individuals to be informed about their illnesses. Psychoeducation empowers patients and families by providing a realistic appraisal of the consequences of the illness and the difficulties they face in life. Psychoeducation restores the patient’s independence, self-esteem, and dignity. Psychoeducation enables patients to manage the effects of the illness in a proactive manner, focuses on developing collaborative and trusting treatment relationships, and allows patients and families to actively participate in the treatment. Empowerment is associated with improvements in mental wellbeing, and personal and family functioning[17,19,35-37]
Enhancing the patient’s and family’s ability to cope with illness	Psychoeducation provides the means to manage, cope, and live with a chronic psychiatric disorder. Enhancing coping improves the acceptance of the chronic nature of the illness for patients and families. Organizing the subjective perceptions and experiences of patients and families objectively helps in developing adaptive attitudes and behaviours and inculcates a sense of mastery over the illness. The ability to deal with the stresses and strains of the illness develops with time. Families learn skills to deal with the patient’s problems similar to the ways that professionals handle these demands. Improved family coping reduces conflicts and improves family functioning. Improved awareness and belief in the ability to cope with the illness reduces stigma, improves motivation, encourages treatment seeking, and promotes treatment engagement[19,34-36,38]
Provision of emotional and practical support	Psychoeducation provides support for patients and their families. Emotional support is provided to the individual to deal with the stressful consequences of the illness. Practical support or tangible assistance is often necessary for patients to improve resilience and handle the demands of the illness. Group support helps reduce the feelings of isolation, despair, low self-esteem, and stigma. Families need emotional support to deal with psychological consequences of the patient’s illness. Practical support is provided to families by informing them of resources such as groups or organizations. Efforts are made to increase their social network by increasing interpersonal, social, recreational, and health-service contacts of the families. Supportive interventions are associated with better treatment outcomes, increased wellbeing, and improved patient and family functioning[27,29,30,34,38]
Achieving recovery	The goals of treatment of mental illnesses have gradually shifted from clinical, to functional, and social recovery. The goals of psychosocial treatment have similarly moved from achieving clinical remission and relapse prevention to supporting and sustaining functional and social recovery. The focus is on creating the optimal environment in which the patient can achieve recovery and helping families to contribute to the patient’s recovery[30,39-42]
Reducing stress and improving functioning	Psychoeducation aims to reduce stress in patient and the family through behavioural and supportive methods. Resilience to stress is built by imparting information and teaching skills to deal with the illness-related stressors. Supportive techniques are used to promote adaptive and improved functioning of the individual and the family. Supportive family environments can help the patient achieve recovery[17,27,34,36,38]

Table 2 The fundamental principles of psychoeducation

Principles	Explanation
Simple form of psychotherapy	Unlike the more complex or “skilled” psychotherapies, psychoeducational treatments are a simpler form of psychotherapy. Psychoeducation is not based on an elaborate theoretical framework. Psychoeducation is easily understood by clinicians, patients, and their families. The techniques used are simple and do not require extensive training. The person providing the treatment needs to have expertise and experience in dealing with psychiatric disorders and the basic skills for conducting psychotherapy. Psychoeducation is traditionally delivered by trained mental health professionals, but models using peer education are also effective. Psychoeducation can be used in different clinical and non-clinical settings. Psychoeducation has specific and modest goals. Psychoeducation is an easy-to-administer and relatively inexpensive form of treatment. Psychoeducation is usually more accessible than complex psychotherapies[19,35,36,44,45]
Structured form of psychotherapy requiring several skills	Psychoeducation is also a highly structured form of therapy. Research suggests that structured and evidence-based psychoeducational treatments are more effective than unstructured interventions. Psychoeducation integrates educational, behavioural, cognitive, and supportive techniques. The skillful delivery of psychoeducation requires that the therapist be conversant with health education techniques, proficient in teaching coping strategies, and have the ability to foster alliances through support and empathy[19,32,44,46]
Flexible treatment with diverse uses	Although psychoeducation is a structured form of therapy, it incorporates a degree of flexibility and sensitivity to the needs of the patients and their families. The simplicity and flexibility of psychoeducation ensure that it is useful in many psychiatric disorders and in community, outpatient, day-care, and inpatient settings. Psychoeducational treatments can be tailored according to the phases of the illness. Cultural adaptations are also possible. In theory, it should be easier to disseminate and implement psychoeducation than more complex interventions. However, in practice, there are several barriers to the dissemination and implementation of psychoeducation in clinical settings[20,31,33,34,47]
Core component of treatment	Psychoeducation is a core component of most psychotherapies. Psychoeducation forms a part of the routine management of all psychiatric disorders. Medications, psychoeducation, and more complex psychotherapies are the three principal elements of treatment for all psychiatric disorders[21,48]
Adjunctive treatment	Psychoeducation was developed as an adjunct to medication treatment particularly in severe mental illnesses. As an adjunctive treatment, the principal goal of psychoeducation is to improve medication adherence. Psychoeducation also addresses the domains of functional impairment and interpersonal problems that are not addressed by medications. The combination of medications and psychoeducation is often better than either treatment delivered alone. The efficacy of psychoeducation results from a synergistic combination of pharmacological, psychotherapeutic, and social approaches[17,18,40,49,50]
Patient-centredness, collaboration, and shared decision-making	Psychoeducation follows a patient-centred approach in which consideration is given to patients’ and families’ views and preferences about treatment. Psychoeducation is based on an equal partnership and collaboration between professionals with illness expertise and patients and families with personal expertise. Decisions about the treatment are the outcome of open discussions between professionals, patients, and families. A “teamwork” approach is followed, in which patients, families and professionals share a common understanding of the disorder and its treatment. The collaborative, person-centred, and shared-decision making approaches are useful in fostering strong treatment alliances, which are a fundamental component of psychoeducation[11,20,31,36,51]
Positive orientation	Psychoeducation aims to instill hope and optimism about the outcome of treatment in patients and families through improvement of awareness and social interactions. Patients are encouraged to believe that they can lead productive lives despite the negative impact of the illness on their lives. Psychoeducation uses a “no fault” approach by avoiding blaming either the patient or the family for the illness. Psychoeducation replaces the feelings of despair, fear, stigma, and low self-esteem with optimism and increased self-worth, and encourages patients and families to be active partners rather than passive recipients of treatment[18,19,21,34,52]
Normalization	Psychoeducation attempts to normalize the patient’s symptoms and dysfunction by focusing more on the healthy aspects of the person’ functioning and attempting to reach an optimal level of functioning rather than curing the illness[21,32,43]
The positive cycle of treatment engagement and psychoeducation	Information about the illness leads to the understanding that it is a treatable condition. This persuades patients and families to commit to long-term treatment and their motivation for treatment is enhanced. Treatment engagement and adherence is one of the principal tasks of psychoeducation. Treatment engagement creates a positive cycle - adherence reduces symptoms and allows the patient to take part in psychoeducation, which in turn facilitates subsequent adherence[17,18,21,35,36]
Medical model and biopsychosocial approach	In clinical settings, psychoeducational treatments follow a medical model by considering all psychiatric disorders to be primarily caused by abnormalities of brain structure and function. In other settings, the predominant approach is a biopsychosocial one. The biopsychosocial approach is more holistic and competence-based, treats the person as a whole, and considers individual strengths and weaknesses. Psychoeducation focuses on the present and avoids delving in the past[19,20,31,34,38]
Stepped care approach	Psychoeducation follows a stepped care approach, where the treatments proceed from simple to more complex techniques, and from stand-alone psychoeducational treatments to psychoeducation integrated with other psychotherapeutic interventions[29,53]

Table 3 The essential elements of psychoeducation

Elements	Techniques and uses
Imparting information	The objective is to provide patients and families with information about the illness and its management[29,34]
	Comprehensive information about symptoms, causes, treatments, and the prognosis of the illness is provided
	Misconceptions about the illness are corrected[17]
	The impact of the illness on the patient’s behaviour is also discussed[18]
	Knowledge-based competence allows patients and families to cope with the consequences of the illness and improves their engagement with treatment[18,34,54]
	Conveying information also aids the development of adequate treatment alliances[55]
	Informing patients and families about the illness is usually a two-step process. The first step consists of conveying information that is universal and common for all patients and families
	A series of structured lectures is used to convey such information as efficiently as possible[18,20,34,54]
	The most effective way to convey the basic information about the illness is by utilising psychoeducational groups[17,18,20,34,54]. Groups also help in providing support, reducing feelings of isolation, and normalising the experience of the illness
	Cognitive-behavioural techniques are utilised for this stage[18]
	The methods to convey information are didactic, explicit, and standardised[17,18,56]
	The next step is to provide information specific to the patient and the family that is tailored to their circumstances[18,21]. This is usually done on an individual basis and utilises supportive techniques[18]. Didactic lectures eventually give way to a two-way communication pattern at this stage
	The information is conveyed in the simplest manner by avoiding professional jargon as much as possible[17,18]
	Written sources of the informational material are almost always required[17,34,38,54]. Different formats, such as face-to-face contact, films or videos, self-help manuals, or digital modes, can be utilised
	The information should be in the local language and adapted to the social and cultural backgrounds of the patients and their families[33]
Enhancing coping skills	The information provided during the initial phases of psychoeducation is used as a basis for teaching specific management skills for patients and families as they deal with the illness[18,20,34,38]
	Cognitive-behavioural techniques of role-play and modelling are employed to teach coping skills[20,57]
	Cognitive-behavioural techniques are also used to enhance the presentation of information by allowing people to rehearse, review and integrate the information taught[34]
	Stress management and promotion of healthy lifestyles are encouraged as techniques to improve coping with the illness[20,38]
	Informational and emotional support are also provided to enhance the learning of coping skills[39,41,48]
	The areas addressed include day-to-day survival skills, common emotional responses to the illness, family atmosphere and conflicts, dealing with illness-related crises, and coping with stigma[39,41,51,57-59]
	Psychoeducational treatments teach problem-solving and communication skills, and the use of resources during periods of crisis[20,39,41,57,60]
	The eventual goal is to transform patients into experts in dealing with their illnesses and for family members to learn to act as “co-therapists” working on equal footing with professionals[18]
	The enhanced ability to cope with the illness can positively influence attitudes and behaviours towards the illness and its treatment, promote active participation in the treatment, enhance the motivation for treatment, and improve engagement with the treatment[18,34,40]
Fostering treatment alliances	The treatment alliance is the most crucial part of psychoeducation[18,21]
	It forms the basis for delivering the other two components of information giving and enhancing coping competence[18,55]
	The alliance is founded on mutual trust rather than the clinician’s authority[19]
	The other components of an effective alliance are collaborative relationships between clinicians, patients and families (mutual agreement on goals and tasks of treatment and emotional bonding), a patient-centred focus, shared decision-making, open communication, confidence in the therapist, support, and stability and continuity of the treatment relationship[19,61-63]
	Client-centred therapy techniques such as empathy, unconditional positive regard, and genuineness are used to build alliances with patients and families[18,21]
	Empathic listening counteracts the dysfunctional cognitions while accepting feelings of uncertainty and demoralisation[18]
	Providing emotional support and promoting stability in treatment relationships also builds strong alliances[18,38]
	The holistic approach followed treats patients and family members with respect and dignity and considers their strengths and weaknesses[38,63]
	Patients and families are viewed as invaluable allies who work with the clinicians to share the burden of managing the illness and moving towards patient recovery[18,64]
	Instilling hope, providing reassurance, and not blaming the patient or families for the illness are the other important aspects of an effective alliance[18,63]

Table 4 The content of psychoeducational treatments

Topics covered	Details
Engagement	Engaging patients and families using a "no fault" or "no blame" approach attached to the illness
Information about the illness	Symptoms, signs, causes, course of the illness. Dispelling misconceptions about the illness. Explanations about the diathesis-stress model
Information about treatment of the illness	Medication and psychosocial treatment options available. The benefits of treatment. The efficacy of combined medication and psychosocial treatments. How to obtain treatment. Components of psychosocial treatments. Side effects of treatment. The possibility of long-term treatment. Need for treatment adherence and engagement. Expected outcome of treatment
Coping skills	Day-to-day survival skills. Self-management skills. Coping with negative feelings of demoralization, low self-esteem, isolation, helplessness, shame, and stigma
Problem-solving training	Identification of common problems such as medication refusal or disruptive behaviour. Clarification of causes and consequences of problem behaviours. Helpful strategies to effectively combat problems
Communication training	Awareness about negative emotions, distorted cognitions and disturbed communication patterns. Training in adaptive communication styles. Improving ways of providing positive and negative feedback
Improving support	Provision of practical support from professionals, self-help organizations, and peers. Promotion of social, recreational, and occupational contacts to expand the social network
Stress management	Education about the effects of stress on the illness. Learning techniques to reduce stress in patients and families. Adopting healthy lifestyles
Detection and prevention of relapse	Identifying early warning signs of relapse. Accessing resources to deal with relapses. Understanding that exacerbations and remissions are an inevitable part of the illness. Treatment cannot cure the illness but is effective in preventing relapses
Moving towards recovery	A stepwise plan arrived at by patients, families, and clinicians for reintegrating the patient into family and community life

Table 5 Formats and models of psychoeducational treatments

Formats/models	Details
Psychoeducational interventions with patients
Individual psychoeducation for patients	Psychoeducational treatments conducted with individuals with the illness[68,69]
Group psychoeducation for patients	Psychoeducational treatments conducted with individuals with the illness in group formats[68,69]
Brief psychoeducation	Psychoeducational treatments lasting for less than 10 sessions and 3-4 months[70]
Psychoeducational interventions with families
Behavioural family management	A family-based approach including psychoeducation, structured problem solving, and communication training[31,71]
Family-focused therapy	A family-based treatment for bipolar disorder modelled on the behavioural family management. Consists of psychoeducation, communication enhancement training, and problem-solving skills training[72]
Family psychoeducation	A model that involves connecting with the family, providing illness education, and ongoing support and crisis intervention during treatment[31,71]
Relatives’ groups	Relatives’ groups providing education and teaching coping skills for patients and families. Relatives’ groups without patients providing support and problem-solving for the family[31,71]
Multi-family psychoeducational groups	Multi-family psychoeducational groups are conducted with several families simultaneously. Consists of engagement, psychoeducation, problem-solving training, teaching coping skills, and supporting families[31,71,73]
Professional family education programmes	Family education programmes do not involve the patient and do not focus on patient outcomes. The focus is on information and support for families and their well-being and functioning. Family education programmes are run by professionals[25,31,71]
Family consultation treatments	An individual family psychoeducational treatment where the family meets with a consultant (professional or peers). Education, advice, and support are provided according to the family’s needs[31,71,74]
Peer-led family education treatments	Psychoeducational treatments for families conducted by family members of other patients or persons with mental illnesses. Consists of education, teaching emotional coping, problem-solving, communication, and self-care skills. Includes advocacy for patients and their families[31,71,74]
Crisis-orientated individual psychoeducation	Outpatient-based crisis intervention sessions for patients and families[75]
Modified forms of more traditional family therapies	Modified forms of systemic family therapy[30]

Table 6 Efficacy of psychoeducational treatments

Outcome parameters	Selected meta-analyses and systematic reviews
	Schizophrenia	Bipolar disorder	Depressive disorders
Prevention of relapse or re-hospitalization	Pfammatter et al[76], Pharoah et al[77], Lincoln et al[78], Bighelli et al[79], Rodolico et al[80]	Bond et al[26], Miklowitz et al[81], Chatterton et al[82], Lam et al[83], Miklowitz et al[84]
Symptom reduction	Zhao et al[70], Lincoln et al[85], Xia et al[86], Asher et al[87], Mc Glanaghy et al[88]	Bond et al[26], Gonzalez-Pinto et al[45], Swartz et al49], Miklowitz et al[81], Chatterton et al[82]	Donker et al[44], Cuijpers.[89], Bevan Jones et al[90], Katsuki et al[91], Tursi et al[92]
Improved socio-occupational functioning	Pharoah et al[77], Lincoln et al[85], Asher et al[87], De Silva et al[93], Bighelli et al[94]	Swartz et al[49], Batista et al[59], Chatterton et al[82], Reinares et al[95], Reinares et al[96]	Bevan Jones et al[90], Tursi et al[92], De Silva et al[93], Brady et al[97]
Improved treatment adherence	Pfammatter et al[76], Lincoln et al[85], Xia et al[86], Mari et al[98], Pilling et al[99]	Bond et al[26], Levrat et al[50], Batista et al[59] , MacDonald et al[100], Demissie et al[101]	Bevan Jones et al[90], Tursi et al[92]
Wellbeing, satisfaction, quality of life	Xia et al[86], Pekkala at al[102]	Bond et al[26], Gonzalez-Pinto et al[45], Levrat et al[50], Miklowitz et al[81], Demissie et al[101]	Brady et al[97], Bevan Jones et al[90], Mhango et al[103]
Improved insight, knowledge, awareness about the illness, and attitudes to treatment	Pfammatter et al[76]	Bond et al[26], Levrat et al[50], Batista et al[59], Demissie et al101], Rouget et al[104]	Bevan Jones et al[90]
Reduced caregiver burden and psychological distress	Cuijpers[105], Yesufu-Udechuku et al[106], Sin et al[107], Claxton et al[108]	Soo et al[109]	Tursi et al[92]
Reduced expressed emotions	Pfammatter et al[76], Pharoah et al[77], Mari et al[98], Sin et al[107], Claxton et al[108]	Reinares et al[95], Reinares et al[96]
Reduced stigma	Alhadidi et al[110]	Levrat et al[50], Demissie et al[101], Soo et al[109]

Table 7 The content of brief psychoeducation for obsessive-compulsive disorder

Topics covered
1 What is OCD or obsessive-compulsive disorder? What are obsessions and compulsions?
2 How common is OCD?
3 How does the patient feel while experiencing OCD?
4 How do people develop OCD?
5 How is OCD treated? How effective is the treatment?
6 What are the medications used to treat OCD?
7 What is CBT and ERP treatment for OCD?
8 How effective and safe is CBT/ERP?
9 How is CBT/ERP carried out?
10 How long will the treatment take?

Brief psychoeducation consists of brief education sessions delivered before the commencement of exposure and response prevention (ERP) or cognitive behavioural therapy (CBT)[11,21,111,119,121]. Early education about obsessive-compulsive disorder allows the patients and families to make decisions about treatment based on the evidence. It helps to motivate patients and families and prepares them to tolerate the anxiety that may arise from exposure sessions. Once patients begin ERP or CBT, more detailed psychoeducation takes place over several sessions. Detailed psychoeducation continues throughout the treatment and during the stage of relapse prevention. CBT: Cognitive behavioural therapy; ERP: Exposure and response prevention; OCD: Obsessive-compulsive disorder.

Table 8 Psychoeducation as an exclusive treatment in obsessive-compulsive disorder

Ref.	Intervention	Content about OCD	Results
Tynes et al[124]	10-week psychoeducational support group for 21 adult patients and families	Symptoms, diagnosis, assessment, aetiology, ERP, medications, and prognosis	Participants’ evaluation of treatment on a self-designed scale. The intervention was feasible and satisfaction among users was high
Siegmund et al[125]	One-week computerized psychoeducational intervention in 21 patients aged 19-55 years	3 modules on symptoms, aetiology, and the role of CBT	Reductions in YBOCS scores and subjective ratings of depression and anxiety. Feasibility, ease of use, and participant satisfaction were adequate to high
Shishikura et al[126]	Retrospective study of 214 adult outpatients, 64 received psychoeducation for self-ERP, 77 treated with conventional ERP, 18 did not receive ERP	The Four Steps programme of self-ERP	Outcome on GAF and CGI-I scales showed that 46% of the self-ERP group improved compared to 53% of the conventional ERP group
Dissanayake and Drummond[127]	Adult inpatients with contamination fears (number not stated)	3 sessions of psychoeducational group treatment in addition to ERP	Psychoeducational treatment was acceptable and useful in refractory OCD
Mahmoodabadi et al[128]	12-week, controlled study of a psychoeducational support group for 30 adult Iranian patients and families	The study group (n = 15) received eight educational sessions about OCD; the control group (n = 165) did not receive psychoeducation	Significant reduction in the YBOCS scores and significant improvements in family functioning (FAD scale) in the study group
Simsek et al[129]	12-week CBT-based controlled psychoeducational study in 30 adolescents with OCD	Aetiology, symptoms, details of CBT, and the rationale for CBT	Significant reduction in OC symptoms on the Child Version of the Obsessive-Compulsive Inventory. Qualitative data confirmed the efficacy of the intervention

CBT: Cognitive behavioural therapy; CGI-I: Clinical Global Impression Improvement; ERP: Exposure and response prevention; FAD: Family Assessment Device; GAF: Global Assessment of Functioning; OCD: Obsessive-compulsive disorder; YBOCS: Yale-Brown Obsessive-Compulsive Rating Scale.

Table 9 Formats of family-based psychoeducational treatments for obsessive-compulsive disorder

Format/model	Description
Family-assisted CBT or ERP	Family members are actively involved in providing CBT or ERP, family members act as coaches, co-therapists or supervisors of therapy[22,23]
Cognitive-behavioural family-based treatment (CBFT)	Includes all components of CBT or ERP, active involvement of family members in providing CBT or ERP, and training of family members in skills to reduce accommodation and antagonism[24,52,135]
Brief CBFT	Two sessions of psychoeducation and skills training in reducing accommodation for patients and family members[135,141]
Family-based CBT or ERP	Attended by both patients and family members. Family members provide CBT or ERP. Includes training of family members in reducing accommodation and antagonism[111,133,141]
Positive family interaction therapy	Adjunct to individual patient CBT. Teaches family members skills to handle accommodation and antagonism[111,140]
Family-integrated CBT or family-inclusive treatment	Family members join the patient in ERP or CBT and help the patient carry out the treatment. Family members receive treatment independent of the patient, individually or in groups. A combination of both approaches is used[24,139]
Couples-integrated CBT	Includes psychoeducation for patients and partners, couple-assisted ERP or CBT, couple-based interventions to reduce accommodation and antagonism, and couples therapy[115,141]
Parent training (SPACE-Supportive Parenting for Anxious Childhood Emotions program)	An intervention exclusively for parents of children with OCD. Children do not participate. Teaches parents to reduce accommodation, by identifying accommodative behaviours, learning skills to reduce such behaviours, and by providing support for parents[135,140,141,144]
Psychoeducational support groups	Psychoeducational support groups for family members only, or for patients and family members[23,24]
Multi-family treatments
Multi-family behavioural treatment	Combines elements of multi-family support groups, family-assisted CBT or ERP, and communication skills training[23,24]
Multi-family psychoeducational intervention	Psychoeducation and training in reducing accommodation and antagonism for groups of multiple families[23,135]

CBT: Cognitive behavioural therapy; ERP: Exposure and response prevention; OCD: Obsessive-compulsive disorder.

Table 10 Efficacy of family-based psychoeducational treatments for obsessive-compulsive disorder

Ref.	Type of evidence	Details	Findings
Thompson-Hollands et al[138]	Meta-analysis	29 studies of family-integrated treatment (FIT) for OCD	FIT reduced obsessional symptoms and improved patient functioning with large effect sizes. Individually-based FIT and FIT that focused on reducing accommodation were more effective than group treatments
Rosa-Alcázar et al[145]	Meta-analysis	33 studies of CBT for children with OCD	Moderate to high parental involvement in CBT improved the efficacy of CBT
Öst et al[146]	Meta-analysis	25 randomized trials of CBT in children and youth using the Children's Yale-Brown Obsessive Compulsive Scale	The degree of parental involvement or the family-based format of CBT did not affect the efficacy of CBT. A high degree of parental involvement was not a crucial factor for the success of CBT
Iniesta-Sepúlveda et al[147]	Meta-analysis	27 studies of cognitive-behavioural family-based treatment (CBFT) for children and adolescents with OCD	CBFT reduced obsessional symptoms with large effect sizes. CBFT had a moderate effect in reducing accommodation. Individually-based CBFT was more effective than group treatments
Guzick et al[148]	Meta-analysis	25 randomized controlled trials comparing standard CBT with augmented CBT in OCD	Increasing family involvement led to a better outcome of augmented CBT
McGrath and Abbott[149]	Meta-analysis	38 studies of family-based interventions for OCD in children and adolescents	Family-based interventions for OCD reduced obsessional symptoms and accommodation with large effect sizes. Interventions that targeted accommodation and other family factors were more effective
Stewart et al[139]	Meta-analysis	15 studies of FIT for OCD	FIT reduced symptoms of OCD, depression, anxiety, and improved patient functioning. Patient and family treatment satisfaction, antagonism, accommodation, and relatives’ mental health, and relationships also improved. Individually-based FIT and FIT that focused on reducing accommodation were more effective than group treatments. FIT was better than individual CBT. Fewer sessions were associated with better outcomes on certain parameters
Wang et al[150]	Meta-analysis	48 randomized controlled trials of ERP, CBT, CT, or third-wave CBT among children, adolescents and adults with OCD	Family-inclusive treatments had larger effect sizes than individual, group, or self-guided ERP or CBT

CT: Cognitive therapy; CBT: Cognitive behavioural therapy; OCD: Obsessive-compulsive disorder; ERP: Exposure and response prevention.