Diagnosing Codependence – A Practical Guide

Terence T. Gorski
November 01, 1992

imagesIn recent years, the exact meaning of the term codependence has become confused. This confusion is interfering with efficient diagnosis, appropriate treatment recommendations, and the funding of treatment. It is also creating confusion about the relationship between codependence and chemical dependence, and the relationship between codependence and other mental disorders.

In order to accurately define the term codependence — and try to clear up the confusion — let’s begin with a brief review of the history of the term and then describe the various meanings it has developed in current usage.

Historical Perspective

Shortly after the founding of Alcoholics Anonymous (AA) in 1935, it was recognized that adults who lived in committed relationships with alcoholics were damaged by those relationships. This damage was originally referred to as co-alcoholism. In the early 1940’s, AA Family Group Meetings, which later became Al-Anon, were organized to meet the needs of co-alcoholics (Al-Anon, 1979). In the late 1960’s and early 1970’s, treatment centers began to develop programs for families of alcoholics. At first, these programs were directed toward enlisting the support of family members in keeping alcoholic patients sober (NIAAA 1981, NIAAA 1987). The focus of these programs gradually shifted to meeting the needs of the co-alcoholics themselves. Co-alcoholism began to emerge as a separate diagnostic category.

Awareness began to grow that children raised by alcoholic parents suffered more severe and long-lasting damage than adults who were raised in non-alcoholic homes and later married alcoholics. A distinction was made between co-alcoholics (adults from non-alcoholic families who later married alcoholics) and para-alcoholics (children who were raised by alcoholic parents). The specific damage to children was discussed under the term Children of Alcoholics. Since this damage persisted into adulthood, the term Adult Children of Alcoholics (ACOA) came into widespread use. A Twelve-Step Support Group named Adult Children of Alcoholics was developed in the early 1980’s and grew rapidly.

In the late 1970’s, the term chemical dependence came into widespread use and the term alcoholism was conceptualized as a subtype of chemical dependence. As a result, the term co-alcoholic was generalized as the term codependent. As the ACOA movement grew, the term codependent was used to describe both adults who were damaged by marrying chemically dependent partners and children who were damaged by chemically dependent parents.

As more clinical observations were made of codependents (adults and children), it became apparent that people who were damaged by living in committed relationships with chemical addicts did not differ significantly from people damaged by living in committed relationships with other dysfunctional people. The term codependent was therefore expanded again to account for all people who have been damaged by living in a relationship with a dysfunctional person, regardless of the cause of the dysfunction. The term Adult Children from Dysfunctional Families (ACDF) began to be utilized.

As efforts were made to describe the personality characteristics of these now broadly defined codependents, it was discovered that some, but not all, had a personality that was organized around low self-esteem, obsessive involvement with others in order to raise self-esteem, and extreme caretaking behavior that resulted in lack of self-care. This observation caused many people to begin using the term codependence to describe that particular personality style.

Current Usage

As a result of this steady broadening of the concept, the current usage of the term codependence involves four distinctly different definitions:

1.         Codependence is a cluster of symptoms or maladaptive behavior changes that occur in adults who live in a committed relationship with a chemically dependent person. (Al-Anon.)

2.         Codependence is a cluster of symptoms or maladaptive behavior changes that occur in children who are raised by chemically dependent parents. (ACOA.)

3.         Codependence is a cluster of symptoms or maladaptive behavior changes associated with living in a committed relationship with either a chemically dependent person or a chronically dysfunctional person either as children or adults. (ACDF.)

4.         Codependence is a specific pattern of personality traits that are characterized by loss of self-identity, over-involvement with others as a means of establishing self-identity, and excessive caretaking behavior that results in a lack of self-care. (Everyone else.)

The Simple Solution

The easiest solution to the problem of uniform language would be to acknowledge all four general definitions and draft specific language to accurately describe their meanings. This solution, however, would not end the confusion over what is meant by the term codependence. Rather, it would simply force people using that term to specify the exact meaning that they mean to convey.

A Better Solution

A better solution would be to create a special nomenclature that readily differentiates between these four different meanings. The following nomenclature could be used.

Codependent: A general term describing a cluster of symptoms or maladaptive behavior changes associated with living in a committed relationship with either a chemically dependent person or a chronically dysfunctional person either as children or adults.

This term could be further specified using the following terms:

Codependent Adjustment Reaction: A subtype of codependency characterized by the spontaneous remission of codependent symptoms when the person is no longer in the committed relationship with the chemically dependent or chronically dysfunctional person.

Codependent Disorder: A subtype of codependency characterized by the continuation of codependent symptoms even when the person is no longer in a committed relationship with the chemically dependent or chronically dysfunctional person.

Child Onset Codependence: A subtype of codependency (either codependent adjustment reaction or codependent disorder) that is caused by being raised in an addictive or dysfunctional family of origin.

Adult Onset Codependency: A subtype of codependency (either codependent adjustment reaction or codependent disorder) that is caused by being involved in a committed relationship as an adult with an addicted or dysfunctional person.

Severity Scale

Codependent symptoms can vary in intensity from mild to severe. The following severity scale can be used:

1.         Mild codependent symptoms produce subjective distress, but create no social or occupational impairment.

2.         Moderate codependent symptoms produce subjective distress and create minimal social and occupational impairment.

3.         Severe codependent symptoms produce subjective distress and create substantial social or occupational impairment.

The Caretaking Personality Style

This term could be used to describe a specific pattern of personality traits that is characterized by loss of self-identity, over-involvement with others as a means of establishing self-identity, and excessive caretaking behavior that results in a lack of self-care. Both codependents and non-codependents can exhibit a caretaking personality. This can be uncategorized as:

1.         Caretaking Personality Traits:  A form of the caretaking personality that creates subjective distress but is not sufficient to cause social or occupational impairment.

2.         Caretaking Personality Disorder: A form of caretaking personality that is severe enough to cause social and occupational impairment.

The Relationship of Chemical Dependence and Codependence

Approximately 60% of all chemically dependent patients entering treatment for the first time (Hoffman and Harrison, 1986) and 90% of all chronically relapse-prone patients were raised in alcoholic family systems and would be appropriately described as having a multiple diagnosis of chemical dependence and child onset codependence. This high rate of multiple diagnoses has led to confusion about the relationship between codependence and chemical dependence.

If we use the definition of codependence as symptoms resulting from damage caused by living in a committed relationship with a chemically dependent or dysfunctional person, there would be two possible relationships between codependence and chemical dependence.

1.         Codependence could cause chemical dependence, or

2.         Codependence and chemical dependence could be co-existing disorders that have no causative relationship, but do interact dynamically with each other.

There is substantial evidence that codependence (i.e. being raised in a dysfunctional family) does not cause chemical dependence, but can cause serious complications that can interfere with recovery and increase the risk of relapse (Gorski, 1989).

Therefore, the recommended position on the relationship of codependency to chemical dependency is this: Codependency and chemical dependency are independent conditions that often co-exist. Being chemically dependent does not cause a person to develop codependence. Being codependent does not cause a person to develop chemical dependence. Many people suffer from codependence and chemical dependence at the same time. In any event, the presence of codependence can interfere with recovery from chemical dependence. By the same token, the presence of chemical dependence can interfere with recovery from codependence.

Appropriate treatment for a person suffering from chemical dependence and codependence would be:

1.         To bring the chemical dependence into remission first through a program of abstinence, detoxification, and the development of a recovery program;

2.         Treat severe codependency issues that increase the risk of relapse to chemical dependence;

3.         Treat the less severe codependence issues in late recovery after a stable sobriety program has been established.

Hopefully, the use of a system such as this will help guide us through the tangled jungle of terminology about codependence.

Read Gorski’s Blog On Family Involvement In Relapse Prevention

References:

Gorski, Terence T.. “Diagnosing codependence: a practical guide to understanding and treatment. (Special Section: Codependence)(includes related article).” Addiction & Recovery. 1992. Retrieved July 03, 2010 from accessmylibrary: http://www.accessmylibrary.com/article-1G1-13360084/diagnosing-codependence-practical-guide.html

Gorski, Terence T.. “Do Family of Origin Problems Cause Chemical Addiction?: Exploring the Relationship Between Chemical Dependency and Codependence” [Paperback], Herald House/Independence Press, Terence T. Gorski (Author) ON THE INTERNET: http://www.amazon.com/Family-Origin-Problems-Chemical-Addiction/dp/0830905448

Wikipedia, Codependency: ON THE INTERNET: http://en.wikipedia.org/wiki/Codependency

11 Responses to Diagnosing Codependence – A Practical Guide

  1. Suzanne Smith, FNP-BC says:

    This is good. We need an improved definition of codependency. However, I have always felt that the definition becomes vague with the use of “a cluster of symptoms and maladaptive behaviors.” If the definition could include the emotions of shame, guilt, and/or inadequacy, etc. the definition could be more specific.
    The behaviors/actions of the codependent are an attempt to achieve identity and self esteem but the behavior is rooted in shame and guilt.

    • Terry Gorski says:

      I am very interested in your idea of including shame and guilt. In mind, GUILT is the feeling that results from the belief that we have done something wrong. (i.e. I am acting against my own values).
      Nathaniel Brandon had suggested that there are two types of guilt.
      EARNED or LEGITIMATE GUILT is experienced when a person actually violates a legitimate value. UNEARNED GUILT is experienced when we are acting on legitimate or health needs, but we have come to believe that this wad “The wrong thing to do.”
      SHAME is the emotional response that we are something or somebody that is basically flawed and marked Ina way that their flaws are visible and they are constantly being judged, restricted, and ostracized by society and other people.
      Guilt is more personal where shame is more social. The definitions of shame and guilt are difficult and controversial.
      Please suggest specific language for how to include this in the definition and we’ll see if it can fit into the framework
      Thank you for the comment and the idea

      • Terry Gorski says:

        My style is to construct operational ideas of diagnostic criteria starting on a general principle and then moving to the more concrete and specific manifestations of that principle v

  2. Hi! This post could not be written any better! Reading through this post reminds me of my
    good old room mate! He always kept chatting about this.

    I will forward this post to him. Pretty sure he will have a
    good read. Many thanks for sharing!

  3. […] Check out Alanon and find a therapist knowledgeable in codependency. […]

  4. Guy Lamunyon says:

    DSM declined to include codependency as a disorder despite Tim Cermaks book DIAGNOSING AND TREATING CODEPENDENCY. There were so many symptoms that ANYONE could be said to have codependency.

    • Terry Gorski says:

      Janet Woititz and ACOA
      Codependency is anything you can get away with.
      Tim Cermak’s Criteia were specific compared to Janet Woititz, God rest he soul. She said more than 100% of the US population in codependent because you have to count addictive organizations, including the government, as people.
      She was a wonderful person and an interesting and compelling speaker who helped many people.
      http://www.drjan.com/janbio.html

    • Terry Gorski says:

      Janet Woititz and ACOA

      Codependency is anything you can get away with.

      Tim Cermak’s Criteia were specific compared to Janet Woititz, God rest he soul. She said more than 100% of the US population in codependent because you have to count addictive organizations, including the government, as people.

      She was a wonderful person and an interesting and compelling speaker who helped many people.

      http://www.drjan.com/janbio.html

      • Terry Gorski says:

        Having lived through the codependency era, all I can say is we had a great opportunity to do some serious good for people damaged by be raised in abusive families, and we lost that opportunity due to sloppy thinking.

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