Therapy

Psychotherapy with the dependent personality generally has a good prognosis, although with their social support systems intact, most dependents do not seek therapy; their needs for protection, nurturance, and instruction are already met by others. When they do seek therapy, it is usually because some aspect of their social world has been disrupted, as with Sharon and Jack. Whereas self-oriented personalities, such as the antisocial and narcissist, often terminate prematurely, most dependents are highly motivated to continue. The therapeutic relationship itself naturally supplies them with the very resources they feel are deficient in their everyday lives. In effect, the therapist

Jack, a 54-year-old unemployed male, was referred for therapy by his family physician. His wife, Joan, accompanies Jack to all of his appointments. He had just been laid off from his job of 22 years.1 Joan was adamant that Jack suffered from fatigue and crippling back pain, although Jack himself seemed oblivious to why he should be seen and constantly looked to his wife to take the lead in responding to questions. He was seriously physically disabled, she maintained, and should be collecting disability insurance. When no physical cause could be found for his pain, he was referred for a psychological assessment.

Jack is the youngest child and only son in a family with six children. His mother kept careful watch over him, limited his responsibilities, and restricted most of his outdoor activities, fearing that he would be hurt. Throughout childhood and adolescence, Jack's sisters and parents protected him so much that he either learned many important skills late or not at all. Because he seemed naturally unassertive, Jack accepted this comfortable role. Jack recalls that he never went through that "teenage rebellion thing."

In high school, Jack's mother and sisters arranged his social life, even finding him a date for his senior prom. They chose his electives and after-school activities. At the age of 20, Jack's mother fixed him up with Joan, the daughter of a family friend. Joan was five years older than Jack and very eager to take care of him. They were married six months later. Joan efficiently ran the home, assuming all responsibilities for bill paying and household management.

Jack worked for many years as a general assistant in his father's bookkeeping business. Instead of assuming some managerial responsibilities of the company, as his father hoped, Jack failed to learn even the most basic computer or administrative skills. As a consequence, he became the office gopher, fetching coffee for others and delivering the office mail. He was known as a good-natured fellow afraid to disagree with anyone, but he was also the butt of much joking behind closed doors. His daily responsibilities grew to include getting sandwiches, coffee, and cigarettes for the office staff. Joan often ridiculed Jack's lack of ambition and his lack of competence.

Throughout the years, Jack has been content to have others take care of him. He is aware that he has not attained the goals that others have set out for him, but he is not troubled by it. Indeed, he seems ambitionless by almost every standard, desiring simply to "fit in," never to lead. He never followed through on a single company project assigned to him. There is a naïveté and childlike quality to him. His expression conveys the question, "What is everyone making such a big fuss over?"

With money already tight, tensions between Joan and Jack escalated. On multiple occasions, she has threatened to leave him. Each time, Jack would make some half-hearted attempt to work, but he would eventually slide back into his old form and beg her to stay, arguing that he'll be helpless without her. On the day the divorce papers were to be served, Jack developed debilitating back pain that forced him to remain in bed with Joan as his constant attendant. She has agreed to remain in the marriage until he recovers.

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.

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..

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

becomes a kind of surrogate caretaker who listens attentively, offering acceptance, security, and empathy as a counterbalance to the criticism, blame, and guilt that dependents naturally heap on themselves. The strength and authority of the therapist is comforting and reassuring and provides the idealized omnipotent figure that dependents seek to rescue them in time of need. Moreover, dependents are usually ready to trust and to talk, and the therapist is ready to listen. Therapy almost inevitably gets off to an auspicious beginning, creating the impression that progress will be rapid and sure.

Therapeutic Traps

The readiness of the dependent to please the therapist and the promise of quick improvement are the principal barriers to effective psychotherapy. The dependent talks when talking is required. The dependent listens when listening is desired. The dependent follows all instructions and basks in every word of praise and sign of approval.

Not surprisingly, many beginning therapists, faced with intractable borderlines or insufferable narcissists, at first feel they have found the dream client in the dependent. Even experienced therapists with strong narcissistic and maternal needs are vulnerable. More narcissistic therapists are tempted to take up the reins and become more directive, responding to the dependent's underlying message, "Help me, and I will do exactly what you say. I will please you, and I will admire, even worship, your intelligence, strength, and courage." Such covert communications make the therapist feel powerful. The dependent gives up responsibility for the outcome and bonds closer and closer, and the therapist takes up the responsibility, subscribes to the delusion that he or she is actively curing the dependent, and glows godlike in projections of omnipotence and omniscience.

Such therapeutic relationships are pathological, only recapture the client's larger pattern of interpersonal dependency in the microcosm of the therapy office, and inevitably succumb to the same vicious circles that have defined the client's life and provided the very reason for coming to therapy from the beginning. Similar outcomes are likely for therapists with strong maternal needs, for whom the interpersonal pull is to become even more supportive than usual. Here, the dependent effectively seeks to make the transition from lonely orphan to adopted child.

Therapeutic Strategies and Techniques

The strategic goals in working with dependents are the same as for any other personality. Clients can only become a more functional variant of themselves; they cannot be transformed into something completely different. The sweet, innocent, needy dependent will not become a ruthless corporate executive or an intrepid explorer of new frontiers, and it would be pathological to hold him or her to such expectations. Instead, all personalities must learn to play their strengths and minimize their weaknesses. Doing so assumes both a knowledge of these weaknesses and a willingness to step in and interrupt old patterns of relating and perceiving that lead to vicious circles. None of this changes the basic personality pattern, but it does bring them within the normal range of functioning, from which more adaptive possibilities can emerge, both during and after therapy. As is always the case with personality disorders, the key lies in addressing the personality pathology at multiple levels simultaneously, though the exact combinations and order in which these techniques are applied depend on the individual subject.

Focus on Research

Childhood Syndromes Separation Anxiety and Dependent Personality

A number of personality disorders have parallel diagnoses in children. Separation anxiety disorder, first introduced in DSM-III (1980) and elaborated in DSM-IV (1994), provides a diagnostic label for children who experience intense anxiety upon separation from home or from important attachment figures. When separated from caretakers, many children become frightened, requiring frequent reassurance that they will eventually be reunited. Separation may lead to fearful fantasies that the caretaker or the child will suffer a horrible accident or illness and never return. Younger children may fear becoming lost, after which they never find their way home or see their parents again. In more extreme cases, they have nightmares, rarely leave their parents' side, and may not be able to be left alone in a room without one parent present. Many of these children cannot stay overnight with a friend; they resist going to school or even being left with relatives.

Although separation anxiety reflects a pathology of attachment, theorists nevertheless distinguish between attachment and dependence (Ainsworth, 1969, 1972; Bowlby, 1973; Sears, 1972). Attachment is generally regarded positively and refers to an exclusive relationship in which the individual seeks proximity to another individual who is usually stronger or wiser. This proximity increases feelings of security in the individual. Dependency, on the other hand, refers to generalized behaviors that are not directed at any specific individual but designed to elicit assistance, guidance, or approval (Hirschfeld et al., 1977).

Current conceptualizations of dependent personality disorder appear to include components of both attachment and dependency. The sixth diagnostic criterion states, "feels uncomfortable or helpless when alone"; the seventh, "urgently seeks another relationship .. . when a close relationship ends"; the eighth, "is unrealistically preoccupied with fears of being alone to take care of self." Livesley, Schroeder, and Jackson (1990) obtained two factors when studying the dependent personality criterion of the DSM-III-R. One had as its central feature lack of confidence or assurance about themselves and their abilities. People who scored high on this factor were probably "impressionable, dependent on advice and guidance from others, and prone to establish submissive relationships" (p. 138). The second factor was descriptive of insecure attachment and related to persons who are "unable to function independently, and that require the presence of attachment figures to feel secure" (p. 138).

Accordingly, persons could presumably be diagnosed as dependent personalities in two different ways, either suffering the effects of insecure attachment or lacking confidence and assurance in themselves. This duality may help explain the results of some research that shows that many adult patients who can be diagnosed as suffering from separation anxiety disorder do not suffer from dependent personality disorder (Mani-cavasagar, Silove, & Curtis, 1997). For example, some might have a secure attachment but no self-confidence. Others may have developed a level of self-confidence but nevertheless experience an insecure attachment. These are the individuals who are likely to have had separation anxiety concerns as children.

Interpersonally, dependents must learn to interact with others in a way that encourages individuation rather than submission. The key to a successful outcome lies in making use of dependency without indulging it. Although the therapist can be used as a secure base to which the dependent can return, both parties should understand from the beginning that dependency is precisely the problem and that the purpose of therapy is to outgrow the therapeutic relationship. The therapist is obligated to make the a social response (Kiesler, 1996), that is, to be sensitive to the emotional nuances of the therapeutic relationship—what psychotherapists call transference and countertrans-ference—and relate to the dependent in a way that pulls for autonomy. An anxiety hierarchy of instrumental and assertive behaviors can be set up and implemented gradually. Role playing and modeling allow the dependent to rehearse independent living skills and new ways of relating in the safety of the therapy office. Assertiveness training can be used to target submissive behaviors as they occur in session. Group therapy may be particularly useful. Most groups are naturally accepting, and veteran group members are often adept in identifying maladaptive patterns of relating. Abandonment issues may

Focus on Lifespan

Dependent Personality and Partner Illness Separation Anxiety and Dependent Personality

The connection among aging, depression, and dependency is a burgeoning frontier of research. The quality of life for many aging dependent personalities is complicated by the health status of the partner they have always relied on, in many cases for most of their life. Dependents seek out those who are willing to face a cruel and uncertain world and make major life decisions for them. Their chosen protector, usually a spouse but sometimes a mother or father, provides structure and resources intended to shelter dependents from responsibility. Dependents are just along for the ride, so to speak. And that's exactly how they prefer it.

What's a dependent to do, however, when the all-powerful protector begins to succumb to the effects of aging? Because age and stability usually go together, it is not uncommon for the protector to already be many years older. Eventually, the protector may require steady in-home care or even begin to develop a dementing illness, such as Alzheimer's, eliminating his or her role as chief decision maker. Because many families cannot afford round-the-clock nursing care, the burden often shifts to the dependent personality. A role-reversal may occur in which dependents are required to assume control of the family and take charge of financial and legal responsibilities. They may also be required to administer medications on a schedule, watch over the activities of the ailing partner, coordinate their partner's day, or perform a series of medical chores in a routine program. As the illness worsens, dependents must take control of two lives, whereas previously, they sought to forfeit control of their own. In a study examining the relationship between personality and caregiving, Alzheimer's caregivers who were distressed were found to be six times more likely to possess dependent traits (J. T. Olin, Schneider, & Kaser-Boyd, 1996). As the population of the United States continues to age, individuals with dependent traits can be expected to complicate an already troublesome crisis in health care.

be less intense in group therapy, as the dependent has more than just the therapist on whom to rely.

The effectiveness of interpersonal techniques can be combined with cognitive techniques, which help confront the black-and-white thinking of the dependent. In fact, cognitive techniques may be most useful at the very beginning of therapy, for their black-and-white world causes most dependents to see therapeutic change as sink-or-swim and not a gradual deepening of adaptive competencies. Clients can be asked to record their perceptions and feelings in a thought diary throughout the week, and the contents can be processed in session as a means of illuminating automatic thoughts that put them in the submissive mode. Interactions with significant others are particularly important. Whatever cognitive technique is employed, the goal is to actively engage dependents in a more active style of problem solving that disconfirms life as an existence of total helplessness and total isolation and moves them toward a more competent self-image. Moreover, dependents can use the therapist as a sounding board during a session to perform a reality check for their automatic thoughts.

Interpersonal and cognitive techniques are primarily useful in helping the individual understand pathological patterns in current functioning, but they do not explain the developmental basis from which these patterns arose. Psychodynamic exploration may be effective in helping dependents understand the source of such problems, though insight alone is unlikely to be sufficient in producing personality change. If dependents can be led to an understanding of the role of caretakers in their early lives, they will also understand that without their own conscious intervention, their future will be determined by their past. Understanding the role of introjection and idealization in the present is important in interrupting the reemergence of pathological patterns of relating once some level of progress has been achieved. Achieving less idealized images of others inevitably may involve confronting intense feelings of guilt related to more realistic images of parents and spouse as less than perfect, but the role of guilt in perpetuating submission and low self-esteem should be understood; otherwise, its background presence continually erodes any achievements of autonomy.

Although dependents often make rapid progress, for every individual and every therapy, the solidity of gains is checked at termination. For the dependent, the end of therapy means a loss of attachment with the therapist and a possible return to feelings of alone-ness and helplessness: The crutch is gone. When the therapist begins to talk about the future, phobic symptoms and depressive feelings may suddenly escalate. If therapist and subject are somehow covertly aligned in maintaining the dependent pattern, they may spend many, many sessions trying to understand the meaning of these events, only to endure through yet another relapse as termination again approaches. Many therapists remain caught in this cycle, and eventually, most find it absolutely exasperating. The majority of cases, however, are likely to have a happier outcome.

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