• What are the DSM-IV criteria for the dependent personality?

• The devoted and agreeing personalities are normal variants of the dependent. Describe their characteristics and relate them to the more disordered criteria of the DSM-IV.

• Explain how different personality styles combine to form each of the subtypes of the dependent personality.

• How do men and women differ in their willingness to admit dependency?

• How does oral fixation lead to the development of the dependent personality in the psychoanalytic tradition?

• How do the defense mechanisms of introjection, idealization, and denial work in the dependent personality?

• Explain the role of parental overprotection in the development of the dependent personality.

• What are the core beliefs of the dependent?

• How does the inability to make good judgments contribute to the development of the dependent personality?

• Dependents share characteristics with other personality disorders. List these other disorders and explain the distinction between each and the dependent.

• Explain why dependents are prone to depression.

• Is there a relationship between separation anxiety disorder and the dependent personality?

• Why are issues of transference and countertransference important in psychotherapy with dependents?

• List therapeutic goals for the dependent personality.

Dependent personalities, referred to here simply as dependents for the sake of linguistic convenience, are caring to a fault, allowing others' well-being to come first no matter what the cost may be to themselves or their identity Ever helping and giving, they are committed to their personal relationships, especially to their spouses and the institution of marriage. Essentially, they live their lives through others and for others, to whom they offer warmth, tenderness, and consideration. When people they care for are happy, they are happy. Not surprisingly, they tend to assume the more passive role in their relationships, deferring to the opinions and desires of those they love, whose pleasure and fulfillment they then enjoy vicariously. They prefer harmony in their relationships and tend to be apologetic even when others should take the greater part of responsibility for a disagreement.

Many characteristics associated with the dependent personality are prized and admired in our culture. These include the quality of being happy when loved ones are happy and making personal sacrifices for the good of others, including volunteering to perform many selfless acts. On the surface, they are warm and affectionate, but underneath, they see themselves as helpless and fear doing anything on their own. They need to be taken care of and seek competent instrumental surrogates who reward submission by facing down the problems of the world in their place. Many are incapable of making even routine decisions without first seeking advice. By putting their lives in the control of others, they suffocate their partners with their clinginess and in turn leave themselves vulnerable to abandonment. To protect against this possibility, dependents quickly submit to their partners' wishes or become so pleasing no one would possibly want to leave them. Often, they arrange their lives so that they can avoid acquiring competencies that might allow them to stand on their own. When a relationship does finally dissolve, their self-esteem is devastated. Deprived of support or attachment, they withdraw into themselves and become increasingly tense and despondent.

As the case of Sharon demonstrates (see Case 8.1), dependents find it almost impossible to take the initiative on their own behalf or to provide direction to their lives or careers. Instead, they bond themselves to those they perceive as confident or in control and constantly solicit advice and reassurance before committing to almost anything (see criterion 1). In effect, they piggyback themselves on the talents, abilities, and fortitude of others, often even in trivial matters, such as what to have for lunch or what clothes to buy. Even after working as a teacher's aide for nine years, for example, Sharon still relies on the teachers to tell her what to do. After such a long time in a nondemanding position, Sharon should already know the possibilities and be able to judge for herself what is best given the lessons of the day.

Sharon was lucky enough to have been born into a traditional family and have a big sister to look out for her. She has always been taken care of by others, so much so, in fact, that she never developed a sense of self-identity and never learned to take control of her own life. She needs people to assume control and responsibility in almost everything (see criterion 2). Just look at her childhood: If something went wrong in school, Sharon ran to Brandy, who protected her and made things right again. The whole family participated in infantilizing her; Sharon was their precious little "porcelain doll," put on a shelf and rewarded just for being sweet and cute. You can almost imagine little Sharon with a pink bow in her hair running up to Mommy and Daddy with a big bright smile and receiving a pat on the head and a big hug in return. At every stage of life, her needs were always met; she never learned to drive, for example, because Brandy took her wherever she wanted to go. For Sharon, her early treatment became an interpersonal

Sharon, a 32-year-old teacher's aide, first sought therapy at the suggestion of the school principal, someone she is particularly close to. The principal had "taken her under her wing."1 Although Sharon has worked as an aide at the same school for nine years, she still requires the advice and encouragement of other teachers before starting any new project for the students, sometimes needing reassurance multiple times in the same day.

Sharon is the younger of two sisters. She describes her childhood as "traditional" and "perfect," with her father being the strong figure on whom the rest of the family relied. Her mom was old-fashioned and took good care of everyone. From almost the day Sharon was born, everyone treated her like a "precious porcelain doll." All of her needs were met before she even knew there was a void. In school, her sister Brandy became her guardian. If anything went wrong, Sharon ran to Brandy to make it right, whether it was to protect her from bullies or help her in her classes. Sometimes, Brandy even did Sharon's homework herself. Although Sharon was only an average student, the teachers liked her because she was "sweet and well-behaved." As a teenager, Sharon never learned to drive. Instead, Brandy always took her wherever she wanted to go.

The Saturday after graduating from high school, Sharon married Tom, an appliance mechanic who reminded her of her father. And like her father, Tom loved the idea of having a wife at home who didn't work and didn't mind catering to him, having his meals ready when he got home. He even thought it was "cute" that she was so helpless at many daily tasks. For the most part, Sharon adored Tom and loved playing the role of the traditional wife although she occasionally found it difficult to assert herself in the relationship, fearing that Tim might become angry with her.

Soon, however, Tom began to see Sharon as needy and suffocating. Without her own circle of friends, she insisted they spend every free moment together. Tom eventually convinced Sharon to take a job as a teacher's aide when they were experiencing some financial difficulties, and he encouraged her to keep it once the problems were settled. However, because Tom drops her off at work every morning and picks her up again in the evening, he can never hang out with guys after work or even stay late to earn extra money. Responding to her neediness, Tom eventually decided that Sharon should have more of an identity of her own and insisted that she enroll in junior college. She asked Tom to pick out her classes and warned him that he would likely have to tutor her in the evenings as well as drive her to and from classes. Sharon has reluctantly agreed to go but doubts that she has the confidence or ability to follow through.

Six months into couples therapy, Sharon had begun to take driving lessons. About this same time, however, Brandy was killed in a car accident. The effect on Sharon was devastating. With Brandy gone, Sharon began to slip into depression and began to cling to Tom even more tightly. She dropped all of her classes and stopped going to work. In response, Tom now seems to be in a process of extended emotional withdrawal and is threatening divorce. Sharon feels destroyed, as though, "I have lost a part of myself I can never get back," and cannot imagine how she will possibly make it alone. Though Tom insists that there is still a chance for reconciliation and though Sharon realizes that there were problems all along that she didn't want to face, she nevertheless "knows" he will divorce her.

1Numbers mark aspects of the case most consistent with DSM criteria, and do not necessarily indicate that the case "meets" diagnostic criteria in this respect.

Dependent Personality Disorder DSM-IV Criteria

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

(1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.

(2) needs others to assume responsibility for most major areas of his or her life.

(3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.

(4) has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).

(5) goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.

(6) feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.

(7) urgently seeks another relationship as a source of care and support when a close relationship ends.

(8) is unrealistically preoccupied with fears of being left to take care of himself or herself.

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

dictum: "Please others, and you will be special and they will love you and care for you forever." Sharon's life has always taken whatever direction others might give it, so it is their creation, not her own.

Although Sharon is all grown up, psychologically, she remains a child in many ways. In her private moments, her immaturity scares her, but it is an interpersonal strategy she will continue to pursue, if only because she has failed to develop any other mature strategies of her own. Independence is anathema to her. Instead, Sharon will forever present herself as precious and adorable. In her mind, she must always be pleasing and never disagree with those on whom she depends (see criterion 3). Conflict is not only inconsistent with her self-image but also risks her continued protection, either explicitly by evoking others' anger or implicitly by establishing a separate identity to be respected, a dangerous precedent for any dependent. It seems a better strategy for the dependent to play it safe and submit to the opinions and desires of others. As she herself says, she finds it difficult to assert herself in the marriage because "Tom might become angry with me." Now that Brandy is gone, much of Sharon's insurance against standing on her own has evaporated.

Having others take responsibility for everything in her life has affected Sharon in a variety of ways. She has difficulty starting projects and doing things on her own (see criterion 4). Because others have always been there to take control, her expectation is that all she needs to do is to be sweet and pleasing and everything will be taken care of by others. To the casual observer, her lack of initiative might make her seem depressed. However, Sharon has plenty of energy; she simply lacks direction. She cannot commit to a decision without first knowing that others approve of it. She lacks confidence to set her life on a course of her own making and then follow through. On the surface, she might agree to learn how to drive or to attend college, but she becomes suspicious when other people push such an agenda too hard. If she were to be successful, others might demand that she do even more. They may even demand that she assume a measure of control over her own life, a trend that frightens her. Even the request that she do something on her own might be perceived as rejection. "What happens after I learn to drive?" she wonders. "What else will they expect? Why does Tom really want me to attend college? Is he setting me up to leave me?" Sharon believes that the less she initiates on her own, the better chance she has of holding on to people.

In fact, Sharon's goal is to maintain things as they have always been, a kind of timeless childhood in which she is passive and pleasant and is ensured protection and a comfortable attachment to others. We cannot say exactly what the future holds for her. The case does not state whether Sharon and Tom were able to work out their problems. We do know, however, that Tom feels suffocated, and we can infer that he has begun to see their relationship as something Sharon needs more than she wants. Tom thinks that Sharon should have more of an identity of her own. He may even doubt that she honestly loves him or is mature enough to know what love means. Now that Tom has begun to withdraw, Sharon is feeling the distance, and her desperation and panic are increasing. She will probably react by doing even more for Tom, even volunteering for tasks that are unpleasant (see criterion 5) to secure the relationship. Especially with Brandy gone and her marriage in jeopardy, Sharon is terrified of being left alone (see criterion 6). Worse, there is no one else to whom she can appeal for nurturance and support (see criterion 7), something that is undoubtedly always on her mind (see criterion 8).

With Sharon, we have seen a portrait of the more pathological side of the dependent personality. However, we have also touched on how some of these qualities manifest themselves in healthy and normal personalities. The following section explores this continuum more fully.

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