Previous research

Comprehensive Treatment Approach for Relationship Patterns in Neurodivergent Adults

Based on established psychotherapy research, trauma treatment literature, and clinical experience, the WeTheRooted multi-modal approach addresses the biological, psychological, and social factors that contribute to codependent patterns.

While no studies have tested this specific combination, research on related conditions suggests that sustained, multi-level treatment produces meaningful improvement in approximately 60-70% of people who remain engaged. Individual outcomes vary significantly based on trauma history, resources, current relationships, and other factors.

Comprehensive Evidence Review: Treatment for Codependency in Neurodivergent Populations

Executive Summary of Evidence Status

This review proposes WeTheRooted is a clinically reasonable framework, but there are no controlled studies testing this specific combination for codependency in neurodivergent people.

Evidence Quality Assessment by Component

STRONG EVIDENCE BASE

1. Psychotherapy Effectiveness (General)

What we know:

- Individual therapy shows ~75% effectiveness for relationship and interpersonal problems (when completed)
- Weekly therapy superior to less frequent sessions
- Therapeutic alliance predicts outcomes better than specific modality
- Dropout rates: 30-40% in first 3 months, 50-60% by 6 months

Key sources:

- Lambert & Barley (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy, 38(4), 357-361.
  - Found therapeutic relationship accounts for 30% of outcome variance
- Swift & Greenberg (2012). Premature discontinuation in adult psychotherapy. Psychotherapy, 49(2), 247-256.
  - Meta-analysis: median dropout rate 47% across studies
- Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, 75(6), 842-852.
  - Alliance quality predicts outcomes across modalities

Neurodivergent-specific:

- Minimal research on therapy outcomes specifically for autistic or ADHD adults
- Bernardin et al. (2021). Psychotherapy for adults with autism spectrum disorder. Journal of Clinical Medicine, 10(22), 5404.
  - Review found extremely limited RCT evidence
  - Adaptations needed but not well-studied
  - Most evidence is case series or qualitative

2.  EMDR for Trauma

What we know:

- Strong evidence for PTSD treatment: 60-84% remission rates
- 7-12 sessions typically sufficient for single-incident trauma
- Complex trauma requires longer treatment (no set timeline)
- Comparable to trauma-focused CBT

Key sources:

- Chen et al. (2014). EMDR for recent traumatic events. Evidence-Based Mental Health, 18(2), 37-44.
  - Meta-analysis: effect size d=1.51 vs waitlist
- Shapiro (2014). The role of eye movement desensitization and reprocessing therapy in medicine. The Permanent Journal, 18(1), 71-77.
  - Overview of evidence and mechanisms
- de Jongh et al. (2016). Critical analysis of the current treatment guidelines for complex PTSD. Journal of EMDR Practice and Research, 10(4), 287-304.
  - Complex trauma requires adapted protocols

Limitations:

- No specific studies on EMDR for “codependency”
- Attachment trauma evidence weaker than single-event trauma
- No neurodivergent-specific EMDR research

3. ADHD Medication

What we know:

- 70-80% response rate to stimulant medication
- Improves executive function, emotional regulation, impulse control
- Effects on relationships and social functioning documented

Key sources:

- Faraone & Buitelaar (2010). Comparing the efficacy of stimulants for ADHD. European Child & Adolescent Psychiatry, 19(4), 353-364.
  - Meta-analysis: large effect sizes (d=0.9-1.0)
- Surman et al. (2017). Understanding deficient emotional self-regulation in adults with ADHD. CNS Drugs, 31(4), 273-286.
  - ADHD medication improves emotional regulation
  - May reduce rejection sensitivity (not studied directly)
- Barkley & Fischer (2010). The unique contribution of emotional impulsiveness to impairment in major life activities in hyperactive children as adults. Journal of the American Academy of Child & Adolescent Psychiatry, 49(5), 503-513.
  - Emotional dysregulation impacts relationships in ADHD

Gap: No studies specifically examining ADHD medication effects on codependency patterns

4. Antidepressants/Anxiolytics

What we know:

- SSRIs effective for anxiety disorders: 50-65% response rate
- Combined medication + therapy superior to either alone
- May reduce hypervigilance and people-pleasing (theoretical)

Key sources:

- Bandelow et al. (2015). Efficacy of treatments for anxiety disorders. International Clinical Psychopharmacology, 30(4), 183-192.
  - Meta-analysis of anxiety treatment
- Cuijpers et al. (2014). Adding psychotherapy to antidepressant medication. World Psychiatry, 13(1), 56-67.
  - Combined treatment superior for depression/anxiety

MODERATE EVIDENCE BASE

5. Trauma-Focused Therapy (General)

What we know:

- Complex PTSD treatment shows 50-60% significant improvement
- Requires longer timeframes (12-24+ months) than simple PTSD
- Phase-based approaches (stabilization → processing → integration) standard

Key sources:

- Cloitre et al. (2010). Treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 78(1), 28-38.
  - RCT of phase-based treatment: 42% PTSD remission vs 15% control
- Karatzias et al. (2019). Evidence of distinct profiles of PTSD and complex PTSD. Psychological Trauma, 11(2), 166-173.
  - Complex PTSD requires adapted treatment approaches
- Ford & Courtois (2021). Complex PTSD and borderline personality disorder. Borderline Personality Disorder and Emotion Dysregulation, 8, 16.
  - Reviews evidence for complex trauma treatment

Limitations:

- “Codependency” not studied as trauma outcome specifically
- Attachment trauma research less developed than single-event trauma


6. Gradual Exposure Principles

What we know:

- Graduated exposure fundamental to anxiety treatment
- Starting with manageable steps increases success
- Flooding/immediate exposure can be counterproductive

Key sources:

- Foa et al. (2013). Randomized trial of prolonged exposure for PTSD with and without cognitive restructuring. Journal of Consulting and Clinical Psychology, 73(5), 953-964.
  - Graduated exposure effective for trauma
- Craske et al. (2014). Maximizing exposure therapy. Behaviour Research and Therapy, 58, 10-23.
  - Principles of effective exposure

Application to boundaries: Theoretical extension, not directly studied

7. Social Support and Relationships

What we know:

- Social support strongly protective for mental health
- Quality matters more than quantity
- Loneliness increases mortality risk comparably to smoking

Key sources:

- Holt-Lunstad et al. (2010). Social relationships and mortality risk. PLoS Medicine, 7(7), e1000316.
  - Meta-analysis: strong social relationships increase survival by 50%
- Cacioppo & Patrick (2008). Loneliness: Human Nature and the Need for Social Connection.
  - Comprehensive review of loneliness research
- Mikulincer & Shaver (2007). Attachment in Adulthood: Structure, Dynamics, and Change.
  - Secure relationships promote well-being

Gap: No studies on “teaching codependent people to build reciprocal relationships”

WEAK OR NO EVIDENCE BASE

8. Internal Family Systems (IFS)

Evidence status:

- Very limited controlled research
- Mostly case studies and qualitative reports
- Growing clinical use but minimal empirical validation

What exists:

- Shadick et al. (2013). A randomized controlled trial of an IFS-based intervention for rheumatoid arthritis. Journal of Rheumatology, 40(11), 1831-1841.
  - Small RCT (N=79) showed improvements in pain and depression
  - Only published RCT as of 2024
- Hodgdon et al. (2022). Efficacy of IFS therapy in treating trauma. Journal of Aggression, Maltreatment & Trauma, 31(6), 839-853.
  - Pilot study, promising but preliminary

Bottom line: Clinically popular but empirically under-studied

9. Somatic Experiencing (SE)

Evidence status:

- Weakest evidence base of trauma therapies mentioned
- Primarily case studies and theoretical papers
- Few controlled trials

What exists:

- Leitch et al. (2009). Somatic Experiencing treatment with tsunami survivors. Traumatology, 15(3), 67-73.
  - Uncontrolled pilot study
- Brom et al. (2017). A RCT comparing trauma-focused CBT and SE. European Journal of Psychotraumatology, 8(sup3), 1353383.
  - SE comparable to TF-CBT (small sample)

Bottom line: Theoretical framework reasonable but minimal empirical support

10. Bibliotherapy/Psychoeducation

Evidence status:

- Small to moderate effects as adjunct to therapy
- Minimal effects as standalone treatment for complex problems
- Better for mild depression than personality/relationship issues

Key sources:

- Gregory et al. (2004). Cognitive bibliotherapy for depression. Professional Psychology: Research and Practice, 35(3), 275-280.
  - Effect size d=0.77 for guided bibliotherapy in mild depression
- Cuijpers (1997). Bibliotherapy in unipolar depression. Journal of Behavior Therapy and Experimental Psychiatry, 28(2), 139-147.
  - Meta-analysis: small effects, works for motivated individuals

Application to codependency: No specific studies; likely helpful but insufficient alone

11. Behavioural Activation/Identity Work

Evidence status:

- Behavioral activation well-supported for depression
- “Identity development” as distinct intervention: minimal research
- Self-compassion interventions show promise

Key sources:

- Dimidjian et al. (2006). Randomized trial of behavioral activation. Journal of Consulting and Clinical Psychology, 74(4), 658-670.
  - BA comparable to medication for depression
- Neff & Germer (2013). Mindful self-compassion program pilot study. Journal of Clinical Psychology, 69(1), 28-44.
  - Self-compassion training effective for well-being

Gap: No structured protocols for “identity development” in codependency

Neurodivergent-Specific Evidence

CRITICAL GAP: Almost no research exists at this intersection

What we know about neurodivergent therapy needs:

Autism:

- Cage et al. (2018). Experiences of autism acceptance and mental health in autistic adults. Journal of Autism and Developmental Disorders, 48(2), 473-484.
  - Acceptance (vs. camouflaging) predicts better mental health
  - Implications: neurodivergent-affirming therapy theoretically important
- Hull et al. (2017). “Putting on my best normal”: Social camouflaging in adults with autism. Journal of Autism and Developmental Disorders, 47(8), 2519-2534.
  - Masking associated with worse mental health outcomes
- Kinnaird et al. (2019). Investigating alexithymia in autism. Autism, 23(3), 716-731.
  - 50% of autistic people have alexithymia
  - Implications for therapy: may need somatic/body-based approaches

ADHD:

- Matthies & Philipsen (2014). Common ground in ADHD and borderline personality disorder. ADHD Attention Deficit and Hyperactivity Disorders, 6(1), 3-11.
  - Emotional dysregulation common to both
  - May contribute to relationship difficulties
- Dodson (2022). Rejection sensitivity dysphoria in ADHD. ADDitude Magazine (expert article, not peer-reviewed)
  - RSD widely discussed clinically but minimal research
  - No validated interventions yet

Bottom line: Neurodivergent people likely need adapted approaches, but specific protocols don’t exist

Evidence on Combined/Multi-Modal Treatment

General Principle: Strong support

Key sources:

- Cuijpers et al. (2014).[cited above] Combined therapy + medication superior to either alone
- Laska et al. (2014). The great psychotherapy debate revisited. Psychotherapy Research, 24(4), 439-450.
  - Common factors (alliance, hope, expectancy) more important than specific techniques
  - Multi-faceted approaches may work via multiple pathways

But:

- No studies testing this specific combination for codependency
- No studies comparing different combinations
- No optimization studies determining best sequence or timing

Timeline Evidence

How long does therapy take?

Personality change:

- Roberts et al. (2017). A systematic review of personality trait change through intervention. Psychological Bulletin, 143(2), 117-141.
  - Personality traits can change with intervention
  - Effect sizes modest (d=0.37)
  - Requires sustained effort

Therapy duration:

- Hansen et al. (2002). Empirically supported treatments for depression and relationship distress. Journal of Consulting and Clinical Psychology, 70(1), 164-177.
  - Median treatment length: 12-16 sessions for specific problems
  - Complex interpersonal issues often require longer

Complex trauma:

- No consensus on optimal timeline
- Clinical guidelines suggest 12-24+ months for complex PTSD
- Individual variation enormous

Bottom line: 18-24 month timeline is clinically reasonable but not empirically established

What We Can Actually Say About Success Rates

Meta-analysis findings for related conditions

Personality disorders (most analogous):

- Perry et al. (1999). Effectiveness of psychotherapy for personality disorders. American Journal of Psychiatry, 156(9), 1312-1321.
  - ~52% recovery rate with therapy
  - Median treatment duration: 1.6 years

Chronic relationship difficulties:

- No specific meta-analyses for “codependency”
- Interpersonal therapy: ~60% response for relationship problems

Combined treatment:

- Generally 10-20% improvement over monotherapy

Neurodivergent-specific accommodations

- Clinically sensible but not empirically tested
- No RCTs comparing standard vs. adapted approaches
- Emerging clinical consensus but not evidence-based

Accommodations That Have SOME Support

Explicit instruction:

- Autism social skills research: Mixed results, but explicit teaching can help
- Kenworthy et al. (2014). Unstuck and On Target! Journal of Autism and Developmental Disorders, 44(7), 1524-1535.
  - Explicit executive function coaching helpful

Written supports:

- Standard accommodation for executive function difficulties
- No specific research on written boundary scripts

Alternative communication:

- Reasonable accommodation but not studied
- Aligns with UDL (Universal Design for Learning) principles

What Reduces Treatment Success (Evidence-Based)

Therapeutic alliance problems:

- Strongest predictor of dropout and poor outcomes
- Wrong fit therapist is legitimate concern

Premature termination:

- Dropout rates very high (50-60% by 6 months)
- Early dropout predicts worse outcomes

Untreated comorbidities:

- Active substance use, severe depression, suicidality all reduce treatment effectiveness
- Medication for treatable conditions generally improves therapy outcomes

Lack of social support:

- Isolation predicts worse mental health outcomes across conditions

“Skipping trauma work”:

- Theoretically reasonable if codependency is trauma-based
- No comparative studies testing surface vs. depth approaches for codependency

Red Flags for Higher Level of Care

Evidence-based criteria:

- Active suicidal ideation with plan/intent
- Psychosis
- Severe substance use disorders
- Domestic violence (immediate safety risk)
- Complete inability to function (unable to maintain basic self-care)

Sources:

- APA Practice Guidelines for various disorders
- Level of care determination criteria (ASAM, LOCUS)

These recommendations are evidence-based and appropriate

What we can say with confidence:

       1.       Individual therapy is effective for interpersonal problems (~60-75% improvement with sustained engagement)
       2.      Trauma treatment works for trauma-based relationship patterns (EMDR, trauma-focused approaches: 60-80% for PTSD)
       3.      Medication helps when ADHD/anxiety/depression present (70-80% for ADHD, 50-65% for anxiety)
       4.      Combined approaches likely superior to single interventions for complex problems
       5.      Social support matters for mental health outcomes
       6.      Graduated exposure is effective principle for anxiety-based avoidance

What we must acknowledge:

        1.       No controlled studies of codependency treatment exist
        2.      Almost no research on neurodivergent-specific adaptations for relationship issues
        3.      Timeline and success rates are estimates, not data
        4.      Individual variation is enormous: population averages don’t predict individual outcomes
        5.      This is a clinical framework drawing on related research, not a validated protocol

Key References by Category

Psychotherapy Effectiveness:

        1.       Lambert & Barley (2001) - therapeutic relationship
        2.      Wampold & Imel (2015) - The Great Psychotherapy Debate
        3.      Swift & Greenberg (2012) - dropout rates

Trauma Treatment:

        1.       Chen et al. (2014) - EMDR meta-analysis
        2.      Cloitre et al. (2010) - complex trauma treatment
        3.      Shapiro (2014) - EMDR overview

Medication:

        1.       Faraone & Buitelaar (2010) - ADHD medication
        2.      Bandelow et al. (2015) - anxiety medication
        3.      Cuijpers et al. (2014) - combined treatment

Neurodivergence:

        1.      Cage et al. (2018) - autism acceptance
        2.      Hull et al. (2017) - camouflaging
        3.      Bernardin et al. (2021) - autism psychotherapy review

Relationships:

        1.      Holt-Lunstad et al. (2010) - social support and mortality
        2.      Mikulincer & Shaver (2007) - attachment

Personality Change:

        1.      Roberts et al. (2017) - personality change through intervention
        2.      Perry et al. (1999) - personality disorder treatment

This review presents a reasonable clinical framework that draws on legitimate therapeutic principles.

- We acknowledge the evidence limitations
- We acknowledge how little we know about neurodivergent-specific needs from research, and how we are relying tools developed through lived experiences
- This means the framework is an informed clinical approach, rather than proven protocol

We have ensured the approach itself (holistic, trauma processing, gradual boundary work, social support and medication when needed) aligns with clinical best practices.