In the first article in this series we highlighted needs and motivations behind providing emotional and psychological support to others, touching on the “shadow” side of helping: trying to meet personal needs through the helping relationship. Both professional and non-professional helpers can unwittingly do this, even when they are meticulous, highly ethical helpers, so it is crucial to gain an understanding of how this happens.

The principal concepts we will be working with in this article are narcissism, transference and countertransference, enmeshment, rescuing, co-dependency, and burnout.

Narcissism: the self-centred helper

Defined as the “failure of relationship”, narcissism takes its name from the Greek myth about the aloof but magnetic young man who is enraptured by the beautiful image that he sees reflected back at him in a pool of water. He falls in love with the boy in the pool and wants to be with him always. The gods turn him into a narcissus, the flower that grows by the side of the riverbank, so that he can hang over and enjoy the gazing (Pontikis, 2010).

Similarly, narcissists are seriously self-absorbed. Swinging between an arrogant sense of entitlement (“nothing but the best for me”) and the despair of feeling that they have nothing at all to offer, narcissists lack compassion, both for themselves and for others. Often possessing a veneer of charm, they can attract people to themselves. But their relationships cannot work long-term because narcissists are not in relationship with themselves. Beneath the charm is a stone-cold heart. In between the extremes of emptiness and thinking that they are “special”, there is no middle place of right-valuation of themselves (watch our popular YouTube lecture on Narcissism to learn more about the topic).

One way in which these self-centred behaviours show up in a helping relationship is that, because the narcissistic helper is not truly sensitive to the helpee, the “helping” acts are performed in a way that meets the needs of the helper, but not necessarily the helpee. You may have seen them in action already. There is the professional that you go to see who spends the whole appointment time talking about themselves. There is the volunteer at the disaster scene who is quick to grab the credit when the media’s cameras are rolling. He believes that his little contribution was massive and must be immediately recognised above all others – even if he has done relatively little.

Then there is the self-help group member who just “knows” that her story of addiction recovery is wonderful material for a hit movie; she spends all the time at the meetings letting other members know just how great her particular recovery effort was. Sadly, narcissism is not just seen around Hollywood. It can strike anyone, even adults who were not previously afflicted, if the person – perhaps as a result of life circumstances – comes to regard that he, his gifts, and his life are “special”.

Transference

Imagine these two situations:

1. You enrol in a course on French cooking. As you come in and see the instructor, a pleasant-looking man (or woman) from Paris, you have an immediate and strong emotional reaction. You suddenly find yourself overwhelmed with the desire to cook with creative abandon, and to please him/her by showing him that you can do this French cuisine thing, but you are also aware of an uncharacteristic sense of self-doubt and fear of failure.

2. You offer to run a support group for teenage girls who have just given birth and are solo parenting. You give a lot of attention to one of the young women, Maya, but it is not positive attention. From the very first meeting, you notice that when she says something, you find yourself wanting to argue with her. When she is quiet, you feel the desire to challenge her on lack of participation. Generally, you crack the whip hard on Maya, which surprises you, because you pride yourself on being fair.

If you have ever experienced reactions like those described in the above situations, where you had an intense reaction to someone whom you just met or at least didn’t know very well, then you may already be familiar with the experience of transference. Transference has been defined as a person’s carryover of feelings from past relationships into a new one. The normal relationship-building activities of many sorts of support work create feelings of safety. Being deeply listened to without judgment, being given unconditional positive regard and being inspired with hope create the conditions which can enhance transference. It often operates at an out-of-awareness level, and involves helpees and others putting onto a helper past feelings or attitudes they had towards significant people in their lives. It typically has its origins in early childhood, and often involves a repetition of past conflicts (Corey and Corey, 2007).

In the examples above, the French cooking instructor may have reminded you of your own creative but critical father/mother, whom you tried over and over again – perhaps without much success – to impress. Failing to earn his/her approval, you may have spent most of your life looking for other people who could be in the role of “dad/mum” and from whom you could elicit approvals. Working things out with a “fake” dad/mum, however, is never as satisfying as doing so with the person with whom we had the original, and probably unfinished, conflict, so we keep setting up more such situations, usually without realising it.

In the second example, Maya may have reminded you of yourself at that age. When family-of-origin caregivers lacked compassion towards you, their feelings of non-acceptance may have been planted in your mind. Unable to deal with that at the time, you may gone all these years with the fires of self-hatred secretly smouldering inside you, only to come alive now and be put onto Maya.

Or both of these examples could stem from very different histories. The point about transference is that strong feelings are evoked that do not make sense in the context of the present relationship. The helpee’s feelings that are evoked can be either positive, such as liking or attraction; negative, including such reactions as mistrustfulness and dislike; or neutral. While some types of transference may be more pleasant to encounter in your helping than others, all of them mean that the care recipient is not really seeing you for the person you are. As a result, the person probably will at some stage have expectations of you as helper that you are not willing or able to meet. Even if the relationship does not terminate as a result of the transference, you will undoubtedly be sitting with some strong emotions.

Counter-transference

So far we’ve looked at the reactions of recipients of emotional and psychological care. What about for the person offering the support? As helpers we may believe that we should be perfectly neutral responders to the people to whom we give social support. We may consider any deviation from that to be faulty: an emotional reaction that we must forever hide – or risk exposing ourselves as an incompetent imposter. Those just beginning to work with helpees would undoubtedly be shocked to realise the variety and intensity of emotions that helpees evoke in their helpers during the work.

Some of the more unnerving ones include: anger, frustration, resentment, pain, shame, fear, sexual attraction, anxiety, inadequacy, self-doubt, exposure, and the need for reassurance. In a survey of American psychologists, over 80% reported such feelings (Pope and Tabachnik, 1993), and these were professionals! So note that, if you are a lay person – you will undoubtedly encounter times when you react, even strongly, to your helpee. Countertransference is defined as “the helper’s strong emotional reactions to a client” (Young, 2005). It is information that needs to be dealt with effectively within helping sessions, and sometimes beyond them (Pearlman and Saakvitne, 1995). The tricky aspect of handling countertransference arises partly from the paradox in which it occurs.

To be effective in supporting someone, we need to be sensitive to our helpee’s feelings and concerns, but respond to them from a place that is not caught up in their pain. In order to be sensitive, we must be able to feel our own feelings. But it is exactly those which get triggered in helping work, drawing us out of our “safe” place and into areas of unhealed pain – often similar to what the helpee is dealing with. For example, you may be supporting a person with a close relative in hospice. The person may be stuck in grief over the impending finish of that loved one’s life. Their sadness and inability to let go and move on could reawaken your own unresolved grief. The main goal with transference may be to simply become aware of when it is happening. If as helpers we fail to realise that transference is at hand, we have changed the contract. Where before we had an agreement to set our own “stuff” aside and engage the helpee as a partner to achieve a goal we derived together – a goal to help the helpee – now we have an agenda in which the care recipient becomes something else to us: possibly a friend, a sexual object, a “fake” someone (surrogate) for our unfinished developmental work, or even a reflection of our own selves.

Transference, whether coming from you or your helpee, can be subtle and hard to recognise.

• Concentrate for a moment on someone whom you may have met fairly recently. Reflect on how you feel and behave when you are with them.
• In what ways might this be different from how you normally feel and behave? For example, Chris noticed that she was always clumsy – dropping things and bumping into objects – when around her colleague Dale.
• Can you identify any other, possibly more longstanding relationship, where you behave (including involuntarily) in this way?
• Does this recently-met person remind you of anyone you know or have known? If yes, who is it?
• What is your relationship (the longstanding one) like? Are you aware of any unmet needs you have as a result of this relationship? Are there any unresolved issues between you?

Enmeshment

Also called “fusion”, enmeshment in a relationship happens when those relating do not have clear boundaries. It is necessary to include discussion of it in any text which tries to assist helpers in being more effective, because it is what happens when helpers get too close to their helpees. If a person is fused or enmeshed with another, it means that their personal boundaries are blurred. They are unclear about where they end and the other person begins. An enmeshed person is often confused about their feelings, needs, and even thoughts. Such a person will not have a strong sense of self, and may experience a range of terrifying emotions, such as being smothered, empty, or lost. If healthy limit-setting and protection of their emerging self is not learned early in life (say, in the family), the person will probably not have the capacity for true closeness in personal relationships. On a professional level, or in informal helping relationships, it may create confusion and false expectations for both helper and helpee, and this could damage the helping relationship. Look at these terms describing enmeshment (Whitfield, 1993, p 129):

• Pushes Buttons
• Over-responsible
• Over-involved
• Clinging
• Walking on eggs
• Triangle
• Needing to control
• Loose or rigid boundaries
• High tolerance for inappropriate behaviour
• Fear of abandonment
• Feeling obligated
• Can’t say no
• Weighed down
• Exploited
• All-or-none
• Stuck
• Resentment
• Frustration

Not surprisingly, the issue of enmeshment is closely intertwined with that of independence/ dependence. A person with unhealthy independence may be rigid and disengaged in relationships, whereas a person with healthy independence maintains appropriate distance and privacy. Similarly with dependence, an unhealthy dependence happens when a person is co-dependent with another (more on co-dependence in a moment). A healthy dependence results in appropriate closeness and sharing (Whitfield, 1993).

Though the place we “draw the line” in any given situation may be somewhat open to interpretation, the helper who would avoid enmeshment is neither rigidly independent and disengaged, nor resentfully dependent and stuck in the place of martyrdom. The above description seems clear about how enmeshment might happen in a personal relationship. But how does it show up in a supporter’s relationship with a helpee? The support person with enmeshment issues can be identified by behaviours such as:

• Making the helpee’s decisions for them
• Becoming too involved with helpees, such as community caregivers that are paid to assist someone for, say one hour, but routinely work much more, to the detriment of their other responsibilities
• Passing resentful or snide remarks: “Well, I’m going grocery shopping for the Queen Bee today.”
• Failing to say no to helpees when they need to, and feeling frustrated and exploited
• Tolerating rude or aggressive, put-down behaviour by helpees without addressing it;
• Finding difficulty trusting others in the helping situation. This could include agency managers, other volunteers or caregivers, those with whom they liaise in the community (e.g., professionals in the health system), or the helpees themselves.

As unfortunate as enmeshment is, there are also many other ways the process of social support can go awry. We turn to rescuing.

Rescuing

Imagine this scene. You are walking on a beach when suddenly you hear cries for help. Out on the water, where the wind is whipping up the waves, you see a person struggling to avoid drowning. Alarmed, you kick off your shoes and begin swimming out to save her. You hadn’t counted on the seas being so rough, though, or the drowning person being so heavy and unwieldy. You are trying to help, but she — in her desperation – is fighting you every step of the way, clutching at your throat and succeeding several times in pulling you down. You are getting quickly exhausted, and with the tide going out, you see that you are making precious little progress towards shore. You wonder how you will do it, but little by little you inch your way back towards the beach. You both survive, and you are hailed as a hero in the local papers.

Now take your thoughts up one octave, to the realm of mental health. This time the drowning person is an alcoholic. Somehow you also get caught up in this rescue effort, only it takes months – threatening to roll into years – of intensive working with the person to “save” them from their addiction. You try everything, from rehabilitation programs to self-help 12-step groups, to religion. Though there are victories along the way, the person keeps going under: being arrested multiple times for drunk and disorderly behaviour and losing their job and their partner in the process. After one particularly disheartening incident, you pause and take stock. The person hasn’t thanked you; they don’t even seem to care, and they are still just as addicted to the bottle as they were when you started helping them. The formal community support systems don’t recognise all that you’ve done, and you are mentally and emotionally exhausted. You have been diagnosed with depression and you are burning out.

In the first situation, you achieved what in general English usage we call a rescue. It had the enormously positive social benefit of saving a life, although you almost lost yours in the process. In the second situation, however, the type of “saving” that you were doing is described by the technical usage of the mental-health-field term “rescuing”. It refers to the process of trying to change or “fix” another person, or “save” them from themselves, possibly doing things for them that ultimately, they must do for themselves. It often springs from a motivation of needing to care for others, as we discussed previously, and it usually does not achieve its stated goal of change for the person being rescued. It is also called compulsive caretaking.

Helping types are fond of drawing parallels between their situation and that of Chiron, the wounded healer. In Greek mythology, Chiron is the son of a god and a goat. A centaur (half man, half goat), Chiron sustains a deep wound. As the child of a god, he works teaching other children of gods, but Chiron’s highest gift is that he also possesses special healing powers, and is able to heal many who come to him. Sadly, he cannot heal himself, and his own wounds remain largely unhealed. (Crystalinks, undated).

Helpers such as counsellors, psychotherapists, social workers, and lay persons, like other groups of human beings, vary in their capacity for compassion, and for allowing themselves to be vulnerable. Those who would be effective at helping, however, must be able to walk a fine line. It is between allowing themselves to be vulnerable and sensitive in a way that serves their work as helpers, and being vulnerable in a way which shows inability to move past their own hurts. The latter would limit their healing/helping capacity. It is this special ability of helpers to be both wounded enough to be sensitive, and yet healed enough to assist wounded others that enables helpers to sit with those in distress.

Baker (2003) is clear about the dangers of rescuing: “Compulsive caretaking may appear to observers as involving a deep level of empathy or a strong commitment to being helpful and cooperative. But in actuality, compulsive caretaking is a reflexive, conditioned reaction, driven by the caregiver’s own unacknowledged self needs. It manifests in an overattunedness to others’ needs, feeling overly responsible for others, a compulsion to fix other’s problems, and a deep hunger to be needed and appreciated. In such cases, the overt helping self covers over underlying feelings of inadequacy and dependency on external validation of one’s worth” (p 53).

Co-dependence

Also related to blurred boundaries is the condition of co-dependence. Popularly termed the disease of the lost self, co-dependence can occasionally be problematic for people in their relationships with helpees, manifesting as a strong focus on helpee needs and feelings to the detriment of the helper’s own, and a taking of inappropriate responsibility for the helpee. Often, though, it is a condition which helpers must learn to recognise in helpees whom they are supporting. The implications of co-dependence for helpees are significant, in that changes the helpee wishes to make in his/ her life are filtered through the boundary distortions and exclusion of care for their own needs. In co-dependence, there may be a less available sense of self – the “I” who directs the change effort – for the supporting person to work with.

Co-dependence was originally defined as being a family member of an alcoholic, and refers to “the set of maladaptive and/or immature responses, behaviours, and feelings that may be experienced by someone closely involved with an actively chemical dependent person. The chemical(s) involved may be alcohol, other drugs, or combinations” (Sullivan, Bissell, & Williams, 1988). Most co-dependence occurs from childhood, and usually no other disorder in the co-dependent person causes it, although one or more disorders – including addictions – may exist alongside of it. In recent years the concept has broadened in popular usage, and it is now used to refer to both stress-related disorders and early personality disorders as well as close association with chemically dependent persons. If you suspect that someone you are helping is co-dependent, you can be on the lookout for symptoms such as:

• Gaining self-esteem from being able to control their own and others’ feelings and behaviour;
• Assuming responsibility for meeting others’ needs to the exclusion of acknowledging own needs;
• Anxiety and boundary distortions in situations of intimacy and separation;
• Enmeshment in relationships with personality-disordered, drug-dependent, and impulse-disordered individuals;
• Three or more of the following symptoms:
• Holding back emotions with or without dramatic outbursts;
• Depression;
• Hypervigilance (being excessively alert);
• Compulsions;
• Anxiety;
• Excessive reliance on denial;
• Substance abuse;
• Recurrent physical or sexual abuse;
• Stress-related medical illness;
• A primary relationship with an active substance abuser for at least two years without seeking outside support (Zetterlind and Berglund,1999, pp 147-148).

Co-dependence may not be the worst distress a helper or helpee ever experiences, nor is it the most prevalent. But recognising its symptoms and moving in the direction of professional help – towards the recovery of the self – is ultimately rewarding.

Burnout

Herb Freudenberger (1974) first used the term “burnout” to talk about therapists who were no longer functioning effectively. He defined it as, “a depletion or exhaustion of a person’s mental and physical resources attributed to his or her prolonged yet unsuccessful striving toward unrealistic expectations, internally or externally derived” (p 223). Like other terms starting in the mental health field, its usage has broadened considerably. Professionals in many fields now commonly talk about getting burned out. The symptoms include fatigue, frustration, disengagement, stress, depletion, helplessness, hopelessness, emotional drain, emotional exhaustion, and cynicism (Skovholt, 2001, p 107).

Causes of burnout may arise within one’s own mind or in the environment in which one works and lives. The physical, emotional, and mental exhaustion is a function of both emotional pressure and intense, long-term involvement with people. It has been called the “terminal” phase of therapist distress. Burnout is characterised by feelings of helplessness and hopelessness, and increasingly negative views of oneself, one’s life, and other people. It can be measured it in terms of emotional depletion, detachment from other people – especially one’s helpees – and a decline in feelings of personal competence and achievement in one’s work. It represents “an erosion of the human soul” (Maslach & Leiter, 1997, p 17).

The factors that lead to it are work overload; feeling unappreciated, unrecognised, or unrewarded; lack of control; loss of community; and value conflicts, usually arising in one’s work. A candidate for burnout may feel that there is great unfairness in their work. These factors generate a loss of morale, feelings of depression and a decreased capacity for effective coping, which undermines productivity and tends to increase feelings of isolation. As we noted before with some of the motivations associated with helping, a person on the way to burnout is becoming steadily more depleted, physically, emotionally, and mentally. Their emotional bank account has had many “withdrawals”, but no significant “deposits”, and the person is running on empty, with little to give (Maslach and Leiter, 1997; Baker, 2003).

Review this list of typical symptoms: Do you see yourself in any of them?

• Feeling emotionally drained and exhausted
• Loss of enthusiasm and energy
• A cynical attitude towards (helping) work
• Loss of idealism and trust
• Feeling pulled by numerous, meaningless projects
• Feeling that one’s offering is not wanted or not received
• Feeling unrecognised, unrewarded, and unimportant
• Feeling a loss of control
• Experiencing a sense of inadequacy
• Going about one’s duties with a routine, mechanical attitude
• Failing to see any results from one’s efforts
• Shift towards negative responses to others, and particularly, to one’s helpees
• Irritability
• A sense of oppression by “the system” (institution, agency, or perhaps even general profession)
• A sense of being isolated
• Feelings that any personal initiative will only be stifled and/or rejected
• A general feeling of deadness
• Loss of interest in formerly pleasurable activities (such as leisure interests, or sex)
• Withdrawal from colleagues, friends, and family (adapted from Corey and Corey, 2007, p 363).

If you are looking at the list with horror and becoming anxious that today you are ok, but tomorrow you may be as described above, you probably don’t need to worry. Burnout is not a “yes-no” phenomenon, where you have it or you don’t. Rather, it should be thought of as a continuum, in which we may as helpers slide from fresh idealism and enthusiasm (such as beginners have), to – in the worst case scenario – the jaded, cynical, “nothing’s ever going to change and I’m stuck here” stance of the frustrated (long-term) helper. If you have observed a number of these symptoms in yourself or people you know, they have probably been building for months, or even years. The problem is that as helpers we generally like to think of ourselves in a positive way, so being willing to face these sorts of symptoms is difficult. Denial is rife.

There are also some indirect symptoms of burnout that you might recognise if none of the above click with you:

• The helper frequently indulges in daydreaming and escapist fantasies;
• Drugs are abused when the stress is prolonged;
• Helping sessions lose their excitement and spontaneity;
• The helper’s social life suffers;
• The helper resists suggestions by concerned others to explore the causes and possible cures for his/her condition (Kottler, 1993).

As helpers, we need to see that what we do matters, yet the nature of helping is that, often, the fruits of our labour are not immediately able to be harvested. In fact, we don’t even see them growing sometimes! If you are working as a helper in isolation without much exchange with fellow helpers, if you have very demanding or difficult helpees, or if you have few interests outside of work, you are probably more vulnerable to burnout. This is also true if, as we noted above in the section on motivations for helping, you are engaged in a type of helping where there is little variety or flexibility for you to put your own individual stamp on things. For a helper, this could mean working with only one type of helpee population, or only one sort of presenting issue (for example, the helper working only with abused women, or only with recovery from substance abuse). Let’s look at some of the principal causes of burnout. There is usually not a single cause for it, but by examining typical factors leading to it, we may be more easily able to recognise it when it begins to happen.

Following are situations which often lead to burnout:

• Doing the same unvarying type of work
• Giving much of yourself personally but not getting much appreciation or positive response back
• Sensing that your helping work lacks meaning
• Working with resistant helpees, those who don’t choose to come but are forced, or those who show little progress
• Lack of trust in professionals
• Little or no opportunity for personal expression or taking the initiative; an atmosphere in which creativity and innovation are discouraged
• Unrealistic demands on your time and/or energy
• Helping work that taxing, without offering opportunities for continuing development or training
• Having unresolved personal conflicts beyond the job situation, such as health, financial, or relational problems (Corey and Corey, 2007, p364).

Helpers can experience burnout from both individual and organisational factors. With social support, the relevant factors are more often individual, as below:

1. Your helpees need you. Being seen as indispensable is a potent and addictive elixir. Once we’ve experienced a bit of it, we want more. Let’s say you have been a beginning helper. You have been on a “high” getting feedback from your care recipients, who are so grateful for your help. You sense that you have endless energy, and think, “I don’t really need that holiday, after all.” Remember: your energies are finite, and eventually you will pay the price: physically, emotionally, mentally, and probably spiritually, for allowing yourself to become captive to others’ professed needs at the expense of your own.

2. The agency (or the disaster relief) needs you. Chronic underfunding of social support agencies means that you may be chronically overworked, with too many helpees, and too much to do, even if you are efficient. If you are a volunteer following on from a disaster, you may come to realise that, even if all the volunteers give very long hours with no days off for the foreseeable future, you all will still collectively fall short of the helping goals (say, of providing all the refugee families with a tent, or all the displaced flood victims with a hot meal). In these types of situations, nothing is ever enough. It is not surprising that social supporters wonder where to draw the line.

3. You feel unrecognised and unappreciated. As stated above, you probably would not have become a supporter if you weren’t truly keen to help people, but face it: human nature is such that, as a helpee, a person may take any level of service for granted after a while, and it becomes difficult to continue acknowledging the provider of that help. At other times, the help we give is not perceived as perfect, or even adequate, so we are criticised for the imperfect part, and not praised for the part that we did well. What is your approach for action in this case? More internal locus of control. That is, you must begin to appreciate, acknowledge and thank yourself.

4. You lost that sense of inspiration. If you came into helping work because you are a visionary sort of person, one who has no trouble seeing how the world could be a better place, and how your own contribution could be part of that, it may be burnout territory to turn up to the helping assignment day after day and see little if any of your idealistically-inspired goals bearing fruit.

This article series was adapted from AIPC’s “Mental Health Social Support” e-course. For more information, visit www.mhss.net.au.

References

• Baker, E. K. (2003). Caring for ourselves: A therapist’s guide to personal and professional well-being. Washington, D.C.: American Psychological Association.
• Corey, M. S. & Corey, G. (2007). Becoming a helper, 5th edition. Belmont, California: Thomson Brooks/Cole.
• Crystalinks, The wounded healer (n.d.). Retrieved from: hyperlink.
• Freudenberger, H. J. (1974). Staff burnout. Journal of Social Issues, 30, 159-165.
• Guy, J.D. (1987) The personal life of the psychotherapist. New York: Wiley. In Baker, E. K. (2003). Caring for ourselves: A therapist’s guide to personal and professional well-being. Washington, D.C.: American Psychological Association.
• Maslach, C. and Leiter, M.P. (1997). The truth about burnout. San Francisco: Jossey-Bass. In Corey, M. S. and Corey, G. (2007). Becoming a helper, 5th edition. Belmont, California: Thomson Brooks/Cole.
• Pearlman, L.A. and Saakvitne, K.W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: W.W. Norton. In Baker, E. K. (2003). Caring for ourselves: A therapist’s guide to personal and professional well-being. Washington, D.C.: American Psychological Association.
• Pontikis, N. (2010). Echo and Narcissus. Retrieved from: hyperlink.
• Pope, K.S. & Tabachnik, B. (1993). Therapists’ anger, hate, fear, and sexual feelings: National survey of therapist responses, client characteristics, critical events, formal complaints, and training. Professional Psychology: Research and Practice, 24, 142 – 152. In Baker, E. K. (2003). Caring for ourselves: A therapist’s guide to personal and professional well-being. Washington, D.C.: American Psychological Association.
• Skovholt, T.M. (2001). The resilient practitioner: Burnout prevention and self-care strategies for counselors, therapists, teachers, and health professionals. Needham Heights, MA: Allyn and Bacon.
• Sullivan, E., Bissell, L. & Williams, E. (1988). Chemical dependency in nurses: The deadly diversion . Menlo Park, C.A.: Addison-Wesley. In Williams, E., Bissell, L., & Sullivan, E. (1991). Research report: The effects of co-dependence on physicians and nurses, British Journal of Addiction 86, 37-42.
• Young, M. (2005). Learning the art of helping: Building blocks and techniques, 3rd edition. Upper Saddle River, New Jersey: Pearson Education, Inc.
• Zetterlind, U. and Berglund, M. (1999). The rate of co-dependence in spouses and relatives of alcoholics on the basis of the Cermak Co-dependence Scale, Nord Journal of Psychiatry, 53(2).