By Debra Alper, LCSW

Clinicians see clients who present as being stuck in relationships that they can’t seem to leave no matter knowing how painful and destructive the relationship continues to be. Through a clinical lens this can present in a familiar way. Codependency. Anxious Attachment. Low self-esteem. All of these are viable diagnoses; however, they are lacking in a broader framework. Addictive love, although not a specific diagnosis, is a pattern that needs to be treated and understood holistically and without the full framework of understand it becomes very difficult to help the client trapped in the toxic relationship.

There is much very important literature and teachings on attachment theory and codependency. What is lacking theoretically is an understanding of how addiction and relational attachment collide. This space is where addictive love lives, and it may have aspects of anxious attachment and codependency and low self-esteem as a part of it but it is not the same thing and should not be treated the same.

The Codependency Misread

Understanding codependency began as a way of explaining the relational patterns of people who were involved with substance abusers. It broadened to describe an excessive focus of taking care oof other’s needs at the expense of one’s own needs and interests. Certainly, there are many clients who present with behaviors that fall squarely into this framework, but it is not a one size fits all explanation for everyone. For people who stay stuck too long in a relationship, understanding it as codependence alone can do more harm than good.

When a clinician sees this client thru the codependent lens, treatment focuses on boundary setting, self-care and rebuilding an individual identity. No doubt this is all part of the work that needs to be addressed but focuses on the surface behaviors and interventions without addressing the neurobiological and psychological factors at play. This results in the client doing real work but still either not being able to leave or leaving and going back, developing a relational cycle. At this point, clinicians not aware of the deeper explanation can easily see the client as being resistant.

The Anxious Attachment Misread

Attachment theory does address some of the neurobiological issues that present in addictive love relationship. It recognizes the hypervigilance, the complete absorption the client experiences and the fear of abandonment that is ever present in addictive patterns. But attachment style describes a relational style that pulls people toward closeness or away from intimacy. It looks at a style of relating in a relational world that develops in childhood and presents pervasively in relationships.

Addictive love is a state of activation that is directed to a specific person in a particular dynamic. The pattern that evolves is reinforced by intermittent reinforcement, inconsistency, unpredictable reward and the biochemical changes that occur from living in this relationship.

This matters in how a clinician treats this client. Anxious attachment responds very well to understanding the clients’ relational models and seeking more secure partners and communicating with them around potential triggers. Addictive love requires something closer to what we understand about addiction recovery, including an honest understanding of the withdrawal process, the way the nervous system will manufacture reasons to return that have nothing to do with love and everything to do with regulation and the high and probable rate of repeated return without incurring self-shame. A client who is told she has anxious attachment and is encouraged to work toward a more secure style is being given a map to the wrong destination. She is not anxious in general. She is addicted to a specific person, and the mechanisms driving that are not fully addressed by helping her feel more securely attached.

What Gets Missed When the Diagnosis Misses

The most important element that gets lost in each diagnostic misreads is the experience of treating the relationship as an addiction. When leaving an addictive relationship, people don’t just grieve and move on. They go through a process very similar to substance or gambling withdrawal that includes obsessive thinking about their partner, physical symptoms of insomnia, loss of appetite, an overwhelming pull towards returning to the relationship, and a distortion of the way they remember the relationship, the abusive behaviors and the person themselves. I call this the Fog, because everything gets blurred and diminished and instead of being able to hold on to the truth, an idealization blows in. Their partner begins to feel irreplaceable, and people can feel as though they can’t exist without them. An abusive relationship that intermittently brings some moments of connection feels better than sitting with the emptiness that is left in the wake of the ruptured connection. Clinicians who do not understand or view the dynamic through the lens of addiction can pathologize the withdrawal as unresolved attachment rather than a predictable path of recovery.

Also, the inevitable feelings of shame that accompany these relationships can be exacerbated by seeing the withdrawal through the wrong lens. Codependency, even when looked at compassionately through therapy, carries the implicit message that the clients’ actions and choices are the primary cause of the situation. For someone in an addictive relationship, who is with a coercive controlling partner, that is just not accurate. Clients in these relationships already carry enormous shame about their inability to leave, about the gap between what they know and what they can do. A framework that locates the problem primarily in their relational style adds another layer to that shame without giving them anything more useful to work with.

Toward a More Accurate Clinical Picture

None of this is to say that there is not an important role for attachment theory and work around codependency in relationships. But it is an important distinction to make that addictive relationships can have attachment and codependent issues involved in the relationship, but also need to be treated  in a way that looks at the neuroscience issues, the role of intermittent reinforcement, the withdrawal process itself, the repair of the trauma bond and the rebuilding of the self. The treatment needs a strong framework that attends to all these issues, not just familiar diagnoses that seem to fit.

For clients going through these patterns, getting the diagnosis right is the difference between a treatment that meets them where they are and one that asks them to work harder at something that was never going to change the relational dynamic. The clients deserve a more accurate treatment and understanding and clinicians deserve a framework precise enough to meet their client’s needs.

Debra Alper, LCSW, is a licensed clinical social worker with 26 years of experience specializing in coercive control, emotional abuse recovery, and relational strategy. She maintains two practices in Chicago: Life Transitions Counseling, PLLC, and Debra Alper, Divorce Consultant | Relational Strategy. She is the author of the forthcoming book Undertow: The ISLAND Method for Breaking Free from Addictive Love.