Co-dependency and Enmeshment — a Fusion of Concepts

Co-dependency and enmeshment have been used interchangeably in psychological and psychotherapeutic practice. The commentary offers a discussion on the conceptual development of both concepts, highlighting the historical differences and similarities. It suggests that there are specific schemas and modes which operate within the scope of both concepts. The Bacon & Conway - CODEM Model 2022. is introduced to describe the schemas and modes associated with enmeshment and co-dependency. The conceptual model of enmeshment and co-dependency is offered with the intention to help the reader to identify and find ways to address these patterns. A fictional clinical case scenario was offered to illustrate the discussion. Further research is currently being developed to offer a robust empirical base for the model proposed.


Introduction
There is a recognized acknowledgment that co-dependency and enmeshment are complex problems affecting the psychological wellbeing of many individuals.Although co-dependency and enmeshment have common features and have been used interchangeably in practice, the concepts are often confused, thus impacting the understanding and treatment of both problems.
This commentary article offers a comparison of conceptual definitions, historical development, and similarities, and differences between both concepts.It describes the specific patterns which operate within the scope of both concepts.A conceptual model of the relationship between enmeshment and co-dependency is offered with the intention to help the reader identify ways to address these patterns.This conceptual model is influenced by schema therapy, an integrated psychological approach that provides a thorough definition of enmeshment and how a person might develop an enmeshment pattern.The conceptual model provides a framework for understanding the relationship between enmeshment and co-dependency.This discussion is geared to shed light on increasing understanding, improving therapeutic interventions, and benefiting clients.

Co-dependency
The concept of co-dependency is widely used in healthcare practice, especially in the field of drug and alcohol rehabilitation (Bacon et al., 2017).Despite its considerable usage, there is much controversy and misunderstanding about co-dependency as this concept is not clearly defined and understood.There are no agreed diagnostic criteria for co-dependency; it is not listed as a psychological disorder in the DSM-V (American Psychiatric Association, 2017) (Bacon et al., 2020a, b).
The concept of co-dependency carries a history of complex and interconnected terms, assumptions, and models that have been interpreted differently over time, reflecting a set of values and meanings carried by diverse communities operating in different time periods.Successive attempts have been made to present a unified definition of co-dependency.These efforts have generated models and research; however, they overlap and continue to operate simultaneously in the present (Bacon et al., 2020a, b).
There are 3 main streams of influences in the historical development of the concept of co-dependency: (1) psychoanalytic perspectives, (2) the 12-step approach for drug and alcohol treatment, and (3) family therapy models.
Initial formulations of co-dependency appeared in the USA in the 1940s and were linked to the work of Horney, a neo-Freudian psychoanalyst prominent at the time (Horney, 1950).Horney talked about "morbid dependence" described by her as a "drive for total surrender," "the longing to find unity through merging with a partner," and the "drive to lose oneself."These behaviors were observed as typical of spouses of alcoholics, leading health professionals to suggest a simple linear causal relationship between the non-alcoholic spouse's behavior and the problem drinking of the alcoholic (Bacon 2015;Bacon et al. 2017).
The concept of co-dependency gained strength within the growing Alcoholics Anonymous (AA) movement in the USA during the 1960s-1970s.The twelve-step recovery movement was pivotal in framing the concept as a psychological disorder, suggesting that people who were in close relationship to alcoholics or any substance user were enablers, "co-alcoholics" or "co-dependents" (Bacon et al., 2020b).
Co-dependency was also influenced by models of family therapy which emerged in the USA in the 1970s (Bowen, 1974;Bowlby, 1973;Minuchin, 1974;Satir et al., 1994).The structural, Bowenian, psychoanalytic, and attachment models agreed on the influence of early formative experiences within the family (behavioral, emotional, and interactional patterns) in shaping problematic relational patterns, including co-dependency, in adult life (Bacon, 2015).
Co-dependency became more disseminated in clinical and popular arenas from the 1980s onwards (Bacon, 2015, Bacon et al., 2020a, b).Three models were suggested: the disease model (Whitfield 1989), the personality model (Cermak, 1986), and the interactionist model (Wright & Wright, 1991).The disease model offered a perspective of co-dependency as a medical illness and attempted to offer diagnosis and treatment.The personality model of co-dependency attempted to identify personality and constitutional factors in predisposing individuals to develop co-dependency (Cermak, 1986).The interactionist model offered a combination of both interpersonal and intrapersonal factors in the development and maintenance of co-dependency (Wright & Wright, 1991).
Definitions of co-dependency have been attempted over the years.A useful systematic analysis of the most cited definitions available in the literature to that date identified a common thread of four factors repeatedly mentioned by the different theorists: external focusing, self-sacrifice, interpersonal conflict and control, and emotional constraint (Dear & Roberts, 2005, p. 294).
A systematic review of the interventions used to treat co-dependency found they were grouped into three main modalities: group therapy, family therapy, and cognitive therapy (Abadi et al., 2015).The authors highlighted that group treatment promoted the most interventions targeted to address co-dependency; however, the authors pointed out that the lack of agreement about definitions and measurements for co-dependency were factors that prevent development of more effective co-dependency treatments.
A qualitative analysis of the lived experience of co-dependency by Bacon (2015), Bacon et al. (2017Bacon et al. ( , 2020a, b) , b) revealed that self-identified co-dependents experienced an undefined sense of self and looked for external frameworks to obtain self-definition.The research found that co-dependents behaved like chameleons; their lack of clear sense of self drove them to over-adapt to the needs of others, excessively so, even in detriment of their own needs.These participants experienced enduring pattern of extreme emotional, relational, and occupational imbalance, and linked problems of co-dependency to formative experiences of parental abandonment and excessive control in childhood (Bacon et al., 2020a).They used recovery groups for co-dependency to obtain a framework for their lives.The group met some of their needs for validation, safety, and belonging (Bacon et al., 2020b).
In summary, co-dependency is a chameleon concept, which takes many forms and is not clearly understood (Bacon et al., 2020a).The co-dependency literature offers various models, treatment, and recovery perspectives based on individual and group therapy modalities (Abadi et al, 2015;Askian et al., 2016); however, the evidence on the effectiveness of models and treatment approach is still debatable (Bacon et al., 2020b), thus justifying the need for additional exploration into advanced models and interventions.

Enmeshment
Enmeshment can be defined as the experience of confusion of one's separateness from others, a diminished sense of self that includes a loss of autonomy in relationships, and an inability to fully experience, understand, and value one's own thoughts, feelings, and needs in the context of relationship.
The concept of enmeshment also has its origins in family therapy models in the 1970s.The concept appeared more prominently within the structural family therapy model (Minuchin, 1974).Minuchin (1974) proposed that family systems were organized into subsystems (the spouse subsystem, the parental subsystem, and the sibling subsystem).These subsystems carried a set of boundaries which defined roles and participation in family functioning.These boundaries exist on a linear continuum, ranging from diffuse boundaries (enmeshed) to rigid boundaries, on opposite ends of the continuum.While diffuse and rigid boundaries are viewed as dysfunctional, the normal range boundaries, in the middle of the continuum, are ideal for facilitating functional relating and adaptation.Minuchin explained that family enmeshment happens when family members are not differentiated and become over-dependent on each other, thus blocking individual family members from attaining autonomy (Nichols and Schwartz 1998) .

Schema Therapy Perspective on Enmeshment and Co-dependency
Schema therapy is an integrative conceptual and treatment model developed by Young and colleagues in 1990 (Young et al., 2003).The model integrates key elements of cognitive behavioral therapy, attachment theories, Gestalt therapy, object relations, constructivism and psychoanalysis.Young et al. (2003) define early maladaptive schemas as a theme or pattern comprised of memories, emotions, cognitions, and physiological responses, which are developed during childhood and elaborated throughout lifetime, causing a degree of dysfunction (p. 7).The model describes how internalized maladaptive schemas are engendered through repeated episodes of emotional and relational need neglect and/or toxic experiences during the developmental period of a person's life.It highlights the impact of unmet needs during that critical period as the root cause for chronic intrapersonal and interpersonal struggles.
The development of various schemas in one's early life sets the stage for an adult life viewed through the prism of these specific inculcated schemas.These have important implications for forming relationships, as well as many, if not all, adult life choices.
There are five domains of unmet needs that lead to the development of the 18 schemas which are behaviorally addressed and sometimes directly expressed in various modes.The domains are as follows: I. Disconnection and rejection II.Impaired autonomy and performance III.Impaired limits IV.Other-directedness V. Over-vigilance and inhibition

Schema Domain II -Impaired Autonomy and Performance
In schema work, the enmeshment and undeveloped self-schema is under the domain of impaired autonomy and performance.Young et al (2003) define enmeshment and undeveloped self-schema as "Excessive emotional involvement and closeness with one or more significant others (usually parents or partners), at the expense of full individuation or normal social development.One or both of the enmeshed individuals will often feel they will not survive or have a reason for living without the constant involvement of the other".According to the authors, enmeshment may also include feelings of being smothered by or fused with others or insufficient individual identity.This is often experienced as a feeling of emptiness and floundering, having no direction, or in extreme cases questioning one's existence.
This schema is created in childhood, due to lack of necessary attention placed on the child's need to develop a sense of autonomy and competence.This typically occurs due to the imposition of parental needs ("parent" is used in this paper to cover all care givers) and aspirations that too often took precedence over the child's needs, wants, and cultivation of their self-understanding.
Therefore, when a person's development of autonomy is perpetually tamped down, the capability to interact in a more independent way is undermined, thus weakening their sense of self.This lack of autonomy, along with a lack of attunement or understanding of the need to cultivate autonomy during the early developmental stages of life, undermines a sense of self, which is based on knowing, understanding, and valuing one's thoughts, feelings, and inclinations.What serves as a partial replacement to this weak sense of self is a mode, or way of being, in which the person overfocuses on attending to and garnering the approval of others.This outward-focused, other-directed behavior becomes an inadequate replacement for an actual authentic identity.The external manifestation of these challenges can play out in the dynamic described above as co-dependency.They manifest as co-dependent behaviors such as other-directedness, subjugation, and self-sacrifice.Concurring with this, the qualitative analysis of the lived experience of co-dependency by Bacon (2015), Bacon et al. (2017Bacon et al. ( , 2020a, b) , b) highlighted those self-identified co-dependents experienced an undefined sense of self, and that their lack of clear sense of self drove them to over-adapt excessively to needs of others, in an attempt to find external frameworks to obtain self-definition.

Schema Domain IV -Other-directedness
Within the schema therapy perspective, the Schema Domain IV -Other-directedness represents a tendency to place excessive focus on meeting the needs of others at the expense of one's own needs (Young et al., 2003).Young et al. explain that this happens as the person needs to gain approval, maintain connections, and avoid conflict.This explanation aligns with external focusing factor identified by co-dependency authors (Dear & Roberts, 2005, Lampis et al., 2017;Bacon et al., 2020a, b).These authors highlighted the tendency presented by co-dependents to draw opinions, expectations, attitudes, and behaviors from situations outside the self.So, in being externally focused, the person develops a sense of self and purpose from external factors and persons.
A number of schemas associated with co-dependency fall under this domain.The subjugation schema described by Young et al. (2003) explains the suppression, containment of own preferences and desires, and subjugation of emotions.These behaviors are related to the emotional suppression and emotional imbalance factors found by co-dependency authors (Bacon et al., 2017;Dear et al., 2005;Spann & Fischer, 1990).Within the codependency perspective, emotional suppression happens when there is avoidance of feelings, with the person living in a state of constraint with limited self-awareness of own emotional needs (Dear et al., 2005;Spann & Fischer, 1990).Young et al. (2003) describe self-sacrifice schema as a tendency to excessively meet the needs of others at the expense of one's own needs and gratifications and suggested that this is found in co-dependency.The authors identify common reasons for this as guilt for expressing needs and fear of losing connection with the person.Co-dependency authors agree with this and identified self-sacrifice behavior as a tendency to overlook personal and intrinsic needs in order to focus externally on the needs of others (Bacon et al., 2017).Interpersonal control and conflict were thought to be related to the interpersonal dynamics that occur as a result of engaging in relationships which foster self-sacrificial behaviors and lack of emotional expressivity (Dear & Roberts, 2005;Lampis et al., 2017;Spann & Fischer, 1990).

Co-dependency: an Outward Manifestation of Enmeshment
Co-dependency is an outward manifestation of enmeshment.Enmeshment occurs due to lack of autonomy fostering and parental attunement, causing the person to develop a false sense of self, a self which is directed towards meeting the needs and demands of others.The person engages in self-sacrifice behaviors and attempts to meet unrelenting standards of perfection to draw attention and the approval of others.Self-sacrifice behaviors are linked to feelings of guilt for not perfectly attending to the needs of a demanding other, along with subjugating their own needs due to fear of rejection and abandonment.
Enmeshment includes a complex interplay of the intrapsychic experience and certain kinds of situational and relational variables that activate an internal experience that can lead to co-dependent behavior.Co-dependent behavior can be seen as an over preoccupation with and efforts towards another (enabler), where the person is constantly conforming to the needs of others.This behavior is viewed from a schema therapist perspective as the activation of the compliant surrender mode, which acts in accordance with the schema.This is in contrast to the other coping modes which are activated to provide the illusion that the schema does not exist.For example, the avoidant mode bypasses any possible interaction that could cause a person to submit to the Schema.The overcompensator mode is a way of being that utterly denies the schema and in fact presents a set of behaviors that suggests a person on the opposite side of the internalized schema.
The Bacon & Conway -CODEM Model 2022 described below captures the integration between schemas and co-dependent behaviors.

Bacon & Conway-CODEM Model 2022
The Bacon & Conway-CODEM Model 2022 is a conceptual model, which summarizes the integration between schemas and co-dependent behaviors.It is a dynamic and evolving model, centered in enmeshment and undeveloped self, with key interlinked components causing a dysfunctional synergy manifested as co-dependent behaviors.
The model proposes that the underlying foundational problem for co-dependent behaviors is impaired autonomy and performance, developed in childhood because of deficits in parental attunement and lack of autonomy fostering, which caused enmeshment and undeveloped self.enmeshment and undeveloped self is placed at the center of the model, as the root cause for co-dependent behaviors.
Co-dependent behaviors are manifested as core schemas such as self-sacrifice, perfectionism, and subjugation of needs.When a person suppresses or otherwise tries to control their emotions, it often leads to a range of interpersonal conflicts.Some conditional schemas are developed later in childhood as a way of seeking relief from core schema of enmeshment.These schemas may camouflage the enmeshment schemas, but in reality serve to perpetuate the schema; for example, the other-directness schema often results in co-dependent behaviors.
The Bacon & Conway -CODEM Model 2022 is based on conceptual definitions, previous research conducted in the field, and clinical practice (Fig. 1).The model has been developed with an eye to further research and clinical practice in the field.The authors are currently exploring the connection between early maladaptive schemas and the lived experience of co-dependency.A treatment model aimed to assist therapists working in the field of co-dependency and enmeshment is forthcoming.

Implications for Clinical Practice -Case Example Susan
Schema therapists support clients to meet their core emotional needs: secure attachment, autonomy, freedom of expression, spontaneity, and limits.Therapists aim to support clients to be more attuned to their inner worlds to express needs and feelings (Conway & Aydagul, 2020).The healing of schemas is mainly accomplished by meeting the needs that were originally neglected.This is done within the therapeutic relationship, using experiential exercises combined with and other therapeutic strategies.
The enmeshment and undeveloped self-schema is a schema born of unmet needs of autonomy and attunement.This schema makes it very difficult for a person to develop relationships with others based on mutual respect and understanding.By focusing therapeutic attention on these needs, this deeply ingrained pattern can be changed.This in turn will weaken the modes so that the healthy and autonomous adult can engage others with a sense of agency and an aspiration to cultivate deeper and more authentic connections.
Self-reflection is also an important element of this process, where the therapist helps the client to develop an authentic sense of self based on the person's connection with his/hers/ their own thoughts, feelings, inclinations, and needs.This combined approach will help the person to learn to value their inner life and feel freer to express their thoughts and feelings to others.
Here we offer a fictional clinical case scenario to explain the integration of concepts of co-dependency and enmeshment in clinical practice.

Case Example -Susan
Susan, 35, is married to Tom for 10 years.She came to therapy because she felt unhappy and unbalanced in her relationship and did not know how to change the dynamics so that she could more often ask for what she needed.Susan's motivation to change her dynamic with Tom was intensified with their consideration of starting a family.She believed she was in a co-dependent relationship.She also complained of periods of depression, which she mainly attributed to her difficulty with forming a close and harmonious connection to Tom.That said, she also acknowledged that she had a long history of depression before meeting him.She explained that her current relationship with Tom was like previous romantic relationships.In these relationships, she was preoccupied with what the other wanted and needed, and sacrificed herself to attend to the other.She suppressed her needs and feelings, and asked for very little in return.At times, she would hit a breaking point and would demand that she be attended to as well, which was usually rebuffed with an accusation that she is overly emotional and needy.
Her early history included many arguments between her parents and feeling sorry for and wanting to protect her mother.Her parents' struggles culminated in divorce when Susan was 8 years old.She stayed with her mother and helped her take care of her younger sister and brothers.She also gave a great deal of emotional care to her mother, who complained liberally of her father's failings before, during, and long after their divorce.Susan thought of her father as a bad person until she was a young adult and came to see that he was capable of kindness and supportiveness.It was at this time that she determined her mother had painted a distort, ugly picture of her father, which left Susan to believe her mother had manipulated her to get attention and sympathy.Susan served as a surrogate parent to her mother throughout her childhood and adolescence and, in some ways, still does.Susan often felt that her feelings and needs would get in the way of her mother's needs and so she carried the idea that she did not have any needs worth meeting.Among other schemas, Susan developed a strong enmeshment and undeveloped self-schema.
From her college years forward, Susan became more mistrustful of her mother and, while attempting to keep distance from her, started to struggle with depression.She stopped college for a year to help her mother, who was receiving her own mental health treatment for major depression.During this time, she found herself increasingly angry at her mother.Her attempts to create distance were thwarted by her mother's insistence on being an essential part of Susan's life.
Susan discovered in schema therapy treatment that she served as a surrogate to her mother throughout her childhood and adolescence, and continues to do so in some ways.Among other schemas, Susan developed a strong enmeshment and undeveloped selfschema; building a greater sense of attunement and autonomy was central to the therapeutic relationship.First, the therapist considered the unmet needs that created the enmeshment schema in the first place.Next, in what is called the reparenting relationship, the therapist and Susan attempted to attend to these specific unmet needs.Extra attention was placed on the goals of understanding her experience and strengthening her ability to reflect on her internal experiences, including thoughts, emotions, or both.Therapy then focused on placing a higher value on Susan's internal experiences, especially in relationship with another person.
Building autonomy in the reparenting therapeutic relationship was also essential.To stimulate this in the dynamic between Susan and the therapist, the therapist suggested different topics and strategies for working in a session and asked Susan to consider what would be the most helpful way to work.Therapeutic attention was also focused on interactions with Tom and others in which she tended to meld into the other person to get along.The therapist explored what was going on inside her in terms of the vulnerable child and demanding parent mode and helped her consider other ways she could have addressed a topic or issue in which her thoughts and feelings were also valued.The therapist also did role-plays to create heightened awareness of what Susan felt and thought in various interpersonal scenarios.
After about a year of working together, Susan was starting to reap the benefits of her investment in therapeutic work.She began to cherish her thoughts and feelings more and had become assertive about expressing herself, even in the times when she had conflict with Tom.At moments, it seemed that the relationship would not survive as Tom was rebelling against Susan's new lack of conformity.At other times, Susan questioned how she could go on with a guy who tries to stifle and minimize her point of view and her related emotions.But over time, both seemed to be more accepting of each other.Tom started to notice a new vitality in the relationship, in part attributable to Susan being a more dynamic force.Susan noted Tom's attempts to be more flexible and had hope that he would continue to grow in this way.
It is impossible to know what the future holds for Susan and whether she will continue to cultivate a stronger sense of self that has allowed her negotiate relationships with Tom and others in a more reciprocal way.She appears to be pleased with her progress in this area so far and seems determined to grow as a relational person who is able to be sensitive to the needs of others as well as her own personal and relational needs.

Conclusion
Co-dependency and enmeshment have been used interchangeably in psychological and psychotherapeutic practice.There is still much confusion and misunderstanding about both concepts; they are not clearly defined and understood.Although both concepts are distinct, they carry common features and therefore have been used interchangeably.
The authors discussed the development of both concepts, highlighting the historical differences and similarities between them.Specific schemas operate within the scope of both concepts; a fictional clinical case scenario was offered to illustrate the discussion.
The Bacon & Conway -CODEM Model 2022 is introduced to describe the schemas and modes associated with enmeshment and co-dependency.The authors hope that the model will serve as a base for research and interventions to assist people to break free from these patterns and to experience a more balanced and fulfilling life.
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