Codependency and Addiction


Codependence, as it pertains to addiction, commonly refers to a specific type of dysfunctional relationship in which a family member (or multiple members of the family unit) enables the active addiction.1 While codependency is not a distinct diagnosable mental health condition in the most recent Diagnostic and Statistical Manual of Mental Disorders (the DSM-5), its potential inclusion as a personality disorder was once proposed.2 Despite this, the concept of codependence continues to be used by many in the treatment community to describe an unhealthy relationship pattern, and codependency continues to be a commonly referenced concept (for example, by those active in Alcoholics Anonymous and other 12-step programs).

The American Society for Addiction Medicine describes codependence as a family member’s harmful over-involvement with the addiction process.1 In some cases, this might entail a tendency toward over-concern with the wellbeing of others to the detriment of oneself—physically, emotionally, or spiritually.4 According to the Substance Abuse and Mental Health Services Administration (SAMHSA), people who exhibit codependent patterns of behavior may be controlling of those they feel are incapable of taking care of themselves, have low self-esteem, and tend to deny their own feelings. They may also remain loyal to those who do little to earn such loyalty, be oversensitive to disruptions in the family, and compromise their own values to avoid anger and rejection.3

Though the term has grown to increasingly widespread use over the years, the concept of codependence has not been universally endorsed. Some have argued that it pathologizes otherwise normal, caring responses—such as empathy and self-sacrifice.Originally, the concept of codependency took shape amongst treatment professionals referring to the behavioral patterns of the spouses of alcohol abusers, though the term was eventually expanded to describe a dysfunctional family dynamic seen in people with other types of addictions, as well as any other behavioral or mental health problem.3,5

Symptoms of Codependency

Co-Dependents Anonymous (CoDA), a support group fellowship that adheres to the 12 Steps and 12 Traditions in guiding its members toward healthier relationships.  To better explain the concept of codependency, as well as to provide a means of self-evaluation, CoDA outlines a checklist of several behavioral patterns and characteristics commonly exhibited by codependent people, including denial, low self-esteem, compliance, control, and avoidance. Though individual cases will vary, some characteristic behaviors commonly displayed within each of these patterns include:6

Denial

  • Difficulty identifying feelings.
  • Minimizing, denying, or otherwise altering how one truly feels.
  • Thinks of oneself as unselfish and completely dedicated to others.
  • Lack of empathy for the feelings and needs of others.
  • Sees others as having the same negative traits as oneself,
  • Believes they can take care of themselves without help.
  • Uses defenses, such as humor or anger, to hide one’s feelings.
  • Passive aggressivity.
  • Refuses to acknowledge the unavailable nature of the people one is attracted to.

Low self-esteem

  • Struggles to make decisions.
  • Judges one’s own thoughts, feelings, and actions harshly.
  • Feels embarrassed when given positive attention.
  • Sees the opinions of others as being more valuable than one’s own opinions.
  • Feels unlovable or not worthwhile.
  • Seeks out the praise and recognition of others as a way of relieving feelings of inadequacy.
  • Struggles to admit one’s own mistakes; a need to appear in the right at all times; may lie to make oneself look better.
  • Difficulty identifying or expressing personal wants and needs.
  • Depends on others to provide a sense of safety.
  • Struggles to start and complete projects, as well as meet deadlines.
  • Has difficulty prioritizing and setting boundaries.

Compliance

  • Exhibit unearned loyalty; remain in harmful relationships and situations too long.
  • Willing to compromise own values/integrity to avoid angering others.
  • Sidelines personal interests to do what others want.
  • Hyperawareness about the feelings of others; attempts at taking on those feelings.
  • Fears expressing feelings or beliefs that differ from others.
  • Replaces emotional intimacy with sexual intimacy.
  • Acts without regard to the consequences of one’s actions.

Control

  • Doesn’t believe others can take care of themselves.
  • Tries to control the thoughts, feelings, or actions of others.
  • Gives advice without being asked.
  • Resents those who reject advice.
  • Attempts to gain influence with gifts and favors.
  • Uses sexuality to gain attention and approval.
  • Must feel needed by others to maintain relationships with those people.
  • Expects others to meet personal needs.
  • Using charm in attempts to convince others of one’s capacity to be caring and compassionate.
  • Blames or shames other people to exploit personal emotions.
  • Will not cooperate, compromise, or negotiate.
  • Manipulates outcomes through indifference, helplessness, authority, or rage.
  • Uses recovery jargon to control others’ behaviors.
  • Pretends to agree with others to get what is desired.

Avoidance

  • Acts in ways that invite anger, shame, or rejection from others.
  • Judges others harshly.
  • Avoids intimacy to maintain distance from others.
  • Allows addiction to people, places, and things as a means of avoiding intimacy.
  • Avoids conflict through indirect or evasive communication.
  • Diminished capacity for healthy interpersonal relationships as a result of refusing to utilize recovery tools.
  • Suppresses feelings/needs in order to avoid vulnerability.
  • Pushes other people away should they get too close.
  • Clings to self-will to avoid surrendering to a greater power.
  • Sees emotions as weakness.
  • Reluctance to express appreciation.

Addiction and Codependence

According to an article published by American Family Physician, codependence is a behavioral characteristic sometimes exhibited by people attempting to fulfill a helpful role in a relationship with someone with a severe illness (e.g., substance addiction). At some point, as standard boundaries begin to weaken, such a relationship becomes harmful to one or both of the involved individuals.7 Codependency may develop as people struggle to cope with a stressful family situation involving such as addiction or mental illness. Codependent people grow to unconsciously fear the potential for ensuing anger and abandonment from the struggling individual should they refuse to accommodate their demands. Such situations may make it more likely that family members adopt unhealthy helping roles.7

Though there are different types of enabling behaviors, codependence of all sorts may ultimately end up hurting each person involved in the relationship. For example, a codependent person might enable someone suffering from addiction to continue abusing substances by shielding from or compensating for the consequences of the addicted individual’s problematic behaviors. A more hostile enabler might treat an addicted person with disrespect or aggression over the same types of problematic behaviors.Neither instance of enabling has a good chance of helping to motivate the addicted person toward seeking treatment or recovery help, meaning that the addictive behavior may persist and the dysfunctional family dynamic may be further perpetuated.

Treating Codependency

A cycle of codependence and addiction creates a relationship in which neither individual is encouraged to recover from their respective issues. Addiction is maintained, and the unhealthy thoughts and beliefs of the codependent person are not addressed. Because this relationship pattern is common among the families and loved ones of people suffering from addiction, treatment for substance use disorders often includes recovery support for the family members themselves.1

Counseling for everyone caught in this cycle of codependence can better encourage recovery from addiction, as the enabling behaviors of the codependent person are recognized and addressed. Psychological and interpersonal struggles such as codependence are sometimes addressed through psychotherapy, also called talk therapy.

Family-focused therapy is also commonly employed and can be very helpful for people in codependent relationships, as the entire family unit is typically affected by unhealthy relationship patterns. Family-focused therapy treats mental health disorders by repairing and strengthening relationships between family members, and teaching healthy ways to communicate wants and needs so loved ones can support an individual who is suffering without falling into unhealthy patterns, such as codependency.3

Codependency recovery support, including the Al-Anon and Nar-Anon Family Groups fellowships, as well as Co-Dependents Anonymous, or CoDA, can help people begin to adjust their focus from the addicted individual in their lives to place more emphasis on caring for themselves. Many people find self-help methods and support networks like CoDA—and their emphasis on allowing the addicted person to learn to better deal with the consequences of their drug and/or alcohol use—to be very helpful in dealing with codependency.1,3 Such groups allow the addicted individual to begin working on themselves while maintaining a connection to much needed family support throughout the recovery process.1

References

  1. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.
  2. Morgan, JP, Jr. (1991). What is codependency? Journal of Clinical Psychology, 1991 Sep; 47(5):720-9.
  3. Substance Abuse and Mental Health Services Administration. (2015). Treatment Improvement Protocol (TIP) 39: Substance Abuse Treatment and Family Therapy.
  4. Vederhus, J. K., Kristensen, Ø., & Timko, C. (2019). How do psychological characteristics of family members affected by substance use influence quality of life?Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation28(8), 2161–2170.
  5. Stafford, L.L.(2001). Is Codependency a Meaningful Concept?Issues in Mental Health Nursing, 22:3, 273-286.
  6. Co-Dependents Anonymous International. (2011). Patterns and Characteristics of Codependence.
  7. Longo, L.P., Parran, T., Jr., Johnson, B., Kinsey, W. (2000). Addiction: Part II. Identification and Management of the Drug-Seeking Patient. Am Fam Physician; 2000 Apr 15; 61(8):2401-2408.


About The Contributor

Scot Thomas, M.D.
Scot Thomas, M.D.

Senior Medical Editor, American Addiction Centers

Dr. Thomas received his medical degree from the University of California, San Diego School of Medicine. During his medical studies, Dr. Thomas saw firsthand the multitude of lives impacted by struggles with substance abuse and addiction, motivating... Read More


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