Validity Of The Concept Of Codependency Sociology Essay

Published Date: 23 Mar 2015

Early discourse regarding chemical dependency gave rise to the enigmatic concept of codependency. Codependency quickly became diagnosed in the form of a personality disorder, a disease and a family addiction. However, there is a lack of empirical evidence supporting the concept of codependency as an official diagnosis. Feminist criticism has further contributed to the reduction in popularity of the disease model.

The following literature review will provide an overview of the concept of codependency. It will outline various definitions of codependency found within the literature. These will then be compared with feminist alternatives to the concept of codependency such as "connectedness" and "overresponsibility". Traditional codependency treatment is heavily influenced by proponents of the concept that "alcoholism is a disease" and this literature review aims to investigate those treatments.

Central to the codependency debate is the lack of empirical evidence to support any one definition for the condition. This allows sceptics to question the validity of the concept of codependency. This review of codependency literature thoroughly explores the studies conducted in combination with any scholarly critiques of those studies. As the majority of studies were conducted during the 1990s, the inclusion criteria for this review are not constrained to contemporary literature.

There is a remarkable lack of research into the link between same-sex relationships and codependency. For the purposes of this literature review, and in keeping with the studies conducted on heterosexual married relationships, the codependent will be referred to as "she" and the addicted partner will be referred to as "he".

Definitions of Codependency

The codependency model construes characteristics associated most commonly with women, e.g. caring, nurturing, sustaining relationships, in an entirely pathological way and urges women to self-define on this basis. The search for an agreed definition of codependency is the subject of much disagreement, despite many definitions being proposed within the literature.

According to a study by Dear, no one definition has been empirically derived (2002: 47). The definition of codependency depends on what situation is being described and on the motivation of the person using the term. In treatment terms, codependency is considered one of the most frequently diagnosed concepts despite inadequate research into the model.

In 1991, a review of codependency literature for a core meaning of codependency found six different definitions (in Harkness and Cotrell, 1997: 473-474).

An emotional, psychological, and behavioural condition;

An obsession with interpersonal control;

Learned self-defeating behaviours;

Suffering connected with attending to others;

An addictive disease;

A preoccupation with others characterised by extreme dependency.

According to Lyon and Greenberg, 96% of the general population in the United States has met the loose conditions for codependency at one time or another (1991: 436). It could be argued that everyone who is around an addicted person is considered a codependent.

Below are a few definitions and symptoms derived from codependency literature.

Codependency as a Relational and Behavioural Concept:

This is an example of dependence on addictive behaviours and a need for approval from others to find safety, self-worth, and identity (Anderson, 1994: 678). The term represents any individual involved in a dysfunctional or abusive relationship (Lyon and Greenberg, 1991: 436). This definition applies when a person displays an excessive dependence on other people for approval and identity.

Dear outlined other relational or behavioural codependent traits (2002: 47). These included the impulse to accommodate the needs of others ahead of one's individual needs; participation in self-destructive interpersonal behaviours such as "care-taking" (taking responsibility for controlling another person's conduct); and "rescuing" (taking responsibility for the consequences of another person's irresponsible actions).

Codependency as a Diagnostic Entity:

This perspective diagnoses codependency as a primary disease which manifests itself in every member of an addictive family. Codependency has been defined by scholars as pathological behaviour, and it is considered to be worse than the addicted person's disease of addiction (George et al: 1999: 39; Schaef, 1986). Within this perspective, codependency is a curable diagnostic entity comprised of a predictable beginning, course, and outcome.

Proponents of the diagnostic entity concept claim that a learned predisposition to enter into addictive relationships develops in childhood. Cermak in Anderson (1994: 677) contends that codependency is eligible for addition as a personality disorder to the Axis II Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). He further states that a dependent personality disorder illustrates many features of codependency.

Codependency from a Family Systems Perspective:

This is a pattern of coping which advances because of prolonged exposure to a dysfunctional family. Dysfunctional family rules cause difficulties in expressing thoughts and feelings openly (Lyon and Greenberg, 1991: 436). This perspective contends that enhanced family functioning needs the resolution of the addict's problem as well as treatment for the family members' codependency (Dear, 2002: 47).

The family systems approach reflects a pattern of chronic and pathological behaviour allegedly caused by having a parent or partner who suffers from addiction (George et al, 1999: 39). The term codependent originated in the Alcoholics Anonymous (AA) program. It was then extended to groups such as Al-Anon, CoDA and Al-Ateen.

The word codependent interchanged with the terms co-alcoholic and co-addict to label a family member or anyone who is negatively entangled with an addicted person (Lyon and Greenberg, 1991: 435). The Adult Children of Alcoholics movement adopted the concept of codependency in the 1980s. They extended the application of codependency to anyone who grew up in an alcoholic or dysfunctional family.

Codependency from a Psychodynamic Perspective:

From a psychodynamic perspective, codependency is construed to be a maladaptive way of relating to others. It is characterised by an intense certainty in individual powerlessness and the dominance of others, and a shortage of open expression of feelings. Other indications are extreme efforts to obtain a sense of purpose, identity and appreciation of self.

Cullen and Carr expand this further by including a desire for fulfilment through engaging in personally destructive "care-taking" relationships (1999: 506) which involve high levels of denial, inflexibility, and numerous attempts to control the relationship (Zelvin, 1999: 14).

Codependency from a Feminist Perspective:

When the codependency concept first emerged, it described psychological, emotional, and behavioural problems displayed by the partners, and consequently the children, of alcoholics who unintentionally "enabled" continuance of the drinking problem rather than facilitating recovery. It replaced the less comprehensive terms "co-alcoholic" and "enabler" (Cullen and Carr: 1999: 505).

On a socio-political level, feminist scholars regard codependency as yet another instrument in the oppression of women which fosters a denial of male responsibility (Anderson, 1994: 679).

This position asserts that when men are noticeably impaired, their female partners must also be labelled sick or pathological to retain the balance of power in the relationship.

Lyon and Greenberg highlight some of the symptoms located in codependency literature (1991: 436) which include:

extreme and unbalanced interpersonal relationships;

inability to endure being alone, combined with frantic efforts to avoid this;

constant and chronic feelings of boredom and worthlessness;

treating one's individual needs as subordinate to the needs of another;

overpowering desire for approval and affection;

external referencing;

dishonesty and denial;

low self-worth.

Irrespective of whether one truly possesses the qualities of alleged codependency, self-labelling promotes that one take on the characteristics of the label. It encourages examination of one's own behaviour and experiences as suggestive of these traits, and to engage in conduct which is consistent with the label. George et al. proposed that legitimate psychological trauma or pathology may progress because of social stigmatisation and the negative stereotypes connected with the label of codependency (1999: 40-46).

The codependency label tends to oversimplify multifaceted scenarios; it prevents change and growth; and it denies the uniqueness of a person. As individuals identify themselves with a label, they can assume that treatment centres know everything about their family, know about everything that is "wrong" with them, and know how to bring effective treatment. The codependent label is demoralising for the individual because it implants a fixed and negative understanding of the self and treatment.

Krestan and Bepko claim that codependency should be renamed "overresponsibility" and recognised as a positive impulse gone awry (quoted in Anderson, 1994: 682). "Overresponsibility" for others combined with "underresponsibility" for the self characterises codependent behaviour. Zelvin contends that codependency must be reassessed as a sequence of problematic efforts to connect instead of a failure to separate (1999: 9).

The feminist perspective thus offers alternatives to the traditional concept of codependency, and this literature review will discuss "overresponsibility" and "connectedness" with reference to the definitions of codependency outlined above.

Extension of the Disease Concept of Alcoholism to Codependency

The disease model concept has been intensely and cyclically debated for several hundred years. In the 1940s, the disease concept staged a comeback suggesting that alcohol itself was not responsible for any problematic drinking issues. The concept was rapidly adopted by the medical profession, popularised and then spread from America around the world. (Edwards, 2000: 96-98). Codependency was popularised in the same way with no scientific validation.

Edwards summarised the effects of the alcoholic disease concept (2000: 101-102). If alcoholism is considered to be a disease, alcohol itself is not the problem. Instead, the unfortunate few were predisposed to contracting the "disease". This concept initiated the "two population theory" which viewed alcoholism as an isolated disease which divided drinkers into two categories; "alcoholics" and "social drinkers" (Butler: 2002: 37).

The disease concept legitimised medical and clinical treatment. Insurance companies would now pay claims if alcoholism was diagnosed as a disease. Once a funding system was put in place which ensured a constant flow of alcoholic patients, it can hardly be coincidence that hospitals became advocates of the disease concept.

AA had become a common treatment method since its inception in the 1930s. This style of treatment then extended to codependency with groups such as Al-Anon being formed in the wake of the disease concept. The founder of AA, Bill Wilson, stated "we did not wish to get in wrong with the medical profession by pronouncing alcoholism a disease entity. Therefore we always called it an illness or a malady" (quoted in Kurtz, unpublished). The Oxford English Dictionary describes the term "malady" as a disease. Whether Wilson's comment aimed to intentionally mislead or not, it shows that AA's stance on the disease concept is as contentious as the disease concept itself.

The disease concept ensured that alcoholics now became 'the good guys' and could be welcomed back into society. Alcoholism was no longer considered a moral problem and alcoholics were no longer considered weak or deviant; it was not their fault an uncontrollable disease had engulfed them.

In other words, the disease model excuses men from their alcoholism and their corresponding "underresponsibility" in a relationship. The disease concept of codependency reinforces this belief by claiming that women are "sicker" than men inflicted with the disease of alcoholism.

Women are deemed pathological for reacting with the culturally conditioned feminine response of becoming the over-functioning person in a relationship with an under-functioning person.

All of Jellinek's data (the main proponent of the disease concept of alcoholism) was based on information obtained from a small group of AA members, of which he eliminated all questionnaires filled out by women because their responses differed immensely from the men's (Fingarette: 1988: 18-19). From a critical standpoint, Jellinek's research was inadequate in proving the disease concept of alcoholism.

In the 1970's, Edwards and Gross proposed the concept of an "Alcohol Dependence Syndrome" which resulted in a new worldwide Public Health Approach (1976: 1058). This has dismantled the disease concept of alcoholism. It is not a disease; rather, it is a development of severe dependence.

Once the concept was dismantled, treatment for "alcoholism" changed from a predominantly clinical response to a social, community-based response. By disproving the disease concept of alcoholism, this casts doubt on the context in which the disease concept of codependency developed.

Application of the Disease Concept to Obsessive Compulsive Disorder

The codependency model is frequently used with families having one or more chemically dependent or otherwise addicted individuals (Cooper, 1995: 272). Cooper broadened the population and applied this model to families having one or more members with Obsessive Compulsive Disorder (OCD) and emphasised how families become enablers through no fault of their own. Cooper observed the detrimental impact codependency has on their lives, calling relational codependency a "dysfunctional behaviour" (1995: 272).

Cooper notes that OCD, like chemical addictions, is all encompassing. Family members become inextricably bound to the suffering individual's illness; this manifests in divorce, separation, chemical abuse, and academic problems for younger family members.

Family members demonstrate codependency of those with OCD in a myriad of ways, most often succumbing to the affected individual's requests for rituals. The rituals are often lengthy and time-consuming and significantly disrupt family life (Cooper, 1995: 272). For the purposes of her study, Cooper acknowledged that codependency was multidimensional, pathological, stress-induced, and, most significantly, a disease. The family dynamics of codependency are the neglect of personal needs, being out of touch with one's own experience, and having a high tolerance for extremely inappropriate behaviour (Cooper, 1995: 272). Additional elements of Cooper's disease model are feelings of helplessness, shame, depression, and anger.

Disease Model Versus Feminist Perspective of "Overresponsibility"

Asserting that codependency is a disease removes the likelihood that the codependent woman will pursue other, potentially more empowering methods of remedying her situation (Peled and Sacks, 2008: 390). According to Anderson, the "casual diagnosis" of codependency as a disease is harmful to those with other, valid disorders, as they are likely to place all or most of their issues under the umbrella of codependency (1994: 678). The disease model articulated by Schaef asserts that codependency has a predictable onset, course, and outcome (1986: 7), but she offers insignificant empirical evidence to support this contention.

The evidence that supports the disease model focuses on wives or partners of chemically dependent men. The social mechanisms of medicalisation, however, are inordinately harmful, effectively controlling women by framing the forms of female resilience as illness (Peled and Sacks, 2008: 391). More importantly, the disease model of codependency ignores the so-called codependent person as an individual, failing to acknowledge his or her personal and subjective experiences.

There is a complex web of experiences, interpersonal processes, and psychological dynamics that inform women's self-perceptions as being partners of addicted men. In their qualitative study of women living with alcoholic partners, Peled and Sacks discovered certain dominant themes from the results.

These were the strength shown by the women; the acknowledgement that their husband's issues were deviant and problematic; and their reluctance to display a victim mentality, even when they are consistently abused by their husbands (2008: 391).

This suggests that women who are widely perceived as codependent have much more pressing issues than their codependency. They do not admit being victims of domestic violence. A common theme in the women's experiences was a normative upbringing, courtship, and marriage that evolved into a relationship with a problematic partner.

Though the study did outwardly confirm the tendency for codependent women to feel overly responsible for others whilst taking comparatively less responsibility for their own health and wellness, the feminist critique of the "overresponsible" and "underresponsible" paradigm is largely confirmed by this study (Peled and Sacks, 2008: 392).

The women were clearly socialised to value the needs of others over their own needs, feeling excessive guilt when investing time or energy in self-care.

Given these social norms, women who are in a relationship with an ill or needy partner will inevitably fall into a codependent diagnosis. The disease model of codependency frames ignorance of self-care as automatic and unrecognised yet the results of this study were glaringly inconsistent with that assertion. The participants universally demonstrated awareness of their neglect of personal needs.

The researchers recommended that the codependent diagnosis be dismantled. Noting that the participants too often believed they were merely an instrument in their husband's addiction, a belief facilitated by codependency theories, Peled and Sacks called for greater emphasis on personal experience and empowerment when counselling women living with alcoholic partners (2008: 395). The goal of treatment, the authors assert, should be geared toward helping women find other paths toward self-fulfilment, beyond the provision of service to others.

Sharpe and Taylor conducted a study of how identity variables such as self-esteem and peer relations relate to intimacy issues such as love and codependency in college women who are or have been victims of domestic violence (1999: 165). The researchers acknowledge how socially constructed ideas of romance (and the feminine role within that romance) promote selfless devotion to the partner that can be considered codependent.

The conditions fostered by a disparity between one's self-identity and the achievement of intimacy are also labelled codependent. Aligning closely with the Peled and Sacks' study, these results demonstrate that strength and personal identity are dominant themes in socially embedded female personalities that could easily receive a codependent diagnosis. This counters the disease model of codependency that highlights the affected person as being unable to define themselves in the absence of their partner.

Relational Concept of Codependency and the Feminist Application of "Connectedness"

Gender roles are significantly influential in the relational model of codependency, though they are only modestly recognised in the empirical literature supporting the relational theories.

Aside from feminist criticism of the relational model, studies have asserted that the relational model largely ignores the human need for connections (Townsend and McWhirter, 2005: 191). In short, when individuals do not meet their needs for lasting, functional, social connections, there is a negative impact on the health and wellness of these people, with their entire worldviews being shaped by an absence of interpersonal connection. The resulting separation results in a partial or total lack of social supports. This lack of social support produces numerous negative consequences for the disconnected individual.

The relational model construes interpersonal connections as facilitators of codependency (Anderson, 1994: 677). Townsend and McWhirter conducted a thorough review of over five hundred studies dating after 1984 containing the word "connections" in an effort to discredit the notion that human beings aim ultimately to be independent, self-sufficient, and, by extension, socially disconnected (2005: 191). Thus, interdependence and communality are positive notions within human developmental literature but become less so during the young adult and later life stages.

Townsend and McWhirter identified that crucial components of psychological health are the sense of well-being and safety that stems from interpersonal connections, motivation to operate within the boundaries of a relationship, an increased awareness of self-worth stemming from connections, and the desire for additional connections (2005: 192). From a cultural perspective, Western discourse places considerably more emphasis on individual autonomy, countering the notion that connectedness is integral to development after childhood.

Townsend and McWhirter contend that "by definition, codependency has been characterised as a risk factor for individuals and their network of relationships" because it suggests that "too much" connection, or association, with others is psychologically damaging (2005: 192). The disease model and Cermak's attempt to include codependency in the DSM-III-R essentially links interpersonal connections to addictions (quoted in Anderson, 1994: 677). Codependency literature closely links connectedness with dysfunction.

The loss of connectedness, however, is detrimental to psychological health, rendering relational constructs of codependency not only potentially invalid but also harmful. Significant research by Townsend and McWhirter (2005) indicates that those experiencing bereavement benefit from relational networks. Ironically, the "codependent" interpersonal connections facilitate healing.

Connectedness is defined by a number of interlinked variables, including embeddedness, engagement, companionship, and attachment, all of which emerge to varying degrees in codependency literature. The most empirically valid definition of connectedness reflects active involvement with another person, group, or environment (Ibid: 195). This involvement, used positively, should promote comfort, well-being, and the reduction of anxiety. While codependency is rarely framed as positive, it remains that the active connection is the same in connectedness and codependency discourse.

Gender Roles and the Feminist Application of "Connectedness"

The manner in which the relational literature highlights codependent behaviours as addictions and disease is particularly problematic as these are the same behaviours that are assets in developing interpersonal connections (Townsend and McWhirter 2005: 193). Codependent behaviours are just that; they are behaviours more indicative of gender-related subordination roles in relationships than they are indicative of a disease. The ignorance of gender roles as a significant informant of codependent behaviours is one of the deepest flaws in the relational codependent literature, as most of the empirical evidence relates to male-female relationships, with the man being chemically dependent and the woman enabling his behaviour through codependent behaviours.

The role played by power differentials in the relational literature is a significant one, with far too little credence afforded to the lack of power had by women in heterosexual relationships.

Discussion of gender equality, patriarchy, and a long history of oppression are notably absent from the literature supporting codependency as relational and disease-related (Anderson, 1994: 681). The notion of the "separate self" is dominated by a Western male perspective, challenging the validity of connection-cultivating behaviours.

There are fundamental differences in the way women and men engage in their interpersonal relationships. Townsend and McWhirter assert that the central principle in female socialisation is relational connections (2005: 195).

This principle is comparatively minimal in influencing male socialisation. Conceivably, women tend to both be more connected to others and value that connection more so than men.

"Overresponsibility" and Too Many Definitions of Codependency

The overresponsibility and underresponsibility paradigm is significant with respect to connectedness as it frames flawed attempts at connection as the prime culprit in birthing codependency; this is in contrast to the literature that condemns over-connectedness as the foremost catalyst for codependency (Zelvin, 1999: 9).

Using a sample of seventy-six male and female undergraduates, Cretser and Lombardo investigated the level of codependency between students having an alcoholic parent and those who did not (1999: 629). They hypothesised that children of alcoholics would have a notably higher level of codependency. This hypothesis was glaringly unconfirmed by the study.

The participants who had alcoholic parents received lower codependency scores than those with non-alcoholic parents (Cretser and Lombardo 1999: 629). These findings are significant in that much of the codependency literature centres on the dysfunction of the relationships marked by the condition.

Cretser and Lombardo acknowledged that codependency is thought to originate in dysfunctional families in which children overcompensate for parental inadequacies. They become "overresponsible" for others and "underresponsible" for themselves, and consequently develop an excessive sensitivity toward the needs of others (1999: 629). Their research findings parallel the previously reviewed literature that cites how a large percentage of the population meets the criteria for codependency (Cretser and Lombardo 1999: 629; Lyon and Greenberg, 1991: 436).

In contrast to the feminist debate regarding codependency, the researchers found that there was no significant variation in codependency according to gender and age. While they use their findings to accuse college counsellors of recognising symptoms of codependency in all students, their findings could also warn of the over-diagnosis of codependency.

Anderson, in her 1994 article entitled "A Critical Analysis of the Concept of Codependency", contends that the sheer number of diagnoses of codependency precludes the integrity of the codependency diagnosis. The entire Irish nation could be accused of exhibiting codependent traits for being "overresponsible" in bailing out the "underresponsible" banks and thus eligible for codependency treatment. It is alarming that an entire nation should qualify for treatment on the basis of such contentious and over-inclusive symptoms.

The Cretser and Lombardo study supports Anderson's assertion that codependency is over-diagnosed to the point of invalidity, as even the children of alcoholics - the population who comes only a close second to women in abusive relationships in terms of meeting codependency criteria - do not demonstrate a significantly higher incidence of the condition.

An alternative study focusing on the children of alcoholics highlighted how the codependency model, specifically the disease model, emphasises how children are developmentally impeded from achieving appropriate and normative social functioning due to their parents' addiction (Sher, 1997: 247). Theoretically, the need to take care of parents during childhood fosters codependency later in life, manifesting most frequently as denial, depression, hyper vigilance, and other seemingly fragmented characteristics. Sher questions the validity of the concept of codependency and states that studies

...tend to have serious methodological limitations, examine only a narrow aspect of purported codependent characteristics, and fail to demonstrate whether the concept of codependency has additional explanatory value (1997: 247).

Sher's conclusions align closely with Anderson's assertion that women who are deemed codependent are merely applying normative coping behaviours to their situation (1994: 680).

Fischer and Wampler stress that children of alcoholics consistently emerge as strong individuals who are labelled "resilient" (1994: 469). This is merely a reflection of the limited knowledge regarding the range of forces influencing a child's socialisation and informing his or her experience. For instance, Ferrari and Olivette (1993: 963) studied the hypothesis of a link between authoritarian parenting styles and the onset of codependency during adulthood. They concluded that no such link existed.

Asher and Brissett wrote the first research-based article on codependency in 1988. The researchers claimed to have proven a link between two common dimensions of codependency from the responses of women in their study namely "notions of care-taking and pleasing others", and "affliction by association with a chemically dependent person".

Arguably, the behaviours of care-taking and pleasing others should be attributed to external causes, such as the patriarchal hierarchy that places women in the position of subordination. From this feminist perspective, their study does not prove conclusively that "care-taking" and "pleasing others" are symptoms of the codependency concept. The second common feature of codependency, namely the "affliction by association with a chemically dependent person" is simply a reflection of the sample used in the study. Contrary to how the researchers interpreted these results, this does not prove a link between codependency and partners of alcoholics. The women had to be married to an alcoholic for inclusion in this study, and meeting that criterion does not conclusively link the two.

Undoubtedly, family systems are comprised of intertwined individuals through which one person's behaviour affects all other family members to a certain degree. The literature suggests, however, that countless factors influence the system.

Simple predictions of codependency are insufficient in addressing all issues in families dealing with disorders, addictions, or any other source of obstacles to which the codependency definition is so quickly applied. By extension, the recovery process for codependent families presents a range of problems.

Feminist Critique of Codependency as a Psychodynamic Concept

The feminist perspective of codependency has become the most popular framework for highlighting the flaws in the codependency movement. Behaviours that are widely perceived as codependent are indicative of a subordinate role in a relationship (Herndon, 2001: 13).

Women play the subordinate role most often in patriarchal cultures. Socially encouraged female conduct is then deemed "codependent". Passivity, compliance, lack of initiative, and a fear of asserting oneself are all integral to the codependent disease model and characterise the individual playing the subordinate role in a relationship.

The traditional, psychodynamic approach to codependency reflects the suffering of the partner of an addicted person (Peled and Sacks, 2008: 390). It claims that codependent persons choose problematic partners and contribute to the addicted partner's addiction. The individual who is chemically or otherwise addicted then does not shoulder the bulk of the blame, as the illness exists on a systems level; this system could be a family or a partnership (Peled and Sacks, 2008: 390).

The entire functioning of the system then becomes centred on the disease. Systems theories, however, fail to acknowledge power differentials with respect to gender roles and the destruction had by the addicted individual on the entire system (Peled and Sacks, 2008: 390). The family systems perspective claims that a woman remains with an addicted partner because she, herself, is sick. This ignores the social expectations of the female role, women's economic dependence, and the existence of a support network outside of the relationship in question.

Normative, appropriate, and caring behaviours can easily be termed codependent. This particularly applies when a non-addicted person displays them towards an addicted person (Peled and Sacks, 2008: 391). The woman's normal attempts at coping with her situation qualify her for a codependent diagnosis (Anderson, 1994: 681). The "overresponsible" and "underresponsible" paradigm implies the more the wife of an alcoholic man does, the less he will do in response to her efforts. Pathologising this behaviour negates valid gender roles which frame the woman as care-taker.

Clark and Stoffel conducted a study in 1992 to determine if codependent persons are drawn toward care giving professions. This has been suggested in the literature as "care-taking" and "rescuing" could be considered traits within the care giving professions. The results showed that students in the non caring profession were more codependent than students in the caring profession. As there were more men on the non caring course, this could mean that the women held a subordinate position within the course indicating that power influences the amount of codependency.

This opposite than predicted result disputes codependency theorists' assumption that codependency is an internal condition. Conversely, it is an external condition affected by how women are viewed within society and a lack of power as a result of subordination.

Traditional Codependent Treatment

Recovery models for codependency operate from the perspective that it is a disease and an addiction within itself. Cooper asserts that these groups follow the stages of the twelve-step model for AA.

These stages include the admission that one has a problem; the assessment of the problem; taking of responsibility for one's behaviour; detachment from the struggle to control or be enmeshed in another's behaviour; and reintegration.

This model for recovery from codependency aligns closely with the literature linking codependency with over-connectedness (Townsend and McWhirter, 2005: 191), as separation is an integral stage to the healing process.

While Cooper frames the detachment phase as a means of letting go of that which cannot be controlled, the letting go process is also socially isolating (1995: 272). The goal of recovery, Cooper asserts, is to help codependent individuals gain greater self-respect and improved ability to care for themselves; she highlights that treatments for codependency should focus on avoidance of overresponsibility for others and increased responsibility for personal needs.

The process of detachment is essentially marked by the breaking of connections with the dysfunctional partner. However, treatments for codependency typically take place in a group environment. Groups may be used to mitigate the negative impact from breaking other supports through the treatment process.

Groups often focus considerably on education regarding codependency first and foremost, deeming codependents to be in dire need of healing (Cooper, 1995: 274). There is an overall absence of empowerment goals in treatment programs for codependency and a converse overemphasis on victim mentality and a lack of power.

Al-Anon programs articulate Step I as follows: "We admitted we were powerless over alcohol - that our lives had become unmanageable" (quoted in Herndon, 2001: 7). There is, by extension, a significant paradox in twelve-step programs, as they should aim to empower their members but instead force them to admit powerlessness. The role played by powerlessness is a strong one in treatment programs, with the relinquishing of control to a higher power consistently emphasised throughout the process (Herndon, 2001: 7).

While proponents of the twelve-step programs often highlight that references to "God" and "Him" are not meant to ostracise those who are not Christian, it is irrefutable that such references liken the higher power to a man, reaffirming patriarchal perceptions of spiritual guidance.

For individuals of both genders, the twelve steps place considerable focus on shortcomings instead of achievements. Undoubtedly, it is difficult to build power when one is constantly focused on one's failures.

The central problem with twelve-step recovery from codependence is that all cultures at present are patriarchal in nature. Power is equated with masculinity and subordination is linked to femininity. Anderson asserts that debate on gender equality is blatantly missing from codependency treatment programs (1994: 681), and women become framed as inherently diseased.

Herndon suggests that women have more ease in admitting powerlessness than men do (2001: 10). She also stated that Wilson aimed to subdue overblown egos before healing could begin. However, while this was necessary for the elite, white men who were AA's first members, it is not required for women as subordinates.

Women in twelve-step programs must turn over their will to a masculine higher power to begin the recovery process. From a feminist perspective, women have already had their power and autonomy stripped away through centuries of systematic oppression.

A treatment method that demands they relinquish power even further will reduce the strength needed for recovery. The extreme gender disparity in codependency literature is indicative of the gender-based power differential, and recovery programs often exacerbate problematic gender roles even further by focusing on "enablers" as facilitators of the addiction.

Codependency treatments focus on the regaining of one's identity, apparently lost due to over-focus on and over-responsibility for another person (Herndon, 2001: 12).

Outside of a treatment perspective, the framing of codependency as a disease without sufficient psychodynamic dialogue regarding the causes of the condition is a problem in and of itself. Herndon corroborates Anderson's position and highlights the gender issues inherent to the disease-model of codependency (2001: 13). Gender inequality, which is not a medical condition, is clearly a crucial cause of what qualifies for dysfunctional, codependent behaviour.

Codependency, from a feminist perspective, is not treatable because it is consistently and culturally reinforced. In framing traits that are female as pathological without grounding any theories in empirical evidence, codependency is little more than a euphemism for internalised oppression. Treatment from a feminist perspective requires society at large to recognise the social conditioning of women to be carers, nurturers and subordinates, instead of internalising these traits as codependent.

Codependency Treatment from a Feminist Perspective

The literature clearly reflects a need for the disease model of codependency and the aligning models for treatment to be dismantled. However, that does not suggest that women living in dysfunctional "codependent" relationships are not in need of therapeutic support.

As the Peled and Sacks study suggests, women in relationships with addicted men do not suffer from a lack of strength. Sharpe and Taylor similarly concluded that college women in abusive relationships do not suffer from a lack of self-esteem. This counters common models of treatment for codependency that encourage women to see themselves as weak against their codependency and concurrently weak in their relationships.

While the goals of empowering women through gender equality are valid as a modality of treatment, the above studies suggest that women who could be labelled as codependent already feel empowered and are self-confident.

An additional issue in treatment programs for codependency is a lack of consideration for individual experience. Anderson encourages that treatment programs do not label women as codependent or otherwise but, instead, to emphasise sources of inner strength as deeply personal (1994: 682). Self-advocacy and empowerment goals are certainly valuable. It could be further argued that targeting that self-advocacy toward the cultivation of healthy gender roles is critical. Finkelstein states that most treatment programs were:

designed initially by and for men; little attention has been paid to the different emotional, social, and economic realities of women's lives. One reality too frequently ignored by funding agencies and treatment providers has been that many women who need treatment have child-rearing responsibilities, and some are single parents" (1994: 7).

This is certainly the case for the origins of AA, which influenced codependency treatment groups such as Al-Anon, CoDA and Al-Ateen.

Women living with abusive or addicted partners already feel burdened by additional responsibilities and are unlikely to have time to invest in treatment. This is indicative of a lack of time and resources. It does not establish it as a choice to ignore the value of the self.

Finkelstein also recommends removing the term "codependency" from treatment discourses altogether (1994: 7). This asserts that the treatment practice of encouraging codependents to break connections can be personally and socially detrimental.

In line with Anderson's assertions that codependency has become too broad to be an effective or meaningful diagnosis (1994: 679), Finkelstein cites that codependency has "been so expanded as to lose much of its theoretical and practical meaning" (1994: 8).

The negative framing of dependency impedes the deeply entrenched feminine behaviours of nurturing and care-taking, and blurs the distinction between healthy relationships and those that are dysfunctional.

Codependency Treatment from a "Strengths" Perspective

Relational strengths are different from personal strengths (Finkelstein, 1994: 9). The literature suggests that women labelled "codependent" have high levels of self-esteem and self-perceived strengths. It would be recommended that relational strengths should be an asserted goal during treatment, using Rogerian principals, Motivational Interviewing and even Cognitive Behavioural Therapy.

Treatment aiming to boost relational strengths for women in relationships must consistently acknowledge the woman as the agent of change for herself (Finkelstein, 1994: 9). It could be beneficial to utilise the Transtheoretical Model or Stages of Change Model as advocated by Prochaska and DiClemente in 1986, which would assist with possible ambivalence on the part of the "codependent". The woman must perceive herself as the agent of change for her own behaviours. Yet, she should not perceive herself as the change-agent for her partner.

The concept of Motivational Interviewing, developed by Miller and Rollinick in 2002, is a promising treatment method. It aims to build rapport, promote change talk, and encourage commitment language from the client. It expands Carl Rogers' humanistic theories about people's capabilities for exercising change through a process of self-actualization.

It is essential that the counsellor is "congruent", has "unconditional positive regard" for the client as well as showing "empathic understanding" (Rogers, 1980: 115-116).

Extreme emphasis on the past and the psychodynamic basis for codependency are problematic. Negative stories keep the woman stuck in a negative state (Finkelstein, 1994: 9). Conveying the possibility of change through personal messages of hope is essential, as is the acknowledgement of how healthy social supports can aid in the facilitation of that change. Similarly, the validation of personal experiences is critical in allowing the woman to move forward.

The role played by gender in relational strength-building treatment is a significant one, and women are largely unaware of how socialised gender roles inform their relationships. Authors White and Tyson-Rawson emphasise that gender crosses racial, class, and place-related boundaries, and any effective treatment geared toward promoting gender equality must acknowledge the diverging experiences of men and women (1995: 253).

Arguably, medical models such as those promoted in the DSM-III-R are more damaging for women who are not sufficiently acknowledged in the empirical literature in terms of gender-specific experience. Strength-based solutions link the existing strengths with the existing problems. Very often, these strengths will focus on fortifying social connections rather than breaking codependent connections.

The individual is more empowered to take control if the issues are externalised rather than internalised like the disease concept advocates. For example, a woman who is living with an addicted and abusive husband is less likely to feel strong to change or relinquish her relationship if she views codependency as a disease that controls her (White, 2002: 271).

In removing the diagnostic labels and psychodynamic language, the affected individual becomes just that; she is an individual with unique problems, experiences, and strengths.

From a family-systems perspective, focusing on embracing and building upon connections without negating the self-empowerment needed by women in particular is a salient treatment focus for individuals deemed codependent. The traditional modalities for treatment of codependency focus on the breaking of connections and the promotion of isolated autonomy (Anderson, 1994: 682).

Townsend and McWhirter argue the codependency label needs to overhaul the way in which it frames dependence and connection and state that counsellors "who genuinely believe in the growth-promoting possibility of connectedness would serve their clients well (2005: 192).

Aligned with an emphasis on connections, focusing on the differences in gender-based and culture-based worldviews is concurrently crucial and allows treatment to be more meaningfully integrated into the individual's life. Additionally, acknowledging the personal nature of the affected individual's experiences counters umbrella diagnoses such as codependency.

Conclusion

The concept of codependency as a personality disorder is markedly broad, so broad that the validity of the diagnosis is weak, and it has not been accepted for inclusion under Axis II of the DSM-III-R.

The disease concept of codependency condemns all women as diseased, and negates the influence of socialised gender roles. The feminist perspective has dismantled the notion that codependency is a disease, in addition to the other definitions, found within this literature review. Similar to the aftermath of the dismantling of the concept of alcoholism as a disease, a community-based response to codependency should take place.

There is a lack of meaningful literature related to same-sex relationships and codependency. In a lesbian relationship, neither partner would be considered a subordinate due to equal gender status. If one or both women display socially sanctioned feminine traits, they could be deemed codependent despite the lack of gender based power issues found in heterosexual relationships. Further research into the link between codependency and same-sex relationships would be recommended.

Emerging from feminist criticisms of codependency is the notion of codependency as a tool for female oppression, essentially forcing blame onto the female partners of sick men in order for men to maintain their balance of power when they are clearly the weaker link.

Gender roles in families construe women as the care-takers. The disease model and family systems perspective defines the socially constructed feminine trait of caring for an addicted partner codependent. The feminist perspective refutes this as the role of "care-taker" is socially sanctioned by a patriarchal society, and these traits are deemed pathological when the woman is "overresponsible" for an underperforming partner.

Overall, the literature reflects that the entire model of codependency is broad, unsubstantiated in empirical evidence, and grossly oppressive toward women.

The validity of the concept of codependency is in doubt, which also questions the validity of traditional treatment for codependency. Treatment programs for codependency that contradict the positive connections in an individual's life do more harm than good. Relational empowerment is a salient goal for addressing the negative attributes of construed codependent relationships. Emphasising the individual as unique and validating positive connections is paramount.