“Codependency” is a word you hear a lot in recovery programs. From my experience—losing a beloved daughter to a heroin overdose and supporting a brother with severe alcohol use disorder—I believe that endorsement in some drug and alcohol treatment programs of the idea of codependency is actually a denial that substance use disorders (SUD) are medical diseases that require medical solutions.
Ideas related to codependency have been bounced around since the sixties and seventies, but the term’s popularity harkens back to a best-selling self-help book titled Codependent No More, published in 1986. In a general sense, it usually means that one person depends too much on another and fails to be independent enough, and the person being depended upon gets inappropriate satisfaction from the dependency of the other. Thus, both people are unwell. The idea in recovery programs is that the person with substance use disorder relies upon a family member who enables the addiction in various ways and keeps the addicted person from getting well.
There is no listing for codependency in the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association’s guide that defines and classifies mental disorders. It is not recognized as a form of mental illness like a mood disorder or a substance use disorder or anorexia. It’s basically just a popular idea that the 12-Step recovery community seized upon and twisted to fit its idea of SUD and how it should be treated, which includes the idea that addiction is a “family disease” and the family members who are not using have to be in their own program to recover from codependency and enabling.
When my daughter was struggling with her opioid use disorder, my mother became ill with myelodysplastic syndrome, a blood disease in which immature blood cells in the bone marrow do not mature and therefore do not become healthy blood cells. Symptoms include fatigue, shortness of breath, easy bleeding, and frequent infections. As her illness progressed, my mother required continual care and support of all kinds. My siblings and I were included in meetings with doctors and participated with my mother in decision making about her treatment. We provided transport to medical appointments, assistance with household tasks, and most importantly, love and compassion. We imposed restrictions and protocols to prevent infection, some of which she did not like. We insisted on installing a baby monitor in her room so that she could call for help easily if she needed it. We gently but consistently encouraged her to use the oxygen ordered by her doctor, which most of the time she resisted. No one told us that we were creating dangerous “codependency” with our mother.
When I look back at the course of my daughter’s illness and treatment, I wonder what the difference is. She needed help with treatment decisions, transportation, and during some periods required continual care. Sometimes we negotiated with her to encourage compliance with treatment rules. At times we would not allow her to use a car, determining it was unsafe for her and others. Nothing was more important to her than knowing that she was loved and that we would not give up on trying to help her get well. Yet we were told in more than one treatment setting that we were codependent, and therefore ill, and thus “had our own work to do” in a treatment program for codependent people like us. Worse, we were told that we were compromising her recovery because we were enabling her addiction and not letting her “hit bottom,” a dangerous concept because “hitting bottom” for people with OUD frequently leads to death.
Is this difference of viewpoint because recovery programs that have grown from AA/NA don’t really view SUD as a chronic, relapsing illness like other medical conditions such as lupus or diabetes or bipolar disorder, and thus conclude it shouldn’t be treated in the same way? Instead do they actually believe that SUD develops in a weak-willed person who is enabled by an ill person who gains satisfaction from the dependent person’s illness? I think so. While treatment facilities may call SUD a “disease” many do not treat it as a more typical mental or physical illness would be treated, but with pop psychology ideas like codependency.
With both my daughter and my brother, I was blind-sided by their illness and its virulence. My daughter died before my brother’s illness erupted. I knew very little about OUD when my daughter became ill and I grasped at solutions offered by people working in licensed facilities who I assumed knew what they were talking about. Several years later, when my brother’s SUD emerged, I rejected all suggestions of codependency and the implications that the patient is at fault for his disease and his supportive family members are making his illness worse. We are still supporting him with evidence based care—monitoring by doctors, medication, individual and family therapy with a qualified therapist, reasonable behavioral expectations, and love.