George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), doesn’t like the word “codependency,” and he likes the word “enabling” even less. “Codependency is a pejorative word, and it implies that someone else is at fault—and one of the major components of Alcoholics Anonymous is to take full responsibility for your actions.” However, that doesn’t mean that the family doesn’t need attention, says Koob. “The fact is that recovery in many cases requires family therapy, having the family help facilitate recovery,” he says. “It can produce long-lasting benefits.”
While not all clinicians agree with Dr. Koob, the addiction field has clearly become less enamored with terms such as codependency. In this article, I will bring you up to date on some tried and true approaches for working with the families of patients with substance use disorders (SUD).
Codependency and enabling: A history of the terms
The term “codependency” has deep roots in the psychoanalytic theory of self (Horney, Karen. Neurosis and Human Growth. Norton, 1950). It is often defined as the unhealthy behaviors exhibited by the person who has a relationship to the alcoholic. Codependency became a household term with the publication in 1986 of “Codependent No More” (Melody Beattie’s Codependent No More, which sold more than 5 million copies in several languages. The book became especially popular amidst the rising self-help movement because Beattie made observations that seemed so universally relevant to people’s lives, whether or not alcoholism was an issue (Beattie, Melody. Codependent No More. Centre City, MN: Hazelden Foundation, 1986). In the words of Christine Timko, PhD, who is also consulting professor with the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, patients who have what is called codependency “take care of other people to the detriment of themselves and maybe even to the detriment of the person that they’re supposed to be taking care of.”
“Enabling” is a term that is related to codependency in that both are done by the person who has a relationship to the alcoholic. Enabling is more easily defined as actually encouraging the alcoholic to keep drinking. Although codependency and enabling became part of the pop therapy culture of the 1980s, the terms “fell out of favor because the individual with the alcohol problem was essentially blaming someone else, and wasn’t taking responsibility” for their own drinking behavior, says Koob. In fact, codependency has never achieved official diagnostic status, remaining more a “syndrome” than a disorder. There is no DSM-5 diagnosis for being codependent or enabling, and there is no actual pathology involved either. Using DSM-5, the closest a clinician can get to codependency is “dependent personality.” There is no mention of any related illness, such as a SUD.
On the other hand, for addiction treatment clinicians, the word “codependency” can be useful as a way to reach those affected by the substance use of others, says Michael T. Flaherty, PhD, a Pittsburgh-based psychologist who treats patients with SUDs. The word “confirmed that addiction seldom happens in a vacuum, and that to treat the illness, you had to also get to those closest to it who were often also suffering.”
Working with the family
How should we use these terms in our work with families? Austin Houghtaling, PhD, a marriage and family therapist who is clinical director of recovery enrichment programs at Caron Treatment Centers, based in Wernersville, Pennsylvania, frequently hears families use the word “codependent,” but he is careful not to use it himself. “We found that when we as practitioners use terms like ‘codependency’ or ‘enabling,’ the families tense up,” he says. “It feels like labeling, it feels diagnostic, and it makes them feel as if you’re assessing them. It’s better to align with them from a compassionate standpoint instead of from a pathology standpoint.”
However, Houghtaling doesn’t correct them if they initiate the term. He’ll ask family members who are in therapy with the patient with the SUD patient to describe in 1 or 2 sentences the nature of their anxiety—which can be a major part of codependency. “Most commonly they describe their self-sacrifice and how it detracts from their own self-care,” he says. “We will then say something like: ‘This is a normal way to respond, of course you’re going to invest yourself in helping your loved one, and of course you’re exhausted.’” The family member may also worry that if they get too involved with the recovery of their spouse or child, resentment will be the outcome. When this all comes out in family therapy, the patient with the SUD sees what’s happening.
Sometimes the SUD patients, in group therapy, will call their families “sick” and “codependent” in ways that are, in fact, meant to blame them. In fact, some families do have their own substance use and other problems— but they are not the ones in treatment. Houghtaling will then point that out to patients: “You have put them [the families] through the wringer, and the way you have coped with stress and anxiety has included drugs and alcohol, and they have their own way.”
When Houghtaling has an adolescent SUD patient and a parent—typically a mother—in therapy, the parent frequently expresses feelings of guilt, which is a part of codependency. He tells the parent: “Look at all the ways you tried to help here.” The parent acknowledges that he or she got the child into treatment, sometimes multiple times. He then asks how the parents feel, and the response is that he or she is “wiped out and scared to death and exhausted”—to which Houghtaling says, “No kidding.” At that point, the adolescent will usually open his or her eyes wide and say they never had seen what “this has done to my [parent],” says Houghtaling. “They get it.” Then, when Houghtaling explains that the parent is choosing to go a route that involves self-care, the adolescent is usually immensely relieved. “The kid will say, ‘That’s a pressure off my shoulders.’” Instead of using fear of disappointing his or her parent as an incentive to recovery, the adolescent uses love, and is happy that the parent will be able to handle his or her own self-care.
Guidance for psychiatrists
Psychiatrists can help patients identify the behaviors that can be triggers to drinking or using drugs, says Brendan Young, PhD, assistant professor of communication at Western Illinois University Quad Cities. A common pattern, for example, is a nagging-withdrawal cycle in which a family member repeatedly confronts the drinker, who then withdraws into more drinking. However, he said it is not correct to assume that all such relationships are codependent. “There are healthy ways of sustaining relationships with people with SUDs,” he says. “When it becomes problematic is when they become controlling.”