Case of Bill Jean
A Family Systems Approach to the Treatment of Codependency
The term codependence refers to a pattern of behavior in which the individual’s assessment of self-worth is based on external referents. Because the focus is outside of oneself, the co-dependent’s need for personal validation is often met by excessive caretaking of others to the neglect of himself/herself. The codependent underreacts to internal cues regarding feelings and situations and finds it difficult to make decisions and choices based on personal needs. The codependent demonstrates a pre-occupation with the behaviors and feelings of others, inappropriate levels of guilt when attempts are made to be assertive, fears of abandonment, and tremendous resistance and anxiety when feelings begin to emerge in therapy.
Within dysfunctional family systems, this over-functioning becomes acute as the codependent strives to compensate for another’s perceived, or actual loss of role functioning. Because this caretaking function is reinforced by the family system, it is unlikely that the codependent will experience enough conscious discomfort to initiate changes. The impetus for intervention will be more likely to occur around a life stage transition or the cessation of problematic behavior in a family member. At these times, the carefully nurtured balance of the family system experiences disruption, and unfamiliar, unpredictable demands create high levels of stress. It is at these times that the codependent faces the loss of familiar relationship patterns and may seek treatment on behalf of another family member. Because the family is so integrally bound in maintaining codependent behavior, family therapy is essential in its treatment.
Jean was such a client. Her marriage of 25 years was under extreme stress because of events surrounding her husbands’ decision to discontinue drinking after 20 years of active alcoholism. Despite the realization of her wish that he stop drinking, Jean reported in our first telephone contact that the family was “even worse,” referring to an increase in conflict between her husband and their 18-year-old son. She stated that at different times, both her son and her husband had threatened to move out. Jean noted that her physician husband had recently completed a 28-day inpatient program for alcoholism following an intervention by his colleagues. He had been sober for 6 months and was attending two Alcoholics Anonymous (AA) meetings per week. She suggested that counseling would assist her in “calming down” her son and husband. I requested that the entire family participate in therapy despite her misgivings over including her 21-year-old daughter and her husband. Jean agreed to ask everyone to come the next week.
Jean arrived at the first session accompanied by her husband, Bill, age 49; her son, Charlie, 18; and daughter, Amy, 21. Jean was a thin, intense, rather dowdy 48-year-ole homemaker, who looked older than her years. As she described her assessment of the problems at home, she tightly smiled at Charlie as if to check out her statements with him. She used the pronoun we to describe his persistent problems with authority figures. Jean noted that she frequently intervened in Bill and Charlie’s arguments in order to keep them from “getting totally out of control.” Often, she would spend hours speaking individually to husband and son, in order to “help them understand each other.” She was distressed by Charlie’s increasing reluctance to talk over his problems with her and his occasional flashes of temper where previously they had enjoyed a very close relationship. Jean stated sadly that “before, I could tell when he wasn’t happy because I knew what he was feeling even before he did.” She described how helpful and supportive Charlie had been in the past when her husband had “his problem.” Throughout her discourse, Jean referred only obliquely to her husband’s long, stormy relationship with alcohol and vigorously discounted my suggestion that she had also been affected to a great degree.
Throughout the first several sessions, Bill continued to take a rather passive role, glancing noncommittally in Jean’s direction when she was asked to comment on the marital relationship. He appeared to defer to her assessment of the difficulties between he and Charlie, except to note that they got along fine when they were alone together. When asked, Bill stated that his relationship with Jean had waned for many years and that he was unsure of what he felt now that he was no longer drinking. Observing the pained look on his mother’s face, Charlie interrupted his father and reminded him about the sacrifices Jean had made on behalf of the family. Bill responded by challenging Charlie to describe how his “delinquent behavior” had helped things. Jean immediately rushed to limit this first direct exchange between the two by reminding her husband that she had already spoken to Charlie about “how we are going to deal with our DWI (Driving while intoxicated) charge.” Amy remained very quiet throughout the first sessions, except to support her father’s comments about Charlie. She became tearful as he commented on the deterioration of the marital relationship, yet she was unable to verbalize any thoughts or feelings except to state “It just seems like everyone is so upset all the time now.”
In this beginning stage of therapy my goal was to hypothesize what function Bill’s alcoholic behavior had served for this family and what dilemmas and challenges were precipitated by its subsequent absence. During my exploration of the family’s behavior before, during, and after one of Bill’s drinking episodes it became clear that alcohol abrogated Bill’s discomfort with intimacy and closeness. He felt, and was perceived by the family as “more approachable” after several drinks. As his disease progressed, he frequently became enraged by his son’s oppositional behavior. Jean, terrified by glimpses of her own unacknowledged anger at her husband, became an expert in diminishing the intense feelings between father and son by rerouting communication through her. Bill’s periods of sobriety were accompanied by intense remorse and guilt, and he relinquished his role as husband and gather to Jean’s attempts to create the perception that everything was perfect. She appeared fearful of abdicating her role as family caretaker and increased her efforts to help by reinforcing the dependency of Bill and Charlie on her capable shoulders. As the stress increased at home, it was no longer punctuated by the tension-relieving cycle of Bill’s growing self-esteem and his demands for intimacy and closeness in the marital relationship.
These changes had severely compromised Jean’s coping mechanisms and ushered in a dawning awareness of her own feelings, which had been suppressed in the service of her role as caretaker. This role was being challenged by Amy’s impending departure to medical school and Charlie’s threat to move out. She felt as though these events were a sign that she was losing control through her personal inadequacies in making everyone happy. I discussed with the family some of the common dynamics for the newly recovering family and recommended they consider participating in family therapy for the next 6 months. My goals for Jean were to assist her to recognize her feelings, to support her efforts to decrease her controlling behavior, and to help her meet her needs for closeness within the marital relationship. These goals were complementary to our agreement that the overall goal of therapy would be to assist the family to meet the challenges of sobriety.
During the next three months, the family attended sessions on a weekly basis. Jean’s role as the primary spokesperson became more limited through my support of other family members’ contributions through circular questioning. The focus continued to be on creating boundaries between family members and encouraging direct communication. Jean was helped to relinquish some of her responsibility by reassigning it to other family members. The family was given several tasks for the purpose of intervening in triangulated relationships and cross-generational coalitions.
During one session, Jean was able to verbalize her fears that if she let go of her acknowledged control, the family “would explode.” She descried her wish to be taken care off yet how difficult it was to trust Bill’s request that she share her feelings as he had been urged to do in treatment. I supported Jean to verbalize some of her emerging feelings about past and present events in the safe environment of the family session. She became tearful and stated that she was terrified that Bill would lose his temper and get drunk. She was reluctant to share parenting responsibilities with him, stating that “the kids are all I have to make me feel like I’m worth anything….that’s why it’s so hard when they act like they don’t care about me.” Bill reiterated his desire to share more of the parenting, yet also acknowledged his ambivalence about seeing Jean more vulnerable and indecisive. Despite his wish to have her “share feelings openly” it was clear that everyone in the family was quite uncomfortable when Jean discussed her feelings of anger and sadness. Amy, seeing this as Jean abandoning her father, attempted to protect him by suggesting that her mother was “selfish.” Because this occurred in a family session, I was able to help the family recognize and talk about the anxiety that new behaviors had created for everyone. In order to assist the couple to move through this transition, I assigned them tasks where they “courted” each other in establishing a “new” relationship.
At the end of the third month, an anxious Jean reported that Charlie had been arrested for another DWI. As he moved beyond the guilty bravado in his description of this latest episode in an escalating series of misadventures, it became apparent that he was reacting in part to Jean’s growing autonomy. He had encountered her diminished attention as well as greater degree of accountability, from both parents, for his behavior. Jean was able to resist her first impulse to rescue Charlie, and with Bill’s support they confronted him about his irresponsible behavior and drinking problem. It was becoming clear that the shift in the family’s organization had revealed years of denial regarding Charlie’s out-of-control drinking. Early on, I had made participation in Alanon a prerequisite for Jean’s therapy, and it was at this juncture that her growing involvement with other mothers in this self-help community really paid off. Several months later, on follow-up, Jean revealed that she and Bill asked Charlie either to leave home or to get treatment for his alcoholism, and he ad chosen the latter.
During the last month of therapy, the sessions revolved around Bill and Jean. Amy had left for medical school with expressed relief that her participation in family sessions had ended. Charlie had angrily refused to participate as he viewed the sessions as “being just for my mom and dad anyway.” I spent most of the sessions working with the couple on their families of origin and helping them understand how their respective early experiences impinged on their marital relationship. As we worked on Jean’s genogram, she discovered that her father’s chronic absence was due to his alcoholism, which had never been acknowledged by her mother. In her role as her mother’s confidante, Jean’s earliest memories were of guilt and responsibility for failing to ameliorate her mother’s sadness and anxiety. In the absence of a viable marital relationship and her father’s advancing alcoholism, her parents had colluded to keep her at home to “take care of mom.” As the only child, Jean felt responsible for maintaining the tenuous equilibrium of her family. She was able to write a letter to her deceased father and in this way release some of her feelings of anger, sadness, and loss that she recognized she had displaced on Bill since her father’s death shortly after her elopement with Bill.
At the end of the contracted 24 sessions, Bill and Jean agreed to return for marital therapy to continue their exploration into the “silent years” as Jean termed the last 15 years of their marriage. She realized that her fragile sense of self was still vulnerable to Bill’s disapproval and that she still encountered difficulty in avoiding “catching everybody’s feelings like the flu.” Jean wanted to work on her relationship with Amy, however she recognized that this would require patience and understanding, since her daughter might not be ready to address their rather estranged relationship. She continued to struggle with control issues yet was able to recognize that the impulse to “make everything perfect” for everyone else coincided with her need to be perfect, lest she be abandoned. With the support of her Alanon group and marital therapy, Jean reported on follow-up, one year later, that “things were going well, not perfect.” She had recently been hired for a part-time position and was using her prodigious helping skills as a hot-line volunteer one night a week. She was able to recount several instances where she recognized control returning to her relationships and discovered that she was able to address the feelings beneath. Jean closed our phone conversation by relating her discovery that in her anxiety to avoid the “scary” feelings, she had also closed out the wonderful ones that she was not able to experience in her life.
Curry, C. (1992). A family systems approach to the treatment of codependency. In C. W. LeCroy, Case studies in social work practice (pp 92-95). Brooks/Cole Publishing Company.