The Impact of Parental Codependency on Children with Mental Health Conditions

Home , Impulsivity, Parentification

THE IMPACT OF PARENTAL CODEPENDENCY ON CHILDREN WITH MENTAL HEALTH CONDITIONS

Angelus T.W. Dupree B.A. Augusta State University, Georgia, 2005

PROJECT

Submitted in partial satisfaction of the requirements for the degree of

MASTER OF SOCIAL WORK

CALIFORNIA STATE UNIVERSITY, SACRAMENTO

SPRING 2010

THE IMPACT OF PARENTAL CODEPENDENCY ON CHILDREN WITH MENTAL HEALTH CONDITIONS

A Project

Angelus T.W. Dupree

Approved by:

______, Committee Chair David G. Demetral, Ph.D., L.C.S.W.

______Date

Student: Angelus Dupree

I certify that this student has met the requirements for format contained in the University format manual, and that this project is suitable for shelving in the Library and credit is to be awarded for the Project.

______, Graduate Coordinator ______Teiahsha Bankhead, Ph.D., M.S.W. Date

Division of Social Work

iii

Abstract

THE IMPACT OF PARENTAL CODEPENDENCY ON CHILDREN WITH MENTAL HEALTH CONDITIONS

Angelus Dupree

The purpose of this research project is to explore the prevalence of codependency among parents with children that suffer from mental health issues. Children with mental health conditions can be uniquely challenged by the behavioral tendencies of their caregivers.

There is a lack of current literature on the correlations between parental codependency and children suffering from mental health conditions. This research project consists of the background of the problem, and investigation of the theoretical framework, a review of the relevant research, an analysis of the data, research findings, and implications for future research. To explore whether there was a significantly high level of codependence among parents of children referred for outpatient mental health treatment, a sample of

(N= 30) parents of children referred to the Sutter Counseling Center in Sacramento, CA, was given the Spann-Fischer Codependency Inventory to assess for high levels codependency. Results showed higher mean levels of codependency among the sampled population of parents. Specific inventory responses also reveal that codependency among the parents is a way of viewing one’s self which is supported by relevant literature. The

research provides future caregivers and researchers a way of looking at codependency and a foundation for future studies.

______, Committee Chair David G. Demetral, PH.D., L.C.S.W.

______Date

ACKNOWLEDGMENTS

To begin I would like to thank God for being the motivation and inspiration behind every single one of my life accomplishments. You are my life, my hope, and my salvation.

I also want to extend a special thank you to my wife Darline Dupree. Your belief in me, support, and encouragement throughout this project has been unmatched and I am forever grateful. I also want to acknowledge both my children Deangelo and Imani Dupree. My efforts to complete this work were for you both and for the legacy that I am believing that you both will continue in. I am deeply grateful to my mother Pam Sanders and grandmother Johnnie Thomas for the undying faith and acceptance given to me throughout my life and through this latest educational endeavor. I am also grateful to my late aunt Annie Thomas who ‘constantly’ encouraged me to pursue higher education in the field of Social Work.

Next, I want to express my great appreciation to Professor David Demetral for his expert guidance and gentle support from the inception of this research project. I also appreciate the significant contributions of the other Sacramento State University professors for their contributions to my academic progress. In addition, I want to thank Michael “Mick”

Rogers and Margo Durrett for their guidance and supervision during my internships and project completion.

Finally, I would like to thank my siblings, all my encouraging family members, my friends, classmates, and all the other supportive individuals who have been truly inspirational and helpful during this experience.

TABLE OF CONTENTS

Page

Acknowledgments...... vi

List of Tables ...... x

List of Figures ...... xi

Chapter

1. INTRODUCTION ...... 1

Problem ...... 1

Background of the Problem ...... 1

Statement of the Research Problem ...... 7

Purpose of the Study ...... 7

Theoretical Framework ...... 8

Hypothesis...... 11

Assumptions/Definition of Terms...... 12

Justifications ...... 12

Delimitations ...... 13

2. LITERATURE REVIEW ...... 14

Introduction ...... 14

Internalizing Ideas and Patterns of Behavior in Codependency ...... 14

Feminist Perspectives on Codependency ...... 19

Family Origins ...... 24

vii

Predictors of Codependency ...... 25

Effects of Codependency on Children with Emotional Disorders ...... 28

Effects of Parenting Styles ...... 30

Effects of Parenting Stress ...... 34

Solutions for Addressing Codependency ...... 37

3. METHODOLOGY ...... 42

Introduction ...... 42

Study Variables and Population ...... 42

Research Instrument...... 44

Research Design...... 45

Data Gathering Procedures ...... 45

Protection of Human Subjects ...... 46

4. RESULTS ...... 48

Introduction ...... 48

Descriptive Statistics ...... 48

Frequency Distribution ...... 49

Inferential Statistics ...... 51

5. FINDINGS AND INTERPRETATIONS ...... 56

Evaluation and Implication for Future Researchers...... 56

Study Limitations ...... 58

Implications for Social Work ...... 59

viii

Appendix A. Questionnaire ...... 60

Appendix B. Correspondence 1 ...... 62

Appendix C. Correspondence 2 ...... 63

References ...... 64

LIST OF TABLES Page

1. Table 1 Codependency Scores and Gender of Children………………………...52

2. Table 2 Question (10) from the Spann-Fischer Codependency Inventory…...... 53

3. Table 3 Question (9) from the Spann-Fischer Codependency Inventory…….…54

LIST OF FIGURES Page

1. Figure 1 Diagnosis of Child…………………………………………………….49

2. Figure 2 Total Codependency Scores……….…………………………………50

3. Figure 3 Race, Codependency Scores, and Inventory Responses……..……….51

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Chapter 1 INTRODUCTION

Problem

In recent years, there has been a growing amount of research done on the

phenomenon of codependency and its effects on family systems. Historically, the concept

of codependency has met grave challenges as the construct has endeavored to achieve

both a universal operational definition and a consensus on its prevalence among families.

Over time, the concept has also been operationalized by standardized measuring tools used to measure the presence of codependency, among individuals. The theory of codependency has prevailed due in part to undeniable behavioral tendencies among individuals in functional and dysfunctional relationships alike. Lacking at this stage in codependency’s evolution, however, is an isolated focus on its correlated effects on certain targeted populations. This is problematic because children with mental health conditions can be uniquely challenged by the behavioral tendencies of their caregivers.

This leads to the question of whether there are high rates of codependency among parents with children suffering from mental health conditions. This research study explores the prevalence of codependency among parents with children that suffer from mental health issues.

Background of the Problem

The operational definition of codependency for this research project is a maladaptive coping pattern that disguises a fear of abandonment, is perpetuated by a lack of self-confidence, and creates dysfunctional relational patterns, loss of self, and difficulties feeling secure in interpersonal relationships. Codependency includes a lack of 2

clear boundaries and care that sabotages the needy person’s ability to thrive individually.

Codependency can be identified through a series of parental effects such as an

overemphasis on care and neediness to be the only support provider despite the

possibility of other trusted available resources. This definition is a composite of research

findings on the topic of codependency and its correlated effects. Parents with high rates

of codependent behavior may have maladaptive effects on their children although this has

not been systematically studied. The maladaptive parental affects may equate to

emotional maltreatment. Emotional maltreatment can be defined as hostile, indifferent, or

misguided parental behavior that damages a child’s self-esteem, degrades their sense of achievement, prevents healthy and vigorous development, and triggers emotional and behavioral problems (Iwaniec, 2006). Further examples can include inconsistent interactions with a child such as overprotection, restrictions of exploration and learning, unrealistic expectations, and failure to accept a child’s individuality, psychological boundaries, and individual needs separate from those of the parent (Iwaniec, Larkin, &

McSherry, 2007). Emotional maltreatment would need to involve repetitive and sustained acts of omission and commission, which nullifies the possibility of isolated incidences being considered emotional maltreatment (Doyle, 1997). These connections between parental codependency and the possibility of emotional maltreatment spawn the need for further research.

The history of co-dependency as a framework of observation stems back to studies concerning wives and their relationships with their alcoholic husbands. Since most addicted individuals were male, women were more often shown as displaying co-

3 dependent behaviors although in theory or reality this not necessarily the case (Favorini,

1995). By the mid-1980’s, the concept of codependency extended to anyone who became involved in a dysfunctional relationship (Cowan & Bommersbach, 1995). The scope of codependency broadened to include both men and women who grew up in any type of dysfunctional family system where substance abuse may or may not have been a problem

(Stafford, 2001). Proponents of this "dispositional" view had generated a sizable literature that was clinically based and largely popular rather than professional (Wright &

Wright, 1999).

This expanded view of codependency produced two specific perspectives of interest on how it should been defined and interpreted in research. In one definition, the individual displaying codependent behaviors is attempting to control the emotions of the other by continually catering to the needs of that other person (Springer, Britt &

Schlenker, 1998). This is done believing that the other person will be obligated to give the person displaying the codependent behaviors the love that he or she wants. Often, the behaviors and efforts of the one displaying codependent behaviors are neglected or resented rather than rewarded by love causing the one displaying the codependent behaviors to feel a sense of inadequacy, having behaved inappropriately, and a need to do more (Springer, Britt, & Schlenker, 1998). The resentment felt by the individual displaying codependent behaviors is often a guise of compassion covering an intense fear of abandonment that is secretly held (Cameron, 2008).

The second perspective on codependency shows caretaker behaviors in the individual’s displaying codependent behaviors with no connection to boundaries. This

individual will meet the needs of others before meeting his or her own needs and will do

this consistently (Favorini, 1995). Instead of care being provided in order to gain love or

approval, it is done out of a sense of lack of confidence. The individual displaying codependent behaviors lack’s the internal fortitude to care for self and thus unhealthily lives and thrives on the ability to provide support to others. In essence this individual lives their life through the person they are supporting. Similar to the above example, when this ability to give to others is threatened or compromised, feelings of lack resonate.

In many instances, the individual displaying codependent behaviors will continue to maintain this care regardless of the actual need of the person being cared. This individuals efforts may sabotage the needy person’s ability to function and thrive individually, prohibiting self-sufficiency. In both perspectives there are individual traits as well as relationship focuses that must be considered when exploring codependency.

The topic of codependency needs further exploration for several reasons. Children with mental health conditions are among the most vulnerable in the population, and particularly susceptible to dysfunctional behaviors that impede growth and development.

Although not all of the effects of codependency are maladaptive, the negative effects of codependency among parents and caregivers have the ability to negatively impact developmental adjustment into adulthood. Moreover, functional progression and adjustment into adulthood and self-sufficiency is universally the goal of the parents and caregivers of youth with mental health issues. Professional observations among mental health practitioners however, have raised questions about adolescent adjustment into adulthood and some of the potentially limiting factors.

With more research on the prevalence of codependency, social workers and

mental health practitioners may be more equipped to devise interventions to reduce the

codependent behavior. Knowledge about the prevalence of codependent behavior can

encourage more research on codependency’s relationship to other potentially correlated

factors. With more awareness about the prevalence of codependency, parents and

caregivers with children will be more equipped to make self-determined changes and

adjustments to their parenting styles and approaches. In order to examine the prevalence

of codependent behavior, however, it is necessary to explore the existence of correlations

between codependency and actual children suffering from mental health conditions.

There are multiple aspects of parental codependent behavior that may have some

correlation to child development. Associations between codependency and the constructs

of shame-proneness, self-esteem, and parentification show the effects of codependency

on child development (Wells, Glickauf-Hughs, & Jones, 1999). Parentification plays a

major role in the learned behaviors that children experience and influences their

development into adulthood (Wells, Glickauf-Hughs, & Jones, 1999). In addition to this, youth with mental health issues in general, often have unique struggles transitioning into adulthood. These struggles may be due to parental roles, parental depression, a loss of

power, and other environmental family stressors. These struggles may contribute to

feelings of uncontrollability, lower mastery, helplessness, loss of self, and difficulties

feeling secure in interpersonal relationships in latter to adult years (Wells, Glickauf-

Hughs, & Jones, 1999).

There are several factors that must be considered when evaluating the effects of parental codependent behavior on children with mental health conditions. The first factor that must be considered is the determination that codependency does indeed exist in the family unit. Assessing the presence and prevalence of parental codependent behavior is an area that will need careful consideration. Codependency is a clandestine condition observed through overt acts, comments, and behaviors thus it is necessary to use a measuring tool that differentiates codependency from normal acts of support. Asking questions that relate to attachment and enabling will help bring clarity to the presence of codependency within a population. Several scales and inventories have also been developed over the years to measure codependency. These measuring tools will be the ones used to explore this topic.

There are multiple mental health conditions that a child could have that may be positively correlated to parental codependency. In exploring the various mental health conditions, this researcher will focus predominantly on children that are depressed and emotionally disturbed. Depression and emotional disturbances can have a lasting effect on a youth’s transition into adulthood. Exploring trends that contribute to emotional disturbances and youth depression will help researchers understand the interconnectedness between these factors and codependency.

The mainstay problem with codependency lies in its potentially limiting effects on child adjustment. An inability to adjust into adulthood may impair that individual’s ability to make functional life decisions, ultimately prohibiting self-sufficiency and autonomy. Amid other non-related factors, changing codependent behavior in parents

may be a pre-condition for potential change in a child’s behavior. Codependency only becomes a negative attribute when its effects cause a level of maladaptive behavior that impedes personal and social functioning. In this several questions must be explored:

What are the lasting effects of codependency on the development of children with mental

health conditions? In this question, a desire to understand long term affects if any on

children with mental health conditions is sought. What areas of development does

codependency affect? In this question, the specific proponents of social development

potentially affected by codependency are observed.

Statement of the Research Problem

Codependency encompasses a number of behavior characteristics that may relate

to many other environmental variables and social factors. There is currently a lack of

research on the correlations between parental codependency and children suffering from

mental health conditions. Lacking also are interventions to help parent recognize the

development and existence of codependent behaviors. The correlations between parental

codependency and children with mental health conditions as well as interventions to help

parents recognize codependent behaviors will be the focus of this research.

Purpose of the Study

The primary purpose of this research was to test the hypothesis forwarded by the

Sutter Counseling Center clinical staff that there are high rates of codependency in the parents whose children are referred for the treatment of their child’s behavioral and mental health issues. Sutter Counseling is an outpatient mental health service agency located in Sacramento, CA, that focuses on mental health treatment therapy for youth and

8 adolescents. As a social work intern, this researcher has been a participant in the clinical dialogue about these issues at the Sutter Counseling Center, with the clinicians on staff.

The clinical staff has generated the hypothesis that there is a high and significant level of co-dependency in the referred parents. The secondary purpose of this study was to analyze the relationship between those parents who have significant codependency scores and the actual diagnosis of the child that is made by the medical and clinical staff providing treatment upon admission for treatment.

Theoretical Framework

A particular research theory that can be used to discuss and explore the effects of parental codependency on children with mental health issues is the Family Systems

Theory (FST). This theory was developed by the family therapist Murray Bowen and operates on the premise that individuals cannot be understood in isolation, but as a part of their family unit (Prest & Protinsky, 1993). Families are looked upon as interconnected systems with interdependent individuals that are understood within the system (Prest &

Protinsky, 1993). The theory is based upon a basic premise and several interlocking concepts. The basic premise states that relational patterns are learned and passed down through generations. Current individual and family behaviors are a result of these relational patterns, and affect the congruency of the family unit. The interlocking concepts that relate to codependency in the family systems include the differentiation of self, family projection process, the nuclear family emotional system, and the smallest stable relationship system known as triangulation (Prest & Protinsky, 1993).

In the differentiation of self or individuation, individuals in the family unit have the ability to separate emotionally and physically from their family of origin, as well as to achieve emotional maturity and independence without losing the capacity to emotionally connect with others (Charles, 2001). Differentiation can also be defined as an intra- psychic concept: the ability to separate thinking from feeling (Charles, 2001). In relation to codependency however, the theory states that a phenomenon called fusion, which is on the opposite pole of differentiation, often occurs within individuals in the family unit.

This typically occurs when individuals in the family unit begin to lack a clear sense of self and feel responsible for and controlled by others. If this becomes the approach of parents within the family unit, the effects could spill over into the other family system members, namely the children. The children may then experience negativity toward their own individuation and self autonomy. Parental codependency within the family unit therefore would have tremendous affects on the family unit as a whole.

In the family projection process, patterns develop as certain family member's behavior is caused by and causes other family member's behaviors in predictable ways. In this interlocking concept, fusion becomes a consistent long-term pattern of behavior that affects other members of the family unit. Emotional problems carried by parents are typically transferred to children in this concept. Since changes in individual parts affect the whole, long-term dysfunction in varying parts affects the individual parts as well.

Stability in this system may produce patterns of dysfunctional parenting and behaviors that are replicated in children. Children with mental health issues add a level of anxiety to a family unit that may be adversely affected by the premise of relational patterns being

learned and passed down from generation to generation. Positive aspects of

codependency as well as negative presentations follow this pattern of affect within the

family unit.

In the nuclear family emotional system, specific relational patterns define where problems in the family unit can affect the overall unit. The theory spotlights emotional distance and resistance, conflict in marriage, dysfunction in one of the marital partners or caregivers, and impairment of one or more children, as anxiety driven situations that influence the family unit. The highest level of family functioning is reached when the anxiety in the system is low (Charles, 2001). Family systems are not just nuclear families with parents and children, but generations of family members connect to one another by strong emotional ties conceptualized as Intergenerational Transmission Process (Prest &

Protinsky, 1993). In this interlocking concept, children with mental health conditions would quantify as a condition that would add anxiety to the family unit. This condition would be compounded by a parent that exemplified traits of codependence on their children for identity and worth.

Triangulation in the Family System Theory consists of a dyadic system relationship within a system that is inherently unstable. This relationship is looked upon as the basic unit of any emotional system and tends to draw upon a third party to obtain stability when anxiety is raised (Prest & Protinsky, 1993). The three parties make up a triangle in which two parties attempt to either help or work against the third party to reduce anxiety, stress, and conflict. In situations where the varying parties are not differentiated, there becomes a greater level of anxiety that spills over into other family

11 dynamics. With conflicting parties, codependent behavior becomes possible as relational dynamics change from conflicting disagreements to dysfunctional relationship patterns of behavior. Codependency therefore according to FST arises from dysfunctional relational patterns, rooted in intergenerational family emotional systems where there are difficulties developing intimacy and identity (Prest & Protinsky, 1993). These patterns include lack of awareness of feelings while focusing on externally on another person, lack of intergenerational individuation, difficulty with establishing desired levels of interpersonal intimacy or distance, and diminished sense of personal identity and authority (Prest &

Protinsky, 1993).

In summation, the Family Systems Theory is a broad framework that is helpful in accounting for people within family structures who have codependency issues. This theory provides a perspective on when a clear sense of self begins to lack, creating feelings of responsibility for others. In addition this theory illustrates the formation of long term behavior patterns that transfer from parents and caregivers to children within family units. This theory also spotlights varying family conditions that enhance anxiety within the family dynamic creating lower levels of resiliency to conflict. Lastly, this theory expresses approaches family’s use to deal with conflict and the resulting pathology that can be created when efforts go astray.

Hypothesis

There is a positive correlation between parental codependency scores and specific mental health diagnosis of children with mental health conditions.

Assumptions/ Definition of Terms

The concept of codependency has been highly scrutinized due the varying abstract definitions applied to it. This researcher is defining codependency as a behavior

that focuses so much on what is happening with those around them and on trying to have

control over the lives of others that they lose touch with their own thoughts and feelings

(Lindley, Giordano, & Hammer, 1999). The behavior encompasses the use of control to

gain a sense of fulfillment, emotional support, and approval from intimate relationships

with others, in order to build ones self-confidence (Lindley, Giordano, & Hammer,

1999). The objective of the treatment to address this issue is to bring awareness to the negative elements of codependency and create more positive interventions to the individual displaying codependent behavior and to the person being treated. This researcher will be defining adjustment as a means of transitioning into other life stages through an acquisition of knowledge, resources, and opportunity.

Justifications

The purpose of this study is to understand the impact of parental codependent behavior on the adjustment of children with mental health conditions within the family system. This understanding, it is hoped will indicate the degree to which child mental health correlates to parental codependency. Codependency can be identified through a series of parental effects such as an overemphasis on care and neediness to be the only support provider despite the possibility of other trusted available resources.

Delimitations

In order to delineate the boundaries between correlating factors of codependency, there must be a clear focus on the limitations of this study. Typical studies of codependency have focused on alcoholism and their affects on family dynamics. Other conventional studies have used theory to explain the causality of codependency. Still other studies have assessed diagnostic tools in an effort to give credibility to the concept.

Finally, many studies have attempted to describe characteristics of individuals who are codependent. Due to the many ways in which codependency has been defined, this researcher will be relying on an abstract definition of the clinical concept codependency.

The definition was derived from various research findings but has been neither universally operationalized nor accepted as standard conceptual definition. Therefore correlations between codependent behavior and other varying measures will be inferential. In addition, this study will be evaluating a clinical population which may result in a higher rate of correlated factors than in a randomly sampled non-clinical population. This primary focus of this study however will be to place emphasis on the correlated relationships between codependency in parents and caregivers, and children suffering from mental health conditions. A discussion will then be conducted to discuss the relevance of correlated factors or lack thereof.

Chapter 2 LITERATURE REVIEW

Introduction

Codependency has historically been a condition predicated upon factors of chemical dependency. Recent studies however have shown codependency as existing separate from chemical addictions. Viewing codependency as a framework separate from chemical dependency can provide an alternative perspective from which to observe factors relating to codependency. Within the research of codependency and parenting, specific themes resonated: Internalizing ideas and patterns of behavior in codependency, college age populations as measures for codependence, predictors of codependency, parenting styles and stress, feminist perspectives, and solutions for addressing codependency. This literature review explores each of these categories and the relevant available literature.

Internalizing Ideas and Patterns of Behavior in Codependency

Several research articles support and construct the concept of codependency by furthering the discussion on how individuals with codependency relate, internalizing components, and parentification as a byproduct of this relating. A research article by

Wright & Wright (1999) explores the clinically based contention that codependency is a pattern of relating. Though the original research focused on the characteristics of relating, an additional finding showed patterns of relating in dysfunctional relationships stemming from what the researchers call a distinctive codependent personality syndrome (Wright &

Wright, 1999, pp.527). The research design consisted of a sample group of 271 women

and 240 men classified as the control subjects. In addition, 72 women and 20 men were

classified as clinically identified codependents. A measuring tool was created by the

researchers using a set of created codependency scales and adding them to an established

instrument known as the Acquaintance Description Form. The combined measuring tool

was called the ADF-C5 and consisted of 85 statements relevant to the subject’s

relationship with his/her designated Target Person. Findings suggested a three factor

structure that was stable across samples and identical among men and women. These

three factors were labeled in the research design as Factor I- Positive Rewarding

Relationship, Factor II-Defensive and Overprotective Caretaking, and Factor III-

Commitment/Involvement. Codependent relating was significantly associated low Factor

I scores and high Factor II scores which suggests a predisposition to form and maintain codependent relationships (Wright & Wright, 1999). This interrelation was termed codependent personality syndrome.

In supporting the perspective of codependency as a “syndrome”, available literature builds on the concept and seeks to include internalizing components to the concept. In a research article by Wells, Glickauf-Hughes, & Jones (1999), an investigation was done to empirically examine the proposed association between codependency and the constructs of shame-proneness, self-esteem, and parentification.

Guilt-proneness was examined in an effort to determine whether the conceptualization of codependency as a shame-based adaptation, should also include a component of guilt.

The main focus of the study was to determine the need for inclusion of these clinical observations about codependency. A research sample of 200 introductory psychology

students consisting of 65% female, 32% African American, 48% Caucasian, and 20%

other was taken from a large southeastern urban university. The research used one

dependent measure and three independent assessments. Results suggested that there is

strong empirical support for codependency also being a shame-based personality organization. Codependency also has a strong association to parentification, which is the role of the child or individual taking on the role of the caregiver. Codependency thus appears to reflect a specific way of viewing ones “self”, as opposed to a style of responding to a particular behavior (Wells, Glickauf-Hughes, & Jones, 1999). This research supports the fundamental concept that codependency is a behavior that is based upon an internal sense of emotional deprivation and waning self confidence. The parentification of children may lead to them being unable to detach from their original family due to a sense of obligation, inhibiting self-sufficiency, and autonomy. In this, codependency becomes a learned behavior that is perpetuated in the life of the child that is being cared for.

In addition to codependency being viewed as a pattern of relating and as a syndrome, some have proposed that codependency is an actual disorder. A research article by Loughead & Yuan-Yu ting (1998) explored traits for a proposed diagnostic category of codependent personality disorder. Lunghead & Yuan-Yu ting (1998) used criteria from a researcher named Timmon Cermak who propose diagnostic criteria.

Timmon Cermak stated the following diagnostic criteria:

A. Continued investment of self-esteem in the ability to control both one-self and others in the face of serious adverse consequences.

B. Assumption of responsibility for meeting others' needs to the exclusion of acknowledging one's own.

C. Anxiety and boundary distortions around intimacy and separation.

D. Enmeshment in relationships with personality disordered, chemically dependent, other co-dependent, and/or impulse-disordered individuals.

E. Three or more of the following:

1. Excessive reliance on denial. 2. Constriction of emotions (with or without dramatic outbursts). 3. Depression. 4. Hyper-vigilance. 5. Compulsions. 6. Anxiety. 7. Substance Abuse. 8. Has been (or is) the victim of recurrent physical or sexual abuse. 9. Stress-related medical illnesses. 10. Has remained in a primary relationship with an active substance abuser for at least two years without seeking outside help (Cermak, 1986, as cited in Lunghead & Yuan-Yu ting, 1998).

Cermak believed this DSM-IV like criteria could only be made in face of significant impairment in social and occupational functioning making it an inflexible, maladaptive personality trait (Cermak, 1986, as cited in Lunghead & Yuan-Yu ting, 1998). A sample group of 26 participants were administered the Million Clinical Inventory-II (MCM-II) and the Fischer-Spann Codependency Scale. Of those participants, 37 self-identified codependents were randomly chosen from the general public and 26 were chosen from a graduate program. Participants were screened for symptoms of psychosis, clinical depression, and signs of active drug and alcohol use. Results showed a significant support for the first and third criteria. The research presumed that codependents invest inordinate amounts of energy in efforts to improve others in order to find self-worth and they suffer

18 from anxiety and boundary distortions around intimacy and separation (Lunghead &

Yuan-Yu ting, 1998). There were also elevations of Avoidant and Self-Defeating scales in the disordered range of the MCM-II relative to similar elevations when using the same scale to measure personality disorders (Lunghead & Yuan-Yu ting, 1998). The research lacked matched comparison groups in race and gender, but provided a clear glimpse into efforts to make codependency a measurable diagnostic category.

Other researchers have also made efforts to describe and define codependency as a process that develops out of emotional dependency and choices. A research article by

Hoogstad (2008) discusses the development of emotional dependency using Choice

Theory as the theoretical foundation. Hoogstad reports that the Choice Theory concept proposes that humans are internally motivated by five basic premises’ of need for: belonging and love, power, fun, survival, and freedom (2008). Getting these needs met becomes the focus of Choice Theory and the direction taken by the research article.

Individuals in this theory typically take on the role of the victim, the rescuer, or the persecutor in their interactions with others. Victims believe they have no choices over their circumstances because they believe themselves as powerless (Hoogstad, 2008, pp.65). Rescuers secure their relationships by making others dependent upon them which then causes them to become dependent on the person they feel they are rescuing

(Hoogstad, 2008, pp.65). The Victim and Rescuer are described in Choice Theory as having a co-dependent relationship because each depends on the other to accommodate what they each perceive they lack within themselves. Persecutors resort to extreme control to ensure the presence of important people in their life (Hoogstad, 2008, pp.65).

The Persecutor and Victim also have a codependent relationship with each other. The

behaviors in this tri-part interaction are known as the Karpman Triangle as this triangle is

based upon fear since the “fearing” dominates decision making (Hoogstad, 2008, pp.65).

The researcher reports that dependent individuals typically fail to meet many of the basic

premises of this theory because the choices they make involve all or some disconnecting

habits including: blaming, complaining, punishing, rewarding, criticizing, and

overprotecting in order to control (Hoogstad, 2008, pp.65). The researcher went on to

give case studies of experiences in which individuals were immobilized in some aspect of

the tri-part cycle. The researcher expounded upon the lack of boundaries in varying

interactive relationships including parent and child. In the researchers explanation it would seem that codependency can become a role that individuals inadvertently fall into without conscious effort, but within the normal context of everyday living. Lastly, the researcher discussed child scripts that individuals say to themselves as children in order to deal with things they had no control over. In relation to codependency, individuals may interpret mistakes as failures which ultimately diminish their self-esteem. These internalizing ideas and patterns of behavior in codependency make up the basis of current ideas surrounding its development and access into mainstream theoretical approaches.

Feminist Perspectives on Codependency

Arguments against codependency arose in literature as feminists began looking at codependency as strength to women and not necessarily a negative attribute. Not all aspects of codependency are maladaptive and negative. In literature written from a feminist perspective, positive attributes can be found and utilized when exploring

20 codependency. There is also a large commentary on mother-blaming as a phenomenon from the feminist perspective. Lastly power imbalances between sexes in society can be mirrored within the family unit causing a disproportion in power with men having more power over the controls and behaviors in families (Granello, 1998, pp. 349). This focus on positive attributes of codependency provides a more balanced perspective on the overall concept. It is when behaviors become maladaptive and begin affecting self confidence and stress management that codependency must be evaluated for. In dysfunctional relationships and those with a substance abuser, the result tends to be that while the addicted person can blame the chemical for their problem, the codependent person is blamed for being sicker than the abuser himself (Granello, 1998, pp.348). The feminist perspective often criticizes codependency for its ideology toward women, yet it emphasizes the strength of codependency in its ability to emphasis and focus on weaknesses. This focus makes the maladaptive aspects of codependency that much more clear. Screening for codependency then becomes a primary tool needed to address negative consequences of codependent behavior.

Professional perspectives on the responsibility of parental stress and parental styles as causes of pathology in children are underlying thoughts among therapists and health practitioners perpetuated by the feminist perspective. In a previous research, 57% of surveyed licensed clinical social workers agreed that parental dysfunction is a primary cause of serious mental illness in children (Rubin, et al, 1998, pp.418). The disparity between typical parental mistakes and parental pathology severe enough to cause psychopathology in their offspring is not so clear. A research article by Johnson, et al

(2000) was conducted to ascertain the extent to which mental health professionals still assign etiological responsibility to parents. In order to conduct this evaluation, professionals with a clinical focus, a special interest in children, or an expertise in the population were used. This group included a total of 978 mail respondents from of Child

Psychiatrists chosen from the registry of the American Academy of Child and Adolescent

Psychiatry, Psychologists from the registry of the American Psychological Association, and Clinical Social Workers from the registry of the National Association of Social

Workers. Individuals were given a questionnaire on views of mental health professional participants. Results showed that almost half showed some agreement and some disagreement with causality statements which closely matches previous research

(Johnson, et al, 2000). Variations were found among different disciplines and theoretical orientations. Family pathologists and ego psychologists for example, who disproportionately prefer the use of family systems theory, scored higher on causal attributions to parents then child psychiatrists and developmental psychologists, who strongly believe in biological determinants (Johnson, et al, 2000). The attribution of blame toward parents and the ideal that codependency is indicative of pathology may be perpetuated by professionals within therapeutic settings. This is an important aspect in the therapeutic treatment of parents because of the possibility of counter-transference issues among practitioners and patients. Therapists and practitioners in multiple settings would benefit from an initial non-biased approach to causality of child pathology. Thus using codependency as a component to evaluate tendencies in both the parents and children would be a more structured use of the concept. Evaluating behavior tendencies

22 when considering codependency, would allow for the development of structured interventions that enhance parent knowledge and autonomy.

Exploring the context from which the codependency concept is used can help bring validity and perspective to the circumstances in which the concept should be used.

A research article by Jackson & Mannix (2004) used a narrative research approach to explore mother blaming as it has been experienced by a group of mothers themselves.

Participants included 52 mothers with children above the age of 17 with varying education, and ethnic backgrounds. A third of the women lived with their child’s father and all had between one and four children. Each woman was asked in narrative form to give their thoughts and experiences on mother blaming. Results showed a prominent discourse around mother blaming. The burden was placed upon them by others, and in some instances was something they burdened themselves with Jackson & Mannix, 2004, pp.153). The internal self blaming created a great deal of stress for the participants.

Specifically women were blamed when their children participated in antisocial behavior, had major medical conditions, or had crisis events (Jackson & Mannix, 2004). These women reported experiencing feelings of inadequacy, anger, and self-blame (Jackson &

Mannix, 2004). Since these characteristics are also those experienced in codependency, understanding the context of the feelings and those affects on children and others would be necessary before defining the individual as being, codependent. If these feelings began affecting personal and social functioning, then they could be deemed maladaptive. If they then become maladaptive to say the children, then codependency could be the condition.

The researchers of this article sought to express the damage in blaming mothers for

23 natural responses to situations in complex conditions and environments. Parents would benefit from training that helps them recognize self blame as a quality of codependency that can originate internally from some intrinsic sense of lack, or externally from a perceived acceptance of responsibility. This change in focus from mother blaming to the detriments of self blaming would be a more acute usage of the concept of codependency.

A final area from the feminist perspective investigates codependency’s relationship to masculinity and femininity. An exploration was done by Dear & Roberts

(2002) in order to understand gender role identification. Participants included 192 first year university students with 43 participants as men and 149 as women. The participants were given a codependency index to measure how much they endorse codependency and a questionnaire to assess gender role identification. Results showed that endorsement of codependent attitudes and beliefs were associated with gender role identification (Dear &

Roberts, 2002). The only scale that showed a gender difference in responses was the one that most identified with gender-role identification (Dear & Roberts, 2002). Thus the research makes it clear that gender role identification has as much to do with the assessment of blame in the pathology of children as other behavioral attributes. Feminist would argue that a progression toward stereotypical gender roles is the cause and blame for such ideology. Exploring the complex relationship between codependency and gender role identification would need further exploration in order to rule in or rule out codependency as a pattern of gender role identification.

Family Origins

In addition to focusing upon codependency’s definition and context, research shifted its focus from codependency among alcoholic families to the presence of codependency among the varying populations. Researchers of codependency became increasingly interested in early relationship development. Observing college aged populations allowed researchers to explore relationship development among individuals in their early adult years. Researchers also began exploring relationships between codependency and family origins within and outside of student populations. These researcher discoveries would prompt deeper observations about the effects of family dynamics on parental self confidence, competence, the importance of stress management, and better ways to screen for codependency in an effort to focus more on adept interventions. A research article by Cretser & Lombardo (1999) began this development by exploring the occurrence of codependency in a college-aged population. Samples of

165 students enrolled in General Psychology were used for the research. The individuals were given a Codependency Self Inventory Scale that served as an indicator for actual codependent behaviors. Results showed a positive correlation between scores of the self inventory and codependency measured by the characteristics of the students significant relationships (Cretser & Lombardo, 1999). The correlation was slight which may have been indicative of the mean age of the population being sampled. Also limiting this study may have been the tendency of individuals to consider their selves codependent without a universal operational definition. Despite the limitations of the study, suggestions were

made for future research to focus more exclusively on past family pathology and its

relations to codependency.

As characteristics of codependency became more defined through assessment

tools, more correlative aspects of codependency were able to be explored. A research

study conducted by Parker, Faulk, & LoBello (2003) further explored codependency by

hypothesizing that family of origin issues would correlate highly with codependency

among college aged students. Using a similar sample of college aged students, the

researchers sampled 520 associate and baccalaureate nursing program students using a

descriptive, correlative research design. Participants completed a Codependency

Inventory and a self-assessment questionnaire that assessed factors related to dysfunctional families. Results showed a positive correlation between family pathology and codependency scores (Parker, Faulk, & LoBello, 2003). Codependency as a severe problem however, was only found in a small percentage of students surveyed. More studies on correlative relationships between codependency and other behavior pathologies would give a more adequate account of codependency’s individual affects on varying family dynamics such as parenting and self-confidence.

Predictors of Codependency

As the concept of codependency has become more and more concrete, researchers have sought to understand predictors and possible developmental cycles that predate the development of codependency among individuals. A research article by Lindley,

Giordano, & Hammer (1999) explored the relationship between codependency and possible predictors such as age, self-confidence, autonomy, and succorance, or the quality

of soliciting emotional support from others. A sample of 95 individuals was used in the

research design, which included thirty-three male participants and 62 females. Each participant was given an Adjective Checklist with 300 adjectives used to describe a person’s characteristics, the Spann-Fischer Codependency Scale, the Co-Dependents

Anonymous Checklist, and a questionnaire developed by the researchers to complete.

Findings showed a negative correlation between codependence and self-confidence and a positive relationship between codependence and succorance (Lindley, Giordano, &

Hammer, 1999). Self-confidence was the strongest predictor in all three measures inferring that individuals with low or reduced self-confidence are more prone to have or develop codependent characteristics. Parents that lack self-confidence thus may be less effective in their parenting approaches and exhibit codependent characteristics. Poor self- confidence alone however, is not maladaptive unless it begins to affect individual and social functioning. More parental training to deal with the maladaptive effects would need to be sought in future research on self-confidence and codependency.

Family dynamics also have a lasting effect on child development and adjustment.

Research conducted by Fuller & Warner (2000) sought to understand the relationship between chronic stress, family background, and codependency. A sample of 257 introductory psychology undergraduates were given a questionnaire that consisted of a demographic information, a codependency scale, and an assessment of three types of family stressors, physical illness, mental illness, and alcoholism. Results showed that there was not a correlation between codependency and any of the three family stressors, physical illness, mental illness, and alcoholism (Fuller & Warner, 2000). Findings did,

however, show positive correlations when these variables were combined. The significant

difference in codependency scores for participants from stressed and unstressed family

environments also suggests that other types of environmental family stress, not

exclusively parental alcoholism, may lead to codependency. The research suggests that a

combination of family stressors is a better predictor of codependency than individual

factors alone. Parents and families dealing with chronic stress would benefit from more

training on ways to reduce the negative aspects of codependent relating.

Parentification has also shown to produce a great deal of stress within families. A

research article by Byng-Hall (2008) discussed the parentification role that children play

in households. An account was given from therapy sessions of three generations of different family members and their approach to parentification. Each family group was named Family C, Family B, and Family A. Each group had a family member that had taken on a role of parentification at an early age. These roles were putting a strain on their immediate families as these individuals tried to maintain their care giving roles.

Marriages in each group were shown to be in disarray as well as relationships with their children. Each parentification individual was taking care of a family member’s from their

upbringing household. Interestingly, the family members being taken care of also took on

parenting roles in their youth. Byng-Hall (2008) discussed that therapists are often

products of parentification households. The results of his observations showed that there

is a need for therapists to be aware of the roles that individuals play in their families. His

results also showed that taking on parentification roles can have negative effects on

family structure and be perpetuated between generations, although this is not always the

case (Byng-Hall, 2008). Parentification has been shown to augment family stress which

then draws a parallel to high codependency scores (Byng-Hall, 2008). More parental

training into the effects of parentification, would enhance family knowledge and contribute to agencies developing interventions for caregivers and families.

Effects of Codependency on Children with Emotional Disorders

In addition to parentification and family dynamics, research has also shown the struggle that youth with mental health conditions experience transitioning into adulthood.

An article written by Colman, et al (2009) discussed the long term effects of behavior disorders on adulthood. A longitudinal study was conducted using the Medical Research

Council National Survey of Health and Development and its follow up survey. It examined the data from 3,652 survey members assessed by their teachers for symptoms of externalizing behavior at 13-15 years of age. Of these, 348 were identified with severe externalizing behavior, 1,051 with mild externalizing behavior, and 2,253 with no externalizing behavior. Results showed adolescents who had severe externalizing behavior at 13 or 15 years of age had poorer mental health (high rates of depression and anxiety), less successful family lives (including high rates of divorce and relationship problems), and poorer social and economic outcomes (including unemployment and financial difficulties) in adulthood (Colman, et al, 2009) . These associations with poor outcomes in adult life also extended to those with milder forms of externalizing behavior

(Colman, et al, 2009). This research suggests that individuals with mental health conditions may struggle with adjustment to adulthood. Though this article failed to state whether individuals with mental health conditions do worse than those who do not have

mental health conditions; the struggles that these individuals experience in adulthood can

provide a great deal of stress on them and on the relationships they hold with others.

Since family stress is a predictor of codependency, educating individuals on how to

develop healthy patterns of relating could be beneficial and reduce the likelihood that

maladaptive patterns of codependent relating occur.

Other research articles studied the emotional socialization practices in families of children with anxiety disorders. Suveg, Sood, Hudson, & Kendall (2008) conducted the study using a sample of 28 students with anxiety disorders and 28 students without any diagnosis. The two groups utilized the same number of males and females to account for gender differences. Participants were given the Anxiety Disorders Interview Schedule for

DSM–IV: Child and Parent Versions (ADIS-IV-C/P) in addition to an Emotional

Discussion Task conducted with the parents and the children. Results provided support for the role of parents in a child’s emotional development. The results also documented how emotion socialization practices vary in families of anxious youth detailing a specific role for fathers (Suveg, Sood, Hudson, & Kendall, 2008). These results are an indication that the role that parents play in the socialization of children with mental health conditions influences their ongoing development and adjustment. Significant to codependency would be parents who struggle with having a secure sense of self within their relationship with their child. Lagging self-confidence among parents then becomes a risk factor for the development of codependent relating.

Lastly, children with varying pre-existing mental health conditions are susceptible to all kinds of external and internal influences. Typically, when parents promote

autonomy and individual development however, children with and without mental health

conditions benefit positively. This assumption was explored in a research study by Finzi-

Dotton, Manor, & Tyano (2006) which investigated the impact of parenting styles on

attachment patterns in children with ADHD. Participants in this study included 65

children and their parents with the children’s ages ranging from 7 to 15 years old. Several

measuring tools were administered to the participants including a rating survey to

measure the child’s temperament; a parent questionnaire to measure the parents self-

reported parenting style, and children’s attachment style questionnaire that evaluates

attachment styles in adults. Results showed that parental promotion of autonomy with

children with temperamental emotionality predicted anxious attachment (Finzi-Dotton,

Manor, & Tyano, 2006). In reciprocal, parental restriction of autonomy with children

with high levels of temperamental activity predicted avoidant attachment (Finzi-Dotton,

Manor, & Tyano, 2006). This becomes a significant finding when considering codependency due to one of the negative qualities being a restriction in autonomy and self sufficient development. The exploration of codependency on autonomy would need to be coupled with other factors when considering individuals with ADHD and other mental health conditions. With more awareness, parents can feel more empowered and self-assured about the parenting styles and approaches they are using.

Effects of Parenting Styles

Further research has sought to understand the interrelationship between parenting styles and codependency. Parents obviously have a great deal of influence on the life and development of their children. With codependency being a characteristic of personality as

31 well as a relational approach, understanding parental affects on children is necessary for the development of the concept. A research article by Crothers & Warren (1996) began the exploration into parental affects. Their research explored the assertion that children raised by non-nurturing, coercive, and controlling parenting behaviors will score higher as adults on codependency than children raised in more favorable conditions (Crothers &

Warren, 1996). Other assertions tested included how much parents alienated from their self and children raised by parents who engage in certain behaviors compulsively will score higher as adults on codependency. This research would spawn other research including assertions about emotionally harmful parenting and parenting styles as mediators between negative emotionality and early childhood behavior. This research design utilized 442 college student participants. Several measuring tools were administered to the participants including tools used to measure codependency, alienation from or loss of self, compulsivity in parents, and perceptions about child rearing and punishment. Results showed positive correlations between adult codependency and parental coercion, control, and non-nurturance (Crothers & Warren, 1996). Loss of self measures also correlated highly with codependency (Crothers & Warren, 1996). The research concurs that parenting styles most certainly correlate to how parents rear their children. Codependency as an individual personality trait would indicate a parenting style that includes coercion from parents toward a certain behavior that may or may not transfer into codependency among children. This research lacked the direct connection but inferred that antecedents that lead parents into codependency coercively affect their children.

Just as parental coercion can affect children, emotionally harmful parenting can

have drastic and lasting effects. Parenting styles are often hard to assess due to their

elusive nature and lack of prominence in external behavior. Often harmful parenting

includes internal conditions and thought processes of parents that presents outwardly as

maltreatment in the form of neglect, degradation of self-esteem, belonging, health, or any behavior that negatively impacts development. As previously stated, not all aspects of codependency are maladaptive. Even if measures of codependency promote maladaptive responses, resiliency among children and parents alike can often reduce and even eliminate the negative effects. The loss of self experienced by parents however has the ability to coercively or inadvertently drift into parenting approaches that are then taught to their children. This lack of self and the confidence that accompanies it is at the core of codependent parenting. A research article by Iwaniec, Larkin, & McSherry (2007) explored several aspects of emotionally harmful parenting. The researchers conceptualized emotionally harmful parenting as a repeated pattern of caregiver behavior that encompasses both emotionally abusive and neglectful behavior (Iwaniec, Larkin, &

McSherry, 2007). All aspects of maltreatment have an element of emotional harm

(Iwaniec, Larkin, & McSherry, 2007). The researchers found that problems among older children and adolescents who have been emotionally maltreated include dependent behavior amid behavior problems, depression, and low self worth (Iwaniec, Larkin, &

McSherry, 2007). One approach stated by the researchers that could be used to assess emotional maltreatment is identifying patterns of caregiver-child relationships and

interactions, parental styles of attachment, and behavior indicators of stress (Iwaniec,

Larkin, & McSherry, 2007). Understanding parenting styles provides parents and therapists a means of exploring the effects of codependency and the negative aspects that may follow.

A final condition relating to the effects of parenting styles on development concerns parental care and overprotection and their affects on child adjustment. Research conducted by Rekart, Mineca, Zinbarg, & Griffith (2007) explored the idea that a perceived lack of parental care and overprotection are positively related to later symptoms of emotional disorders in children and adolescents. The researchers hypothesized that the effect of a perceived controlling and rejecting family environment during childhood would influence current depression and anxiety, and that these effects would be partially accounted for by the quality of current attachments, perceived control, and attributional style (Rekart, Mineca, Zinbarg, & Griffith, 2007). A sample of 234 individuals completed a 1 hour group discussion and a questionnaire concerning their ideas about family dynamics. Results showed current attachment, perceived control, and attributional style helped to account for relationships between family variables, depression, and anxiety (Rekart, Mineca, Zinbarg, & Griffith, 2007). These results are consistent with the notion that care from codependent parents in early life stages may contribute to feelings of uncontrollability, lower mastery, helplessness, and difficulties feeling secure in interpersonal relationships in latter to adult years. A greater deal of research would need to done to explore the inter relation between variables including overprotection and how codependency may influence it.

Effects of Parenting Stress

Some of the other environmental family stressors that affect child development

may be parental depression. It is universally accepted that chronic, long term stress can

lead to depression. Since parental stress and relational insecurity have shown to correlate

highly with codependent parenting, it is important to also consider the interplay between

parental depression and symptoms experienced by children. Research conducted by

Shelton & Harold (2008) considered the effects of parent depressive symptoms and adult

relationship insecurity in accounting for long-term variations in children’s internalizing

symptoms and externalizing problems. A longitudinal study of 387 schoolchildren,

teachers, and parents living in the United Kingdom was conducted. This study focused on

children’s experiences in family life and their socio-emotional development (Shelton &

Harold, 2008). Participants received questionnaires containing a variety of measures relating to the quality of family relationships, parent and child psychological health, economic conditions, and family demographics. Results underscore the role of the interparental and parent– child relationships as mechanisms through which the effects of adult psychological health are linked to children’s internalizing symptoms and externalizing problems (Shelton & Harold, 2008). These results implicitly show that parental depression can affect short and long term childhood adjustment. Parental stress has the potential to compound the effects of codependency. Parents may feel they are the blame for their child’s problems and which may inhibit their own esteem of themselves.

This lack of self-confidence may enhance more of the maladaptive codependent coping approaches which would ultimately negatively affect the child. More research into how

parents engage with their child during stressful times would be needed to solidify this

presumption. Having screening tools that could explore connections between stress and

depression could focus interventions for parents on developing coping skills that reduce

stress and depression.

Another article by Creswell, et al (2008) investigated behavioral treatment outcomes when dealing with parents with anxiety. Anxiety disorders are common among parents of anxious children and have been found to impede child treatment outcomes

(Creswell, et al, 2008). The researchers pointed out that there is evidence that parental anxiety is associated with patterns of parenting that promote child anxiety with strong implications toward intergenerational transmissions of anxiety (Creswell, et al, 2008).

The research conducted by Creswell, et al (2008) sought to determine where therapy focus needed to be: on the parents anxiety or on the parents behavior approaches toward the child. In order to make this exploration, the researchers provided Cognitive Behavior

Therapy (CBT) to 22 children, ages 6-12 years old that currently have anxiety disorder

diagnosis. Since assessments were made of the mother- child interaction, the mothers of

these children were also given CBT. The primary disorders of the children were

separation anxiety disorder, social phobia, generalized anxiety disorder, co-morbid

anxiety disorder, co-morbid mood disorder, and co-morbid externalizing disorders.

Several of the findings were found in their research. The main findings were that children

did less well from treatment in which their mothers had a current anxiety disorder

(Creswell, et al, 2008). In addition, treatment of maternal anxiety disorders did not show

a positive correlation with child treatment outcomes (Creswell, et al, 2008). Lastly,

36 maternal over-involvement and expression of fear was associated with child treatment outcomes (Creswell, et al, 2008). Interestingly, characteristics of codependency often relate to an over-involvement of parents without clear boundaries. Applying a measure to test for codependent characteristics would allow for a more adequate account of its influence as an attribute of the parent. Since codependency is not necessarily maladaptive, it may be an element of the parent’s personality that creates a sense of balance in the parenting approach. It would thus be difficult to determine whether codependency was a cause or an effect of the parent’s anxiety without further exploration. Specifically, parents with anxiety disorders may benefit from treatment outcomes that specifically target parenting behaviors (Creswell, et al, 2008).

A final area of parental stress considers how it affects children with major mental health issues including psychopathic traits. Personality characteristics such as narcissism, impulsivity, and callous/unemotional traits are not just attributes of psychopathic personalities but can be attributed to that and other mental health issues. Since codependency can be an outcome to parenting stress, it is necessary to explore all correlates to understand its full impact. A research article by Fite, Greening, &

Stoppelbein (2008) explored factors related to parenting stress and varying personality traits. The researchers administered psychopathic trait and parenting stress indexes to parents of 212 children, ages from 6-12, that were admitted into acute child psychiatric impatient units for treatment. Results showed that parenting stress correlated highly to callous/unemotional behavior, while controlling for aggressive behavior (Fite, Greening,

& Stoppelbein, 2008). The other psychopathic traits did not significantly correlate to

37 parental stress (Fite, Greening, & Stoppelbein, 2008). Although the study was limited in its use of parent-report measures, its measure of negative traits that correlate to parental stress was significant. It is possible that codependency is the moderator between parenting stress and the callous/unemotional behavior exhibited by children. More research on codependency’s relationship to specific behavior outcomes would fortify this presumption and promote the established need for more intervention tools to support parents.

Solutions for Addressing Codependency

Parents universally would benefit from education and information geared toward parenting approaches that provide some level of confidence and competence. Ideally, the more self confident and competent parents feel about their parenting approaches, the more positive the outcomes are for their children and their selves. Moreover, parenting competence and education could make parents more aware of codependent behaviors that may be present or arise due to prolonged stress. These parenting approaches can focus on the roles that parents play, but can also focus on the individual self as a narrative of understanding. A research article by Irvine (Irvine, 2000) explored the notion that self is best understood as a narrative in progress. The article premise is that individual narratives of self become even better to individuals than their real life experiences (Irvine, 2000).

Relationships are especially salient for selfhood and enclose stories of self within them

(2000). The researcher attended over 200 Codependency Anonymous meetings over the course of 17 months. The researcher then interviewed several persons from the meetings.

The researcher’s findings showed that individuals typically have a narrative formula or a

38 sequence of narratives that they tell themselves that propelled and perpetuated them into codependent relating (Irvine, 2000). These narrative sequences are similar in process but unique in story to each individual (Irvine, 2000). Narrative themes found by the researcher included abusive or dysfunctional childhood experiences, excusing the dysfunction in child and adulthood, individuals hitting emotional low points that affected their self confidence, and individuals redeeming the past (Irvine, 2000). Within these self narratives, individuals created stories that often defined their life (Irvine, 2000). The

Codependency Anonymous meetings emphasize that if individuals could rewrite their self narrative, they could rewrite their life. The narratives as explained by the researcher are grounded in institutions which give them life (Irvine, 2000, pp. 25). Though the researcher’s work focused on individuals in Codependent Anonymous meeting, he concluded that the findings could be made to the general public (Irvine, 2000, pp. 25).

The researcher also concluded that the proper study of codependency could be the self in narrative, and the study of the narrative should be considered within institutions (Irvine,

2000, pp.25). These research findings show that interventions for individuals displaying codependent behavior should include an exploration of self and the narratives individuals use to understand and exist within their life institutions.

In addition to an exploration of self in dealing with co-dependent behaviors, mindfulness training with parents has shown substantial promise. A research article by

Singh, et al (2006) examined the outcomes of teaching parents to develop alternative transactional pathways as a means of changing child behavior and enhancing self confidence. The researchers examined three mother-child dyads who each requested

39 mindfulness training to improve their interactions with their children diagnosed with autism. The first mother was 28 years old with a 4 year old with an overall functioning of

10 to 18 months. The second mother was a 24 years old with a 5 year old with an overall functioning of 13 to 20 months. The third parent was a 33 year old mother with a 6 year old with an overall functioning of 15-25 months. Aggression, noncompliance, and self- injury were all behaviors targeted among the children. Multiple baselines were followed by mindfulness training in the research design. Results showed that mother’s mindful parenting decreased their children’s aggression, noncompliance, and self-injury, and increased their mothers’ satisfaction with their parenting skills and interactions with their children (Singh, et al, 2006). The mother’s satisfaction with their parenting skills increased to their highest levels when they began using mindfulness routinely on a daily basis (Singh, et al (2006, pp.174). Mindfulness practice can lead to an emptying of one’s mind of limitations imposed by past conditioning (Singh, et al, 2006, pp.174). Though the research presented a need to validate an approach that would quantify subjective experiences, it was clear that significant changes were experienced among the observable child behaviors. Mindfulness as a means to enhance self-confidence could be subscribed to parents with codependent behaviors. The increase in self confidence would then encourage adjustments to parenting approaches that would positively affect their children. Mindfulness as a parenting intervention tool therefore could benefit parents with codependent behaviors.

A final intervention for parental codependency explored by Kirby-Green &

Moore (2001) examined the effectiveness of Cyclical Psychodynamic Therapy on

codependent behaviors. The primary focus of CPT is to reveal the unconscious, unresolved conflict in order to achieve insight and emotional awareness. The research by

Kirby-Green & Moore (2001) used an exploratory study to determine whether CPT would reduce the manifestations of codependence in families with children who were

legally blind. Participants included six parents of legally blind children and three blind

students with ages ranging from 11 to 17. Participants completed 12 weeks of CPT

therapy and completed a life inventory that measured several factors of codependency.

These factors included the degree to which an individual has an integrated sense of self

and the extent to which the individual is aware of and comfortable with his/her emotions

with regard to integrated primary socialization. Results showed a decrease in the scores

on denial and inconsistency measures from the baseline to the 12th week for three of the

four families (Kirby-Green & Moore, 2001). There was also a decrease in codependent

behaviors between the first six sessions and the second six sessions for seven of the nine

participants (Kirby-Green & Moore, 2001). These finding suggest that CPT may have

helped some individuals gain some insights into how the past has unconsciously

influenced their pattern of behavior and contributed to the cycle of dysfunctional family

relationships (Kirby-Green & Moore, 2001, pp.170). Though this research was limited in

the number of participants and the length of time they were in treatment, there are clear

implications for the potential use of this therapy approach.

Overall the recent literature on codependency reflects a need for more research

into its presence among and effects on varying populations. Researchers have collectively

inferred that conscious and unconscious behaviors as well as environmental factors play a

41 role in the development and presentation of codependent behaviors. Research also suggests that more research on codependency among parents can be done as definitions of codependency become more universally accepted and utilized.

Chapter 3

METHODOLOGY

Introduction

This research design in this study was an exploratory, quantitative study using secondary data analysis. The data analyzed was the actual raw data of the Spann-Fisher

Codependency Scale for parents whose children were referred for treatment in the three month period of November 1, 2009 to January 1, 2010. There was a frequency distribution of scores that was used to directly assess the hypothesis. Results of the smaller group were generalized to the larger population. This research design was used in order to investigate the relationship between parental codependency and the mental health conditions in children. An exploratory research design was the most appropriate design because of its ability to address issues with limited written research (Krueger &

Neuman, 2006, pp.21). The goal in exploratory research is to formulate more precise questions that future research can answer (Krueger & Neuman, 2006, pp.21). Since there was a lack of available clinical research on the relationship between these two variables, an exploratory, quantitative research design was used to learn more about the patterns of correlation between these groups. Quantitative research measures tend to be more open to using a range of evidence and discovering new issues (Krueger & Neuman, 2006, pp.21).

Study Variables and Population

The hypothesis in this research project states that there is a high and significant level of codependency among the parents of the children referred to the Sutter Counseling

Center for mental health treatment. The Sutter Counseling Center is an outpatient mental

health treatment facility that treats youth with mental health conditions. Services are funded by the Sacramento County Mental Health Plan and are limited to those who are

Medi-Cal eligible or authorized in an Individual Education Plan (IEP) by their school

district. The independent or predictor variable was the measure of codependent behavior

in the parents of children brought in for treatment at the Sutter Counseling Center.

Codependent behavior was measured using the Spann-Fischer Codependency Scale. The

dependent or criterion variables were the correlations between the codependency scale

and the diagnosis of the children referred to the Sutter Counseling Center for treatment.

Regression analysis was performed to determine how one variable may predict another

(Cohen & Swerdlik, 2002, pp. 121). Variables explored included codependency scores

and the diagnosis of the children in treatment.

The actual participants were the parent’s respondents of children receiving mental

health treatment at the Sutter Counseling Center. A sample of 30 parent/caregivers of

varying demographics between November 1, 2009 and January 1, 2010 were given the

Spann Fischer Codependency Scale to complete. Parents were randomly selected among

the population of parents with children receiving mental health treatment. Since it would

have been impossible to survey every parent who has brought children in for mental

health services, random sampling was used to approximate the best measure of the

parents with children having mental health conditions. This measurement allowed for

the most appropriate measure in evaluating parents in this study within the designated

timeframe.

Research Instrument

The instrument used in gathering the data was the Spann-Fischer Codependency

Scale. This instrument is a self-report, 16-item Likert type (1-6) scale (Fischer, Spann, &

Crawford, 1991). The scale assesses codependency in terms of an extreme focus outside of self, a lack of open expression of feelings, and attempts to derive a sense of purpose through relationships (Lindley, Giordano, & Hammer, 1999, pp.61) which is why the scale was chosen. The scale developed by Fischer, Spann, & Crawford (1991) used separate samples in order to demonstrate the reliability and validity of the codependency scale. Five sample groups were used. The first two samples, Group A, described themselves on interpersonal measures, the third sample, Group B, described their perception of the family of origins, the fourth and fifth samples, Group C, were drawn to represent known groups (Fischer, Spann, & Crawford, 1991). Each group identified as having codependent behaviors and currently seeking help (Fischer, Spann, & Crawford,

1991). Each group was given a packet which contained demographic questions as well as scales on multiple variables including social desirability, locus of control, and other factor based upon a 38 item pilot scale. Corrected item total correlations were scrutinized with item totals falling below .30 omitted (Fischer, Spann, & Crawford, 1991). This resulted in a 16 item version given to Groups B and C with the internal consistency as measured by the Cronsbach’s alpha ranging from .73 to .80 (Fischer, Spann, & Crawford,

1991). These results indicate that the scales reliability repeats from sample to sample and

that similar groups produce similar mean scores on the scale (Fischer, Spann, &

Crawford, 1991).

Research Design

This researcher contacted the Sutter Counseling Center director Mr. Michael Rogers

LCSW, MBA., who is the Clinical Director and on site supervisor and verbally asked for

permission to have a scale administered to clients at the Sutter Counseling. The director

approved and also approved this researcher to utilize the client database for this study.

The director suggested that the scale be administered as a routine part of the intake

process at the Sutter Counseling Center. This researcher agreed and the scale was

administered to parents of children receiving services through the Sutter Counseling

Center from Nov 1, 2009 thru January 1, 2010.

Data Gathering Procedures

In order to gather data, the survey administers were 20 therapists from the Sutter

Counseling Center. The therapists are each Licensed Clinical Social Workers (LCSW and

Marriage and Family Therapists’ (MFT). In order to conduct this study, a random sample group was taken from completed assessment information provided to clients by therapists from the Sutter Counseling Center. Approximately 30 subjects were randomly selected in

this research design. The therapists administered the Fischer Spann Codependency Scale

to parents of children receiving services through the Sutter Counseling Center. Copies

were given to the Clinical Director at the Sutter Counseling Center. The Clinical Director

removed names and identification used to identify the caregivers of the clients in order to

maintain confidentiality and a random sampling. The Scales were coded to maintain a

random sampling. The scale was then given to this researcher. This researcher then

analyzed the scale for prevalence of codependency among parents/caregivers and

collective themes.

Protection of Human Subjects

This research was determined to be exempt because no harm or discomfort was anticipated for the participants. There were no physical procedures in this research, thus there was no danger of physical harm. It was understood by this researcher that psychological harm is a potential outcome for an individual completing a questionnaire, having privacy invaded, and/or inadequate protection for the confidentiality of data that has been given voluntarily. All precautions to maintain the privacy of the participants and the confidentiality of their data were taken. Identifiers of individual participants in the research were separated from the data and destroyed to eliminate the possibility of

inadequate protection of confidentiality. There were no written records linking

participants to the study, and no lists retained identifying those that did participate. Data

concerning sensitive issues such as legal background, alcohol/ drug use, or sexual

practices was not be collected in this research. Therefore taking all aspects of this

research into consideration, this research was determined to be exempt. The Division of

Social Work through California State University, Sacramento, granted approval. The

Human Subjects application was submitted and approved by the Committee for the

Protection of Human Subjects. The approval number given was 9-10-017.

The data gathered was secondary data as this researcher gathered information from the therapists and not directly from the clients served through the Sutter Counseling

Center. Consent was obtained for assessment and treatment as a routine part of the intake process at the Sutter Counseling Center. As each respondent’s (parent) actual name and

social security number were blocked by Michael Rogers LCSW MBA, who is the

Clinical Director and on site supervisor of this research. This researcher did not have any

access to personal or confidential information that would/could violate confidentiality,

cause risk, or harm and thus require consent.

Chapter 4

RESULTS

Introduction

The purpose of this study was to explore the impact of adult codependency on children with mental health conditions. The hypothesis is this research project states that there is a high and significant level of codependency among the parents of the children referred to the Sutter Counseling Center for mental health treatment. The results of the statistical analysis for this study are divided into three sections: (a) descriptive statistics,

(b) frequency distribution, and (c) inferential statistics. The descriptive statistics section reports the basic demographics of the children of the parent participants in the research study. The frequency distribution section reports the key variables that are related to the research purpose. The inferential statistics section confirms and disaffirms relationships and associations between variables. The final section reports additional findings related to the research hypothesis reported in Chapter 3.

Descriptive Statistics

Demographic characteristics of (N=30) children with mental health diagnosis through the Sutter Counseling Center were taken to highlight a focus variable in this study. The children in this study were taken as a secondary data source from the parents who were given the Spann-Fischer Codependency Inventory in this study. The ages of the children of the parents in this study ranged from 6 to 19 years old with 60% of the children’s ages from 14-19 years old. The identified races in the study were Black,

White, and Latina/Hispanic. The total sample was largely White at 53.3%. The sample of

Black children made up 26.7% and Latina/Hispanic children made up 20%. The research

study was also comprised of 16 male children and 14 female children. All of the parent

participants were identified as the same race/ethnic makeup as the children in the study.

In addition, all the parent participants in this study were single female mothers. These

mothers reported that the father was not in the family unit at this time.

Frequency Distribution

This section reports key variables in this research study. Nine diagnoses were identified among the children of the parent participants in this study as shown in Figure 1.

These diagnoses included Psychotic Disorder NOS, Post Traumatic Stress Disorder,

Mood Disorder NOS, Asperger's Disorder, Obsessive Compulsive Disorder, Adjustment

Disorder, Attention Deficit Hyperactivity Disorder, Anxiety Disorder, and Major

Depressive Disorder. Children with Attention Deficit Hyperactivity Disorder and Post

Traumatic Stress Disorder showed the highest percentage of diagnosis, each at 20% of

the reported diagnoses.

Figure 1. Diagnosis of Child (N=30)

In addition to child diagnosis, the codependency inventory scores of the parents surveyed in this research study were reported. As shown in Figure 2, items on the Spann-

Fischer Codependency Inventory range from a low score of 16 to a high score of 96. The mean score for this inventory is 48. Scores in this research study ranged from 32 to76.

The mean for the distribution was 53.9 and the standard deviation was 11.35. The median codependency inventory score was 54.5 indicating that the average scores were just below the midpoint range of this distribution. The mode score was 66. Over half of those surveyed scored 53.9 or better on the inventory which supports the hypothesis that there is a significantly, higher level of codependency among the parents of the children with mental health conditions.

Figure 2. Total Codependency Scores

Inferential Statistics

In this section the association between variables is reported. Cross tabulation was used in Figure 3 to report the relationship between codependency scores and race/ethnicity. Latino’s scored higher on the codependency inventories with a mean score above 62.3. Black’s had a mean score of 58.3, which was on the higher tier of the distribution of scores and above the mean average for this distribution. White’s had a mean score of 48.3, which was below the mean average for scores in the distribution.

Codependency Scores

Figure 3. Race, Codependency Scores, and Inventory Responses

Table 1. Codependency Scores and Gender of children

Gender of Children

Male Female Total

total codependency score 32 0 1 1

34 0 1 1

37 1 0 1

38 0 2 2

44 1 0 1

46 1 0 1

47 1 1 2

49 1 1 2

50 0 1 1

52 1 0 1

53 0 2 2

56 0 1 1

57 1 1 2

58 1 0 1

59 1 0 1

61 2 0 2

62 1 0 1

64 0 1 1

66 2 1 3

69 1 0 1

70 1 0 1

76 0 1 1

Total 16 14 30

Cross tabulation was used to report the association between codependency scores and the sex of the children in the household. Table 1.1 reports slightly higher codependency scores associated with parents raising boys versus girls. Codependency scores for parents raising boys had a mean codependency score of 62. Codependency scores for parents raising girls had a mean codependency score of 60.7. There was no statistically significant difference in the number of male children and the number of female children.

Table 2. Question (10) from the Spann-Fischer Codependency Inventory

Inventory Frequency Percent Cumulative Response Percent 5 16.7 16.7 Strongly Disagree 4 13.3 30.0 Moderately Disagree 4 13.3 43.3 Slightly Disagree 7 23.3 66.7 Slightly Agree 7 23.3 90.0 Moderately Agree 3 10 100.0 Strongly Agree 30 100.0 Total

Table 2 included Question 10 asked on the Spann-Fischer Codependency

Inventory. The total percentage of the parent respondents to this question is above the mean score for the overall distribution of codependency scores. Question 10 states

“Sometimes I get focused on one person to the extent of neglecting other relationships”.

A total of 56.6 % of the parent respondents’ answers ranged from “Slightly Agree” to

“Strongly Agree”.

Table 3. Question (9) from the Spann- Fischer Codependency Inventory

Inventory Frequency Percent Cumulative Response Percent

3 10.0 10.0 Strongly Disagree 10 33.3 43.3 Moderately Disagree 5 16.7 60.0 Slightly Disagree 7 23.3 73.3 Slightly Agree

5 16.7 100.0 Moderately Agree

30 100 Total

Table 3 included Question 9 asked on the Spann-Fischer Codependency

Inventory. The total percentage of the parent respondents to this question is above the mean score for the overall distribution of codependency scores. Question 2 states “I do not do things for others that they are capable of doing themselves”. A total of 60% of the parent respondents’ answers ranged from “Slightly Disagree” to “Strongly Disagree”.

The percentage of parent respondents’ answers to this question were the largest of any individual question in the Spann-Fischer Codependency Inventory.

There were no associations between the other variables and the codependency scores in this research project. Chapter 5 will explore the significance of the findings and make conjectures about the need and direction of future research on codependency and its correlated variables.

Chapter 5

FINDINGS AND INTERPRETATIONS

The purpose of this study was to explore the prevalence of codependency among parents with children that suffer from mental health conditions. Through this exploration of codependency’s impact on children, the theoretical usage of codependency can be supported with empirical literature. In addition, exploring correlating variables of codependency provides a basis for informing future studies into other research variables and the long-term effects on the children and parents alike. This exploration can aid in providing a stronger knowledge basis from which parents as well as practitioners can benefit.

The different sections of this study have consisted of reviewing varying ideas about codependency and its efforts to develop into a universally accepted framework.

Varying theories and perspectives on codependency were compiled to create a working definition for this study. The preceding chapters investigated empirical literature on codependency. The foregoing chapters also reported the methodology used in this study and the results of the research analysis. This final chapter provides a discussion about the findings and recommendations for future research on codependency.

Evaluation and Implication for Future Researchers

The fundamental hypothesis of this research project stated that there was a high and significant level of codependency among the parents of the children referred to the

Sutter Counseling Center for mental health treatment. As expected, the codependency scores of the parents in the study were higher than the average scores on the inventory.

In addition, frequency distribution showed Latinos and Blacks as having the highest rates of codependency among the ethnic groups in the research study. Scores for both populations were above the mean codependency score. Few available studies have focused on codependency and the specific ethnic cultures. Research has however focused upon predictors of codependency such as self-confidence, and combined combinations of family stressors such as alcohol, physical illness, and mental illness as predictors of codependency (Fuller & Warner, 2000). Further studies would need to explore the associations between these variables their specific proponents within a cultural context.

In addition, more incidences of PTSD and ADHD were reported among black children. A considerably small sample was used in the study preventing a clear picture of the population at large. The implications of this research however infer a need for more exploration into ethnicity and child mental health disorders. A research article by Finzi-

Dotton, Manor, & Tyano (2006) reported that parental promotion and restriction of autonomy with children with high levels of temperamental emotionality predicted anxious and avoidant attachment. Anxious and avoidant attachment are characteristic of

ADHD. More exploration on the cultural impact of parental promotion and restriction of autonomy would provide deeper ethnic correlates between codependency and mental health disorders.

In addition, high responses to the varying codependency questions such as (a)

“Sometimes I get focused on one person to the extent of neglecting other relationships” and (b) “I do not do for others things they can do for themselves” reflect the internal view of self of the many parent respondents. Research by Wells, Glickauf-Hughes, & Jones

(1999) supports the idea of codependency being a specific way of viewing ones “self”, as opposed to a style of responding to a particular behavior. Extreme focus on others to the degree of self neglect seems to be the major characteristic of the parents in this research population. This finding is consistent with Lunghead & Yuan-Yu ting (1998) theorizing of individuals with codependent behavior as persons who invest inordinate amounts of energy in efforts to improve others in order to find self-worth. Further research would need to be conducted to determine whether these high responses are indeed an attempt to obtain some level of self worth or an unrelated response to the inventory given.

Additional findings included no associations between codependency scores and parents raising boys versus raising girls within the research study. There were also no significant associations between codependency scores and the ages of the children receiving mental health services through the Sutter Counseling Center.

Study Limitations

There were several limitations in this research study. A substantially small research sample was used to explore the research hypothesis. A larger sample size may have allowed a greater representation of the actual population of parents and children with mental health issues. Using other minority populations could provide clarification of reported differences in scale elevations for ethnic groups. In addition, the sample group was a clinical population from the Sutter Counseling Center. Since Sutter

Counseling Center is an outpatient mental health facility that treats children, the research population used may be neither representative of the greater population nor indicative of a universal clinical population. Also, there was a minimal number of represented child

59 mental health diagnoses represented in the research study. Due to the varying nature of diagnoses and the tendency of agencies to change and update diagnoses, there is a need to explore correlations between parent codependency and child mental health diagnoses at varying intervals during the therapeutic process. Lastly, the population of parent respondents in this research study was specifically mothers. A study using male participants would help to identify the range of various personality disorders among men diagnosed as codependent and address sexual stereotypes within parenting roles. Further research would need to explore other parental dynamics including dual parent households, same sex parents, and children parented by other “non-parent” relatives.

Implications for Social Work

Overall, this research project has practical applications for future research in social work. The reported data shows that there is indeed a need for social workers to explore parental codependency among child mental health populations. This research provides a sound review of relevant literature on the historical development of codependency, predictive factors of codependent behavior, parenting styles, parenting stress, and the effects of codependency on children. With this research, social workers should be more inclined to explore larger sample sizes, varying minority groups, and more representative population with greater depth. With increasing depths of research social workers will be more equipped to support parents with codependent characteristics as well as children with mental health conditions.

APPENDIX A

Questionnaire Please circle the answer the most fits.

Q1. It is hard for me to make decisions. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q2. It is hard for me to say “no”. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q3. It is hard for me to accept compliments graciously. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q4. Sometimes I almost feel bored or empty if I don’t have problems to focus on. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q5. I usually do not do things for other people that they are capable of doing for themselves. Strongly Moderately Slightly Moderately Slightly Agree Strongly Agree Disagree Disagree Disagree Agree

Q6. When I do something nice for myself I almost feel guilty. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q7. I do not worry very much. Strongly Moderately Slightly Moderately Slightly Agree Strongly Agree Disagree Disagree Disagree Agree

Q8. I tell myself that things will get better, when the people in my life change what they are doing. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q9. I seem to have relationships where I am always there for them but they are rarely there for me. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q10. Sometimes I get focused on one person to the extent of neglecting other relationships and responsibilities. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q11. I seem to get into relationships that are painful for me. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q12. I don’t usually let others see the “real” me. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q13. When someone upsets me, I hold it in for a long time, but once in a while I explode. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q14. I will usually go to any length to avoid open conflict. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q15. I often have a sense of dread or pending doom. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

Q16. I often put the needs of others ahead of my own. 1. Strongly 2. Moderately 3. Slightly 4. Slightly 5. Moderately 6. Strongly Disagree Disagree Disagree Agree Agree Agree

APPENDIX B

Correspondence 1

From: Rosenfeld, George W. [mailto:[email protected]] Sent: Tuesday, September 22, 2009 2:05 PM To: Fischer, Judith Subject: Reprint request

Judith Fischer:

Could I please have a reprint of your article: Measuring codependency. By Fischer, Judith L.; Spann, Lynda; Crawford, Duane W. Alcoholism Treatment Quarterly. Vol 8(1),1991, 87- 100.

And a copy of your Fischer-Spann codependency inventory for a student who is interested in using it for his masters dissertation.

Thank you.

Sincerely, George Rosenfeld, Ph.D.

APPENDIX C

Correspondence 2

From: Fischer, Judith [mailto:[email protected]] Sent: Tuesday, September 22, 2009 1:26 PM To: Rosenfeld, George W. Subject: RE: Reprint request

Here is the copy you requested. The scale is on the last page of the article along with how to score it. The student has permission to use the scale; however, the copyright remains with us. I would appreciate a copy of the abstract when the student has concluded his work. I wish him well on it!

Judith Fischer

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