Roots of codependency
The concept of codependency began as a grassroots idea in the 1960s to describe family members, usually wives or mothers, who were deemed excessive in their caring for their husband or son with addiction. The term was used to describe women who had an overresponsibility for relationships, rather than a responsibility to self. Support groups for codependency, such as Co-Dependents Anonymous, Al-Anon/Alateen, Nar-Anon, and Adult Children of Alcoholics, based on the 12-step program model of Alcoholics Anonymous, were established. Codependents were negatively labeled as rescuers, supporters, and confidantes of their family member with substance use disorder. These helpers were described as dependent on the other person’s poor functioning to satisfy their own emotional needs.
In these early descriptions, there was a lack of discussion about possible deeper family dynamics: Inequality in financial independence of each partner, the desire for family stability focusing on the welfare of children, the real possibility that disrupting a relationship might result in violence if the woman was more assertive. Women were blamed for trying to love their spouse out of the addiction. One aspect of codependency is self-sacrifice, which used to be considered an important trait of the good wife but became a negative trait in the 1960s. Recovery from codependence was considered achieved when the wife or mother expressed healthy self-assertiveness. Some scholars did state, however, that they believed that codependency was not a negative trait, but rather a healthy personality trait taken to excess. In most studies, women with high codependency ratings have tended to be unemployed and with lower educations. Their behavior had been considered worthy of a DSM inclusion as a personality disorder, but luckily, this was thwarted.
A family is forced to make some accounting when an individual develops a substance use disorder. If the family tries to maintain equilibrium and keeps things as stable as possible for the sake of maintaining the family unit or the stability of the lives of the children, accommodation will be required. Accommodation minimizes the impact of the addiction: the sober spouse stepping up to complete the roles of the ill relative and in all ways reducing the impact of dysfunction on the family. If you swap out the illness and consider the ill family member as having cancer or respiratory distress, then you reframe the spouse’s “codependence” as the behavior of a caring spouse.
This long preamble is intended to illustrate how little family dynamics have to do with the etiology of addiction. Addiction is a chronic neurobiological disease, and like all diseases, individuals, and couples and families have the option of learning to cope well. We, as psychiatrists, must move away from blaming people (usually women who have less-than-optimal coping skills) and consider how best to engage partners and families in optimal programs.*
Families can benefit from specialist treatment and thus contribute to the recovery process. One example is a telepsychiatry program that aimed to improve family coping skills to cope with relatives who have substance use disorders. The Tele-intervention Model and Monitoring of Families of Drug Users is based on motivational interviewing and stages of change. Families were randomized into the intervention group (n = 163) or the usual treatment (n = 162). After 6 months of follow-up, the family members of the telepsychiatry group were twice as likely to modify their behavior (odds ratio; 2.08; 95% confidence interval, 1.18-3.65) (J Sub Use Misuse. 2017 Jan 28;52[2]:164-74). This model was organized so that each of nine calls had a specific goal to stimulate the family members in their process of change.
Family change and engagement also can occur through Alanon (Subst Use Misuse. 2015; 50[1]:62-71) and the use of the Arise program of Judith Landau, MD, (Landau J et al. Am J Drug Alcohol Abuse. 2000;26[3]:379-98).
In summary, the family can be engaged in treatment and can develop family coping skills to support their relative with this chronic neurobiological disease.
Dr. Heru is professor of psychiatry at the University of Colorado at Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose.
*Updated on January 12, 2018.