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.”
It’s also important to recognize that a family member may resent the psychiatrist who has helped the patient with the SUD when the family member has been trying to accomplish the same thing for years, says Young.
“The goal for the psychiatrist is to have the family member be part of the team,” says Lorenzo Leggio, MD, PhD, chief of the joint NIAAA-NIDA (National Institute on Drug Abuse) section on clinical psychoneuroendocrinology and neuropsychopharmacology. For example, medications are one of the tools used in treating alcoholism and other SUDs. “We know that it’s not easy to comply with taking a medication, so the family member may have to play a key role in that,” he says.
In addition, family members should not drink, says Koob. “This is just common sense—having a drink in front of an alcoholic is like waving a flag in front of a bull.” It’s also important to remove all of the liquor in the house, some of which may be hidden.
Finally, family members may need to be encouraged to seek psychological care for themselves. “At some point, someone may need to see the family member as a patient,” says Leggio. “With substance use disorders, we are talking about a medical problem as it affects the whole family.”
Al-Anon: An adjunct to family work
In addition to individual clinical work, the organization Al-Anon can be quite helpful for families of substance users. Al-Anon was started in 1951. According to lore, Bill Wilson (who co-founded AA in 1935) realized that since AA was attended mainly by men, their wives would wait for their husbands who were in meetings. It became clear that a companion group was needed for family of AA members. The original proposed name was AA Family Group, but AA leadership objected because the sixth tradition of the organization states that the letters “AA” should not be used by an outside enterprise. Thus, the founders decided to use “Al-Anon” (a contraction of Alcoholics Anonymous); the full name is now “Al-Anon Family Groups."
“For family members of patients with SUDs, this type of organized support group can be a lifeline,” says Timko. I’ve talked to people who say Al-Anon saved their lives. They came in exasperated, at the end of their rope, not able to solve the problems they are facing. There’s a huge sense of relief when they see other people who went through this.” Like all mutual support groups, having a community of people who have not only shared experiences but learned how to live with them is very helpful. In addition, Al-Anon “offers activities that get you outside of your life,” says Timko.
A recent study by Timko and colleagues found that sustained attendance at Al-Anon improved quality of life, increased self-esteem, and decreased depression. The bonding, goal direction, and access to peers helped to explain these associations. (Timko C et al, Psychol Addict Behav 2015;29(4):856–863).
For someone who has a spouse with an addiction, Al-Anon would encourage the person to practice self-care, but not to get a divorce, says Timko. “Al-Anon doesn’t say to cut off your relationship with a drinker,” she notes. Rather, at Al-Anon, there would be discussion of how to work things out.
There is also Alateen, which is a subgroup of Al-Anon. Alateen is specifically for adolescents who have a family member who is an alcoholic (http://al-anon.org/for-alateen).
How to discuss Al-Anon with your patients
Psychiatrists should be able to briefly describe Al-Anon to patients who have a family member with an addiction problem, says Timko.
“I would probably step back and say, ‘This is a hard way to live, to be caring for someone who is engaging in this harmful behavior, so it’s important to take care of yourself and stay healthy,’” she says. The psychiatrist could recommend Al-Anon, explaining that it’s a resource for someone who has a family member who is drinking or using drugs. “The important point would be to say that Al-Anon doesn’t tell people what to do,” Timko says. Al-Anon meetings are free and open to the public. The psychiatrist might attend a few meetings to enable the making of referrals. Tips can be gained there for working with alcoholic patients as well.
Houghtaling of Caron says that referring family members to Al-Anon is tricky. If you use Al-Anon as a way to say, “You’re sick or codependent, and Al-Anon is your treatment,” it wouldn’t be accurate, and it wouldn’t work. Instead, it’s better to say, “You’ve been exhausted from making all these sacrifices, and now you finally have a chance—you deserve Al-Anon.” As for telling the SUD patient to go home and suggest that the family member go to Al-Anon, that’s “dangerous,” he says. “There will only be more resentment, with the family member saying, ‘Now you’re telling me what to do?’” Very few patients are grounded enough to be able to tell a family member to go to Al-Anon in a way that isn’t “guilt-provoking.”
Some psychiatrists do get the spouse to come in so there can be a 3-way conversation, and this would be the right time for the psychiatrist to suggest Al-Anon to the family member. “Everything in addiction treatment is focused on the patient, but this would be a chance for the focus to be on you,” the psychiatrist could say.
The bottom line: Supporting the families of your patients with SUD—whether through therapy or Al-Anon, is crucial for effective treatment.
For further reading:
Timko C et al. Social processes explaining the benefits of Al-Anon participation. Psychol Addict Behav. 2015;29(4):856–863.
Timko C et al. Al-Anon Family Groups: Newcomers and Members: J Stud Alcohol Drugs. 2013;74(6): 965–976.
Young LB and Timko C. Benefits and Costs of Alcoholic Relationships and Recovery Through Al-Anon, Subst Use Misuse. 2015;50(1).62–71.