by Vicki Lavick, M.D.Ed.

Many people do not realize that co-dependency is an addictive process -- a disease just like any other addiction. Co-dependency can be described as a dysfunctional pattern of living in which one overreacts to things going on outside of oneself and under reacts to what is going on inside. It involves compulsive behaviors and dependence upon approval from others in order to achieve a sense of safety, identity and self-esteem. Co-dependents put all their efforts into those around them, neglecting to fully take care of themselves, especially emotionally. Co-dependency is a disease that, if left untreated, can lead to other addictions such as eating disorders, substance dependence, workaholism and compulsive spending.

Charactersistics of Co-Dependency

Some of the characteristics of co-dependent people include:

• Positive feelings about themselves stem from being liked and accepted by others.
• Mental attention is focused on solving the problems of others or relieving their pain, and when these goals are accomplished, their self-esteem rises.
• Co-dependents tend to personalize all that happens around them, seeing everything as being directly related to them.
• Unless they are externally validated, they have difficulty trusting their own perceptions.
• Significant others' clothing, personal appearance and behavior are dictated by the co-dependent, as he or she feels that the significant other is a reflection of him or her.
• Co-dependents have unrealistic expectations of themselves, are unable to accept their own limitations, and use control and manipulation to avoid facing reality.
• They view themselves as failures when they cannot control everything or meet everyone's expectations.
• They fear rejection and abandonment, so they feel they must be involved and needed in every aspect of the lives of others. Not to be involved and needed equals abandonment.
• Co-dependents are not aware of how they feel; they are aware of how others feel. Co-dependents are not aware of what they want; they ask what others want. If they are not aware, they assume.
• Social circles diminish as they become more involved in their disease.

This list is not all-inclusive; there are other behaviors that are co-dependent in nature. Co-dependents are very focused on others, yet at the same time they feel what goes on around them is related to them in some way.

Who Is Co-Dependent?

The general consensus among professionals in the addictions field is that educating and treating the family members of their clients is essential to the recovery of all concerned. When a family member suffers from an addiction, the other family members are most likely co-dependent, and have been great enablers to their loved one. It is extremely important for family members to learn how their behavior has affected the addicted individual and others around them, and how they can learn from their behavior and make positive changes.

Everyone within the family system develops a "role" that plays an important part in maintaining the status quo. The main role is that of the addicted individual. The specific symptoms of the addiction may vary, but the feelings that go along with it are most likely guilt, shame and fear. The next major role is that of The Enabler -- usually the spouse, but in the case of young adults suffering from addiction, the main enablers will most likely be the parents. The Enabler keeps the family together at all costs. He or she spends all time and energy on others and often feels tired, lonely and taken advantage of, but also feels a sense of accomplishment when in control. The Enabler is motivated by fear, love and hate, caring, frustration and ignorance, and thus plays a key role in allowing dysfunctional behaviors to continue. The Enabler role is also enacted by children within the family system. The specific roles they play are:

• The Hero: This child is often the oldest, an overacheiver, and is able to help the family look "normal." The Hero is extremely dependable, and perfectionistic, which allows the family to deny that there is a problem -- if the problem is so bad, how could we have such a wonderful child? The child's purpose is providing self-worth for the family. The Hero feels much anger, guilt, inadequacy, loneliness, and hurt, but covers these up with his actions.
• The Scapegoat: Is often in trouble in school or with the law. This child acts out the family's problems, and is blamed for being the source of the family's problems. He or she serves as a distraction and focus for the family. This child feels anger, loneliness, hurt, rejection, fear, and has low self-esteem. The Scapegoat is likely to become involved with alcohol or drugs to cope.
• The Mascot: Provides comic relief for the family. He or she brings a sense of fun and playfulness to the family system. This child's motivating feelings are fear, insecurity, loneliness, and confusion.
• The Lost Child: Uses escape and withdrawal to deal with the family's problems, often "fading into the woodwork." In this fashion he or she offers relief for the family. He or she feels anger, inadequacy, loneliness, and hurt, has a low or no self-esteem, and a lack of identity.

These roles are not mutually exclusive; family members may display traits of any given role at a time. The common thing is that they are all co-dependent in nature, and allow the addicted individual to continue with his or her behavior.

It is important to recognize that, although many co-dependents are involved with addicted individuals, this is not always the case. Remember that co-dependency is characterized by compulsive behaviors, and these can be exhibited even within relatively healthy family systems.

The Road to Diagnosing Co-Dependency

At this time, there is no official "diagnosis" for co-dependency. There is currently no diagnosis in the DSM-IV entitled "Co-Dependency," as there is for other addictions, such as chemical dependence and pathological gambling. This poses a problem for many professionals, as there is no distinct set of criteria from which to assess an individual. Timmen Cermak, M.D., suggests that co-dependency is a personality disorder. His reason is that when specific personality traits become excessive and maladaptive and cause significant impairment in functioning or cause significant distress, this warrants a personality disorder diagnosis. So why could this not be applied to a co-dependent personality disorder? Dr. Cermak proposes the following diagnostic criteria for this disorder:

A. Continued investment of self-esteem in the ability to control both oneself and others in the face of serious adverse consequences.

B. Assumption of responsibility for meeting others' needs to the exclusion of acknowledging one's own.

C. Anxiety and boundary distortions around intimacy and separation.

D. Enmeshment in relationships with personality disordered, chemically dependent, other co-dependent, and/or impulse-disordered individuals.

E. 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.¹

Dr. Cermak goes on to describe each criterion in detail, and explains that based on these criteria, co-dependency can be considered a true disease. We must keep in mind that co-dependency is a very complex concept. It is possible that a co-dependent may not display all of the symptoms of co-dependence. This, however, makes it easy for a co-dependent in denial of his or her disease to de-focus on the symptoms or behaviors that he or she does not display. Dr. Cermak points out that co-dependents can often identify with one specific variant more than the general concept of co-dependency. He states that it is important for the professional to remember that all variants should be seen simply as different expressions of the same underlying issue.²

Recovery Is Possible

The bright spot in this discussion of co-dependency is, as with any addiction, recovery is possible. Recovery from co-dependency generally does best with a two-part program: involvement with a co-dependency therapist and/or profes-sionally led group plus participation in a 12-step program. In their book "Understanding Co-Dependency," Sharon Wegscheider-Cruse and Joseph Cruse, M.D. explain that some behaviors require moderation, while others require abstinence. They point out that most compulsive behaviors are actually just extreme exaggerations of healthy, normal behavior (work, eating, shopping/spending, sexuality, etc.), and recovery consists of the moderation of these behaviors. Recovery from the use of mood-altering substances, such as drugs or alcohol, requires abstinence.³

By working with a therapist, group, and/or a 12-step program, one can learn about his or herself. One can look at motivations, behaviors, identifying feelings, developing positive coping skills, and make positive changes. In seeking professional help, one should look for a therapist who has been trained specifically for working with co-dependents. Twelve-step programs that are geared toward co-dependency include Al-Anon, Co-Dependents Anonymous and Families Anonymous.

The Co-Dependent Professional

Before I conclude, I would like to discuss the challenges of professional co-dependency. Many professionals exhibit co-dependent characteristics at one time or another; often this is part of the profession itself. We are expected to put our own issues aside in order to best serve the needs of our clients. We are taught to maintain control within therapy sessions and create a safe environment for our clients to express their feelings. The basic role of the therapist is to "help" our clients in some way.

Often one becomes a professional in this field because of being raised in some sort of dysfunction and chaos. Having grown up a co-dependent, working in this field seems only natural. Professionals need to be aware of acting out the disease of co-dependency to their clients. We need to be aware of what is going on inside ourselves. The disease becomes active when we begin feeling the pride, shame and doubt that we see in our un-recovering clients. It is all too easy for a co-dependent therapist to begin taking pride in the power of therapy and trying to control the client's behavior. The therapist should be aware of the feeling that he or she can manipulate the clients into becoming healthy. Also, the therapist should not take all the credit for clients' successes.

Shame creeps in when the therapist begins to feel that he or she can truly control the client's behavior. When things do not go right, the therapist feels personal blame. The therapist's sense of well-being becomes directly proportional to the success of the clients, and the disease of co-dependency becomes active once again.

All therapists want to see their clients succeed, but occasionally can doubt their own professional competency. When this crosses over into doubt of oneself as a person, the disease is activated. Every therapist makes a judgement call once in a while, then reflects on whether the right decision was made. If this becomes a habitual practice, one is back in the disease process. It is important for professionals to acknowledge that we must take care of ourselves first, before we can best serve our clients.

For those who are co-dependent, active participation in a 12-step program is essential. Also look at other options for a healthy well-being, such as meditation, relaxation techniques and utilizing a support network, in order not to become co-dependent as a result of our profession. We must be continuously aware of ourselves and take care of ourselves, in order to care for our clients in a manner that is healthy not only for them, but for us as well.

References

1. Cermak, T.L. "Diagnosing and Treating Co-Dependence." Minneapolis, MN: Johnson Institute, (1986).
2. Cermak, T.L., ibid.
3. Cruse, J., M.D., & Wegscheider-Cruse, S. "Understanding Co-Dependency." Deerfield Beach, FL: Health Communications Inc., (1990).

Vicki Lavick serves as the assistant clinical coordinator of outpatient services with Proctor Hospital's Addiction Recovery Center.