The now tenacious attachment of the disease model and 12-step philosophy to caring behavior, commonly known as codependency, represents to me the most confusing, and iatrogenic ideas in the realm of clinical psychology. This popular construct is shunned by research psychologists and behaviorally- oriented clinical psychologists particularly for it's lack of empirical support. The allure of codependency is demonstrated by the sales of books on the topic (the only resources on codependency come from self- help sections and fluffy journals). Millions of codependency books have been sold over the past ten years. One of the more popular ones, Codependency No More, by Mellody Beattie, has sold over three million copies (according to the publisher). This one is also available on audio cassette, for those codependents on the move.

From Where did Codependency Come?

Co-dependent, or co-alcoholic, was originally defined in the late 1970s and early 1980s to help families and spouses of individuals with alcohol and drug problems. Mostly in line with family systems ideas, the model addressed the family members, especially wives, who "interfered" with the recovery. It was suggested that their behavior made it less difficult for the addict to continue drinking or using drugs. The idea was that the caring behavior manifested by family members and spouses actually "enabled" the addict to continue using. At first glance, the emphasis on the family was certainly a welcome step. Regardless of theoretical orientation working with a substance abuser in isolation, who is in an intimate relationship, is missing a rich opportunity to recruit more players into the change agenda. Unfortunately, from the mid eighties to the present, the codependency idea has become bastardized, and with each new self-help book the symptoms of codependency mount. It is literally impossible for anyone walking the planet, with a fourth grade English reading capacity, to finish one of these books and not consider the possibility that he or she is a codependent. What began as a term to help spouses of addicts encourage sobriety and not inadvertently make it easy to continue, the codependency movement of the 80s and 90s has thrown the baby out with the bath water: Not only is all caring manifested by the spouse of an alcoholic deemed pathological, but the very act of compromising one's needs to aid a loved one is now deemed symptomatic of a progressive disease processes, a relationship addiction.

I've read a fair amount of what the popular press has bequeathed upon us regarding the codependency idea. The three books I scrutinized the most were the most popular. They were Facing Codependency, by Pia Mellody, Codependency No more, by Melody Beattie and Codependency, misunderstood, Mistreated. by Anne Wilson Schaef. It is my understanding that the majority of people who consider themselves "versed" in the codependency idea, gained at least some of their knowledge from one or more of these three books.

Below is my understanding of these authors' conceptualizations:

Codependency is a progressive disease brought about by child abuse, which takes the form of anything "less than nurturing." Codependency is epidemic (maybe all of us are codependent) and defines a vast array of psychological and physical symptoms. The caring manifested by codependents is an unconscious effort to keep repressed pain at bay, and the codependent actually contributes to the addictive behavior of their loved ones by enabling. Enabling keeps the loved one addicted so the codependent can go on caring to gain a sense of self worth. Recovery from codependency requires drastic attitude and lifestyle change (Detachment) and a lifelong commitment to the 12-step regime.

Why would a psychologist wish to criticize the codependency idea? Many people claim to have been helped by codependency books and codependency self-help groups. I don't wish to take away anyone's belief that they are better for having integrated the codependency idea into their lifestyles. But it definitely isn't for everyone. Codependency is a nebulous idea, born not of science but of the gut feelings of counselors and frustrated lay people. It's black and white requirements for recovery, though seeming reasonable on the surface, are not in line with empirical research and have dangerous implications with regard to the most human of attributes, caring. My two primary concerns with the codependency idea are:

The Codependency Idea Pathologizes the Natural Tendency to Care for Others.

The cure for Codependency Mandates Action which is Not Necessarily in Line With Prosocial Values.

WHY THE ALLURE?

Lots of different people buy codependency books. For the most part I've found that people who buy them are having problems being assertive in their relationships. I imagine that a fair number of people are able to extract a few tips from these books which help them feel more confident, more able to voice their needs appropriately and more efficient at carrying them out. However, these three books are about more than just being unassertive and needing a few tips toward being more independent . What is conjected is an underlying disease process, a progressive malady which will end in death if gone untreated. They also list symptom after symptom after symptom which weaves a net large enough to include just about any reader.

Do people want to be included in this net? I think many do. What is so attractive about being a victim of a disease? Simply, it renders one in control. Crazy as it sounds, when relationships aren't panning out and life is riddled with pain, anxiety, loneliness and poor decisions regarding our intimate partners, nothing quenches thirst better than an all-inclusive diagnosis. Enduring negative emotional states or repeated life upsets are no longer deemed maladaptive habits, skill deficits or the function distorted principles and styles of thinking, but diseases.

Accountability for our happiness is a scary thing. Codependency allows one to relinquish responsibility for our frustrating lifestyles. Plus we can dump all the blame on our parents, something the psychodynamic people have been advocating for almost a century.

ALTERNATIVES

Caring for an Addicted Person is Not Synonymous with Pathology

After reading these 3 books I felt quite gloomy. I kept conjuring images of women in very difficult situations trying desperately to make order in their lives receiving the message that their compassion and caring are character flaws, needing to be abandoned for overall psychological health. I've heard anecdotes from clients who report that they were told by addiction counselors that they had to evict their child, or spouse in order to help them, that there is absolutely no way that they could aid in helping their family member change other than complete detachment. Or I imagine people who are selfish already and unhappy with their lifestyles coming to the conclusion after reading one or two of these books that they meet the criteria for codependency (a sociopath would find enough criteria in Beattie's book). I've been to parties and had acquaintances report that they were working on "codependency issues" and almost inhaled my pate. Some of these folks need a dose of codependency! Selfish people aligning themselves with the codependency idea certainly makes sense, because it affords license to be more selfish. But this isn't as much of a concern to me as the people who have the capacity for genuine empathy and have instilled strong values for kind treatment toward others getting the message that to act on it (unless it's reciprocated in equivalent allotments) is wrong. Empathy is good and caring is good. Friendships which last are usually based on mutual caring and even occasional self-sacrifice. Mellody Beattie's idea that relationships should always be equitable reflects the temperament of a five-year old. And with regard to the notion that being in a relationship with someone who is addicted is synonymous with pathology, Absurd. There is no empirical data to support the belief that being a member of a family in which there is addiction warrants diagnosis of a personality disorder (e.g. Gomberg,1989).

No more flagrant was this mind set that caring for an addicted person is an illness articulated than in Ann Wilson Shaeff's book. She recklessly articulates that mental health practitioners, are, by definition codependent, her words: "The mental health field has simply not identified the addictive process and the syndrome of codependency because people in the field are non-recovering codependents who have not recognized that their professional practice is closely linked with the practice of their untreated disease." (95). I hope my colleagues share my belief that helping people as a profession brings tremendous feelings of agency and is in no way a flaw. What would these authors recommend that mental health professionals do to address this untreated ailment, I hope it is not the same advise non-professionals are offered, detachment.

The Idea that the Caring Partner is Somehow Responsible for the Endurance of the Addictive Behavior

Judith Gordon and Kimberly Barret, in an excellent critique of the codependency movement, write that this mind set presents a "divide and conquer attitude toward addictive families.(323). Schaeff, without a page of empirical data to back it up, recklessly suggests that alcoholism is a "family disease." She conjects, "The entire family is affected and each member plays a role in helping the disease perpetuate itself." (9). Moos, Finney and Cronkite (1990) found that, contrary to the idea that caring for an addict perpetuates the addiction, families with a broad range of supportive behaviors actually correlate with success in maintaining sobriety.

A case from several years ago comes to mind involving a caring mother who's 27-year old daughter had been abusing prescription opioids and benzodiazapines for ten years. The daughter finally made the decision attempt a methadone detox, following two months of methadone maintenance. The MD at the methadone clinic recommended that she taper the benzodiazapine, which wasValium (methadone doesn't cover non-opiate drugs). The mother was very invested in her daughter's change efforts and subsequently flew in from out of state to live with her while she detoxed. She agreed to dole out the Valium because the daughter felt that she could not do it on her own without relapsing. The mother hid them in her car and stood watch over her daughter during the first three weeks of her transition. The patient voiced that her mother's presence was imperative for relapse prevention at this time. The mother voiced that it made her feel as though she was finally doing something to help daughter which was panning out. She felt so good about her efforts that she went to an Al-anon meeting. She was literally attacked by three attendees who deemed her behavior enabling and, in addition to deeming her responsible for her daughter's enduring problems with substances, instructed her to go back to her home immediately and let her daughter grapple with her troubles on her own. One said, "She's an adult, and a time comes when you have to let them leave the nest or you're just perpetuating the illness."

Thankfully, this woman had enough conviction and confidence in her values to blow off the advice. Many people don't have this much tenacity to their standards. Many are given such guidance and are left in a complete quandary. The mother's contention was that her daughter was completely responsible for her choice to use or not use. She recognized that her daughter had crippling problems with anxiety and panic and had used the drugs to medicate these states. Though her daughter made the choices, she felt that there was a way she could help her daughter follow through with her motivation to better her life. She knew that if she went back home, her daughter would relapse and that relapse at this point would be devastating to her daughter, who had tried just about every method of quitting imaginable. She fathomed that her daughter might discount the whole methadone choice and revert to prescription drug abuse again.

Alternatives to the Enabling idea are:

1. No one can cause another person's addictive behavior. Addictive behaviors are learned habits fueled by expectancies that following through with the behavior will bring about ease, comfort, or the reduction of something negative.

2. Caregiving is not enabling. Caregiving is fueled by the capacity to experience empathy and the desire to make the lives of our intimates more happy. One of the most robust indicators for a positive outcome from most psychiatric maladies is social support.

3. What works in one relationship will not necessarily work in others, and what used to work in one relationship may be ineffective given new circumstances. This does not mean that the previous behaviors need to be abandoned, or viewed as pathogenic. It means that those in a relationship with an addicted person need to evaluate whether modification of one or several behaviors would aid in the motivation to change on behalf of the addicted person.

The Idea That "Less than Nurturing" Experiences are Necessarily Traumatic

We expect relief--quick relief. We are fortunate to live in a time when quick relief for many of the discomforts of life is available, often at a very low price. We not only have remedies for such nuisances as a headache, we can choose between ibuprofen, acetaminophen or aspirin, depending on your preferred means of pain relief. We live in an age in which people believe that life should be fair and comfortable. You don't have to go back very many decades to be assured that things are pretty fair and comfortable these days relative to the lifestyles of our ancestors. I imagine if one of these codependency books was published a century ago there would be very few who would have taken it seriously. Imagine a family migrating west in the 1800s, just barely surviving. Imagine an exhausted wife and mother bouncing along in a horse led wagon, face chapped from the sweltering midday heat. She opens up Pia Mellody's book as she breast feeds her infant while leaning on a loaded shot gun and nursing her husband's wounded arm. Her eyes open wide. She says to herself? "What? a disease of caring?" "I need to relive the "shame" of my childhood and hold all the "bad" people accountable, detach and learn to live for myself because I don't have to take care of anyone but myself?" You can bet Beattie's book would be fire bait that cold dessert night.

The codependency idea offers an easy route to relief in this age of quick cure. In fact, Melody Beattie says "It is not only fun, it is simple (54). At last people who are angry, frustrated, bored, unhappy, clingy, irrational, or guilt ridden can have a diagnosis. What's even more fun is we get to reexamine our childhoods, our families, Everyone's favorite soap opera, as Wendy Kamminer writes in I'm Dysfunctional You're Dysfunctional. Codependency mandates a poignant story. We get to ask, "How did I become codependent? Mellody will respond, "Carried Feelings." She will offer an electrical circuit analogy. You, the child, because of your ill developed boundaries were literally a conduit for the intense feelings of shame which were discharged by your parents. As a child you incorporated these into a "shame core" which is manifested in your "shame attacks" today. You will pass on shame cores to your children unless you unleash the bottled up pain today.

It is recommended that codependents do an inventory of all "less than nurturing" experiences of childhood. Pia Mellody asks that you look at your life from birth to age 17 and identify all the people responsible for "abusing you." No attempt should be made to make excuses for the offenders in our lives or to tell ourselves that they didn't mean it, even if they didn't mean it. These perpetrators include, first and foremost, our mothers and fathers, but also siblings, extended family and members of the community, such as neighbors and teachers and angry garbage men.

Mellody Beattie recommends that we grieve. The purpose of "grief work" is to "separate the abuse from the precious child (118)." This is an actual mandate for recovery, "We must purge from our bodies the childhood feeling reality we have about being abused. The only way we can connect the feeling reality to what happened is to know what happened (122)."

I think few, if any, events rival physical and sexual abuse in terms of the horrible effects that can plague the victim in later life. Talking about these events, identifying the offender and disputing the victim's ideas that she is responsible are integral to adult psychological health. However, these authors are talking about more than physical and sexual abuse. In fact, they pay lip service to the horrors of child abuse by deeming any event in which our parents were harsh, impatient or unfair as abuse. All of the events mentioned in the books having to do with humiliating a child, name calling, yelling at a child and threatening a child are all instances of poor parenting, they may even be associated with ongoing suffering and marred interpersonal relationships. But they don't necessarily make a person a victim of child abuse.

These authors suggest that negative events necessarily lead to pathology, as though the caregivers of our past now hold puppet strings on our continued existence. If you are unhappy, you must examine what happened to you and identify the perpetrators and assign all the unhappiness you experience now to these ghosts. As Wendy Kaminer proclaims in her witty and erudite "I'm Dysfunctional, You're Dysfunctional, "The trouble is that for codependency consumers, someone else is always writing the script. They are encouraged to see themselves as victims of family life rather than self-determining participants. They are encouraged to believe in the impossibility of individual autonomy (13)."

The mandate that we assume the role of damaged victim in order to get better is contrary to not only a century of Existential philosophy and fiction--in which tragedy is discussed as opportunity for transcendence, clarity and strength--but also to a fair number of empirical studies which have suggested that they way people construe past events, not the events themselves, will determine later functioning. These findings are completely opposite the non-scientific recommendations of codependency authors.

For example, in a recent study by McMillen, Zurvin and Rideout (1995) a large sample of adults sexually abused as children were interviewed and asked if they felt that they had benefited in any way from the experience. 47% said that they had. Responses ranged from "growing stronger as a person," "feeling more adept at protecting their children from abuse," "increased knowledge of sexual abuse" and the belief in one's ability to self-protect. In turn, regardless of quality or duration of the abuse, those who saw some benefit scored higher on a number of adjustment.

Not just sexual abuse has been evaluated in this regard, those who experiences natural disasters, serious health problems and personal tragedies have been found to have common perceptions of benefit such as positive personality changes, changes in priorities and enhanced family relationships (e.g. Affleck, Tennen, and Rowe (1991).

The whole basis of cognitive therapy is to help individuals learn to recognize and dispute exaggerated, biased and overly negative automatic thoughts, beliefs, values and standards. The attitude of the codependent authors is Jr. Psychoanalyst. Somehow "events" in their pure form are stored in the labyrinth of ones unconscious and need to be purged and experienced in all their horror in order for the person to get beyond them. As said, people's ongoing unhappiness is not a direct result of the negative events which befell us, but rather they way the negative events are appraised, or the meaning assigned the events by the recipient. People vary tremendously in terms of their appreciation of the same event. The mandate that we catastrophize then detach appears to me more a prescription for a phobia than recovery. As opposed to taking a victimization inventory, the most healthy thing to do would be to conduct a coping inventory, in which negative events of the past are re-evaluated in a manner that makes you stronger, more resilient. There are opportunities to learn and grow from the tragedies and mishaps in our pasts...or their is a quagmire of despair, deception, bad, bad mommies and daddies and precious little lambs with throats extended. You pick.

The Idea that 12-Step Groups are Necessary for Those Involved with an Addicted Person

Whether they commit themselves to the idea that codependency is a disease or not, the three authors are adamant about codependency being a lifelong illness which doesn't go away; rather goes into remission (if you're lucky), like diabetes or schizophrenia. Like neuroleptics and psychosis, codependency and AA-like support groups are intimately linked by these authors. Psychotherapy is deemed insufficient by these authors. Mellody Beattie, by way of an "invisible boat (194-195)" story, implies that therapy is fine for starters, but that the journey will end, and given the fact that codependency is progressive, one will need the 12-steps to continue on course. It is stated in all three books that one has to be a codependent to understand what is gong on with the codependent. That kind of reasoning is as absurd as me firing my rheumatologist, who is chief of staff at a respected hospital in San Diego, because he doesn't have any swollen joints. Some painful knees would be a better qualification than board certification. I should ask a patient in the waiting room if they wouldn't mind taking over my case because of his or her capacity to feel the same throbbing joint pain as me.

The 12-step philosophy endorses the relinquishing of control to a higher power. Though claiming that it's spiritual emphasis is not religious, and that virtually anything can be ones higher power, this is really a clever bait and switch. 12-step groups are more like going to a prayer group than anything else. For many, this forum is commensurate to existing needs and values. For others, it is the antithesis of stable world views. As is the case with alcoholics and drug dependent individuals, you are hard pressed to find alternatives to the 12-step approach. Those desiring help who find the mentality of AA irrelevant or offensive are deemed "in denial" or "into their disease."

Most disturbing is the fact that codependency authors are unaware of the volumes of empirical data backing up non-12-step methods of change for the symptoms delineated in codependency books (anger control problems, depression, anxiety, communication problems, to name but a few of those symptoms listed in Beatties's book). Also behaviorally oriented family therapists have developed methods for helping families in which addiction occurs without the use of 12-step mentality (e.g. O'Farrell, et. al.).

One Step at a Time

It's probably "codependent" of me to believe that I alone can strike the term codependency from the English language. It's entrenched in the addiction vernacular, and though defined in many, many ways depending on which symptoms a person selects from the vast lists, has been implemented into the self concepts of many. I'm sure the codependency books critiqued in this essay, like all self help books, were written with good intentions, the hope that people's lives would be improved. If your life feels better for having read and followed through with the recommendations of these authors, who am I to try to take that away. My article was written primarily as a caveat, a warning that what appears right and good on the surface, may have unhealthy ramifications in the long run if taken on to aggressively, a warning that just because a self-help author mandates one path to happiness, doesn't make it accurate.

As opposed to swallowing the codependency idea whole, I encourage those struggling with problematic relationships or a family member's addictive behavior to use the basic advice of AA, "one step at a time." The codependency idea is so broad that it is possible to extract useful principles and guidance from it. Given the lack of scientific drive behind this concept it behooves you to examine all aspects of your life which are being addressed by this concept. Just because one component of the codependency mind set hits home, doesn't mean you have to engulf the entire world view.

1.Leave the term in the realm of addiction. The codependency idea was designed to help spouses and families of alcoholics and drug users. In this realm it appears to have some implications. Some of the advice in these books may be useful in helping to make sobriety easier for the addicted person . However, with regard to the use of the term for people who have relationship problems or who have difficulty putting themselves first, or who are dysphoric, there are many more specific terms which afford the sufferer some practical tools, without having to incorporate the disease idea, or "purging the unconscious." Earlier I mentioned specific treatments, mostly in the cognitive-behavioral realm for addressing such problems as anxiety, depression, anger control, relationships problems. Before tossing your whole system of values and making the plunge into the recovery lifestyle, consider less invasive measures. If they prove insufficient, up the ante. The treatment tiering approach is very appropriate here. In the realm of medicine, least invasive treatments are usually tried first, and when proven insufficient or inadequate treatment intensity is increased. Arthritis is an analogy I usually use. A competent MD would not prescribe joint replacement as an initial treatment for painful joints. She would first attempt less potentially dangerous treatments, such as non-steroid antiinflamitories. If these prove insufficient, she might try steroids, then up to more intense drugs with potential side effects and so on. I believe the treatment tiering model is relevant to all psychological problems. Consider the least invasive and most potentially effective intervention first, not the most drastic.

There are so many potential problems with over diagnosing and over treating. When people begin to believe that their problems are bigger than life they begin to question the effectiveness of their coping in realms previously not questioned. This doubt and insecurity, which can be perpetuated by "long term therapy" and nebulous diagnoses like codependency, dissolve the mind set that one is robust or resilient, and replace it with one in which one is weak and vulnerable in a cruel world. Our ever broadening