Codependency

Codependency is a concept that attempts to characterize imbalanced relationships where one person enables another person's addiction, poor mental health, immaturity, irresponsibility, or under-achievement. Definitions of codependency vary, but typically include high self-sacrifice, a focus on others' needs, suppression of one's own emotions, and attempts to control or fix other people's problems. People who self-identify as codependents exhibit low self-esteem, but it is unclear whether this is a cause or an effect of characteristics associated with codependency. Codependency is generally defined as a subclinical, situational, and/or episodic behavioral condition similar to that of dependent personality disorder.

History

The idea of codependency may have its roots in the theories of German psychoanalyst Karen Horney. In 1941, she proposed that some people adopt what she termed a "Moving Toward" personality style to overcome their basic anxiety. Essentially, these people move toward others by gaining their approval and affection, and subconsciously control them through their dependent style. They are unselfish, virtuous, martyr-like, faithful, and turn the other cheek despite personal humiliation. Approval from others is more important than respecting themselves.

The term codependency is most often identified with Alcoholics Anonymous and the realization that the Alcoholism was not solely about the addict but also about the family and friends who constitute a network for the alcoholic." The term “codependent” is used to describe how family members and friends might actually interfere with recovery by overhelping."

The application of this term was very much driven by the self-help community. Janet G. Woititz's Adult Children of Alcoholics had come out in 1983 and sold two million copies while being on the New York Times bestseller list for 48 weeks. Robin Norwood's Women Who Love Too Much, 1985, sold two and a half million copies and spawned Twelve Step groups across the country for women "addicted" to men. Melody Beattie popularized the concept of codependency in 1986 with the book Codependent No More which sold eight million copies. In 1986, Timmen Cermak, M.D. wrote Diagnosing and Treating Co-Dependence: A Guide for Professionals. In the book and an article published in the Journal of Psychoactive Drugs (Volume 18, Issue 1, 1986), Cermak argued (unsuccessfully) for the inclusion of codependency as a separate personality disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987). Cermak's book paved the way for a Twelve-step take-off program, called Co-Dependents Anonymous. The first Co-Dependents Anonymous meeting was held October 22, 1986.

Definition

"Dependency" is well-established in psychological literature. Early psychoanalytic theory emphasized the oral character and structural basis of dependency, social learning theory considers a tendency to be acquired by learning and experience, and ethological attachment theory posits that attachment or affectional bonding is the basis for positive dependency, which should be distinguished from the negatively-valanced definition posited by codependence theorists.

Codependency

Timmen Cermak, M.D., proposed that co-dependency be listed as a personality disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987). Cermak reasoned that when specific personality traits become excessive and maladaptive and cause significant impairment in functioning or cause significant distress, it warrants a personality disorder diagnosis. Cermak's definition was published in the Journal of Psychoactive Drugs in 1986.

Cermak proposed the following criteria for this disorder:

1. Continued investment of self-esteem in the ability to control both oneself and others in the face of serious adverse consequences.
2. Assumption of responsibility for meeting others' needs to the exclusion of acknowledging one's own.
3. Anxiety and boundary distortions relative to intimacy and separation.
4. Enmeshment in relationships with personality disordered, chemically dependent, other co‐dependent, or impulse‐disordered individuals.
5. Three or more of the following:
   1. Excessive reliance on denial
   2. Constriction of emotions (with or without dramatic outbursts)
   3. Depression
   4. Hypervigilance
   5. Compulsions
   6. Anxiety
   7. Substance abuse
   8. Has been (or is) the victim of recurrent physical or sexual abuse
   9. Stress related medical illnesses
   10. Has remained in a primary relationship with an active substance abuser for at least two years without seeking outside help.

Codependency has not been included in the Diagnostic and Statistical Manual of Mental Disorders; DSM-III-R or later versions.

Dependent personality disorder

Dependent personality disorder is included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. The definition and criteria have changed in the different versions of the DSM. In the DSM-I, passive dependency personality was characterized by helplessness, denial, and indecisiveness, and was considered a subtype of passive-aggressive personality. By DSM-IV, there were nine criteria with an essential feature of a pervasive or lifetime pattern of dependent and submissive behavior. The DSM-IV definition emphasized the excessive need to be taken care of, leading to submissive and clinging behavior and fear of separation.

Behaviors and characteristics

Individual dynamics

A codependent is someone who cannot function on their own and whose thinking and behavior is instead organized around another person, process, or substance. Many codependents place a lower priority on their own needs, while being excessively preoccupied with the needs of others. Codependency can occur in any type of relationship, including family, work, friendship, and also romantic, peer or community relationships.

Romantic relationship dynamics

Some codependents often find themselves in relationships where their primary role is that of rescuer, supporter, and confidante. These helper types are often dependent on the other person's poor functioning to satisfy their own emotional needs.

Codependent relationships are marked by intimacy problems, dependency, control (including caretaking), denial, dysfunctional communication and boundaries, and high reactivity. Often, there is imbalance, so one person is abusive or in control or supports or enables another person's addiction, poor mental health, immaturity, irresponsibility, or under-achievement.

Commonly observable characteristics of codependency are:

• intense and unstable interpersonal relationships
• inability to tolerate being alone, accompanied by frantic efforts to avoid being alone
• autophobia
• chronic feelings of boredom and emptiness
• subordinating one's own needs to those of the person with whom one is involved
• overwhelming desire for acceptance and affection
• perfectionism
• over-controlling
• external referencing
• dishonesty and denial
• manipulation
• lack of trust
• low self-worth
• victim mentality

In a codependent relationship, the codependent person's sense of purpose is based on making extreme sacrifices to satisfy their partner's needs. Codependent relationships signify a degree of unhealthy "clinginess" and needy behavior, where one person does not have self-sufficiency or autonomy. One or both parties depend on their loved one for fulfillment. The mood and emotions of the codependent are often determined by how they think other individuals perceive them (especially loved ones). This perception is self-inflicted and often leads to clingy, needy behavior which can hurt the health of the relationship. Particularly problematic pairings include:

Personality disorder and codependent pairing

• Borderline personality disorder – there is a tendency for loved ones of people with borderline personality disorder (BPD) to slip into "caretaker" roles, giving priority and focus to problems in the life of the person with BPD rather than to issues in their own lives. Further, the codependent may gain a sense of worth by being "the sane one" or "the responsible one".

• Narcissistic personality disorder – codependents of narcissists are sometimes called co-narcissists. Narcissists, with their ability to get others to "buy into their vision" and help them make it a reality, seek and attract partners who will put others' needs before their own. Codependents can provide the narcissist with an obedient and attentive audience. Among the reciprocally interlocking interactions of the pair are the narcissist's overpowering need to feel important and special and the codependent person's strong need to help others feel that way.

Codependent or impulse-disordered individuals and codependent pairing

• Attention-deficit hyperactivity disorder (ADHD).
• Obsessive-compulsive disorder (OCD)
• Bipolar disorder
• Substance use disorder (SUD)
• Autism spectrum disorder (ASD)
• Personality disorder (PD)
• Traumatic brain injury (TBI)
• Psychosis
• Dementia

Family dynamics

In the dysfunctional family the child learns to become attuned to the parent's needs and feelings instead of the other way around. Parenting is a role that requires a certain amount of self-sacrifice and giving a child's needs a high priority. A parent can, nevertheless, be codependent towards their own children if the caretaking or parental sacrifice reaches unhealthy or destructive levels. Generally, a parent who takes care of their own needs (emotional and physical) in a healthy way will be a better caretaker, whereas a codependent parent may be less effective, or may even do harm to a child. Codependent relationships often manifest through enabling behaviors, especially between parents and their children. Another way to look at it is that the needs of an infant are necessary but temporary, whereas the needs of the codependent are constant. Children of codependent parents who ignore or negate their own feelings may become codependent.

Recovery and prognosis

Not all mental health professionals agree about standard methods of treatment. Caring for an individual with a physical addiction is not necessarily treating a pathology. The caregiver may only require assertiveness skills and the ability to place responsibility for the addiction on the other. There are various recovery paths for individuals who struggle with codependency. For example, some may choose cognitive-behavioral psychotherapy, sometimes accompanied by chemical therapy for accompanying depression. There also exist support groups for codependency, such as Co-Dependents Anonymous (CoDA), Al-Anon/Alateen, Nar-Anon, and Adult Children of Alcoholics (ACoA), which are based on the twelve-step program model of Alcoholics Anonymous and Celebrate Recovery, a Christian, Bible-based group. Many self-help guides have been written on the subject of codependency.

Sometimes an individual can, in attempts to recover from codependency, go from being overly passive or overly giving to being overly aggressive or excessively selfish. Many therapists maintain that finding a balance through healthy assertiveness (which leaves room for being a caring person and also engaging in healthy caring behavior) is true recovery from codependency and that becoming extremely selfish, a bully, or an otherwise conflict-addicted person is not. Developing a permanent stance of being a victim (having a victim mentality) would also not constitute true recovery from codependency and could be another example of going from one extreme to another. A victim mentality could also be seen as a part of one's original state of codependency (lack of empowerment causing one to feel like the "subject" of events rather than being an empowered actor). Someone truly recovered from codependency would feel empowered and like an author of their life and actions rather than being at the mercy of outside forces. A victim mentality may also occur in combination with passive–aggressive control issues. From the perspective of moving beyond victim-hood, the capacity to forgive and let go (with exception of cases of very severe abuse) could also be signs of real recovery from codependency, but the willingness to endure further abuse would not.

Unresolved patterns of codependency can lead to more serious problems like alcoholism, drug addiction, eating disorders, sex addiction, psychosomatic illnesses, and other self-destructive or self-defeating behaviors. People with codependency are also more likely to attract further abuse from aggressive individuals (such as those with BPD or NPD), more likely to stay in stressful jobs or relationships, less likely to seek medical attention when needed and are also less likely to get promotions and tend to earn less money than those without codependency patterns. For some people, the social insecurity caused by codependency can progress into full-blown social anxiety disorders like social phobia, avoidant personality disorder or painful shyness. Other stress-related disorders like panic disorder, depression or PTSD may also be present.

Controversy

While Timmen Cermak, M.D., proposed that co-dependency be listed as a personality disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987), it was not accepted by the committee and, as such, no medical consensus exists on the definition of codependency.

With no definition, the term is easily applicable to many behaviors and has been overused by some self-help authors and support communities.

Some clinicians think that the term codependency has been overused by the general populace and labeling a patient as codependent can be confusing and may even shame them rather than help them focus on how their traumas shape their current relationships.

Codependency is a theory. There is no evidence that codependence is caused by a disease process. Attachment theory may be a more helpful model for understanding and dealing with attachment in adults.

Codependency does not refer to all caring behavior or feelings, but only those that are excessive to an unhealthy degree. Some scholars and treatment providers think that codependency is an overresponsibility and that overresponsibility needs to be understood as a positive impulse gone awry. Responsibility for relationships with others needs to coexist with responsibility to self.

See also