Toby L.'s husband called the psychologist to schedule an appointment. "I don't know if you want to see us together or just my wife. She's driving me absolutely crazy. I love her, but I'm really at the end of my rope here. She's crying in the next room even while I'm calling you." An appointment was set for the couple to come in. The clinician intended to meet with them together to identify if this would become a couples therapy case or an individual case, and, if so, who would be the identified patient.
Mel and Toby L., a couple in their late 70s, appeared early for their appointment, both rising as one to greet the therapist when she met them in the waiting area. She noted that on entering the office, Mr. L. sat on the sofa first, and then his wife sat beside him. She was smiling a sad smile and holding his hand. Mr. L. looked weary and irritated. He was not smiling.
Mr. L. answered the therapist's questions for the couple and was the narrator of their story. When the therapist pointedly directed a question to Mrs. L., she would look at her husband for permission to talk. Her brief comments were followed by a glance toward him seeking his approval. Typically, he would clarify or offer some revision of what his wife had just said.
The couple had been married for over 50 years and had raised two daughters. Both of their daughters were married and lived not too far away. Toby and Mel were devoted to their three school-age grandchildren. Their daughters were in good marriages and generally doing well. At this time, the extended family did not appear to contribute to the couple's distress. However, the older daughter had been increasingly setting limits on her mother's demands and intrusions into her own privacy. Toby not only would insist on knowing how to reach her daughter in an emergency when she made a business trip, but also would call her daughter on her cell phone to make sure the plane landed safely each time she left and returned from a trip. Toby carried around with her a calendar of when each child (and grandchild) would be away, where they were staying, and how they could be reached. The daughter refused to comply when her mother started requesting the name of the carrier and the flight number stating, "I want to listen to the news on your travel days."
What led to Mel's call of distress was that his wife began to insist that he take her grocery shopping and drive her to and from the hairdresser's. The absolute red flag was when Toby began to insist that Mel accompany her on lunch dates with her women friends. Toby would proclaim, "I need you to keep up the conversation. I just can't do it alone. I'm not up to it, and you're so good at chitchat."
When asked if there were any other events or behaviors he experienced as particularly disturbing, Mel responded that Toby's constant illnesses and complaints led to so many doctor visits that there was little time for anything else, especially because Toby's energy level was low. "If you look at our calendar, there's not a day when we don't have some doctor or lab appointment, or physical therapy appointment, and almost all of them are for her. Toby carries a calendar for all those appointments, too. And a notebook. You have no idea how many different doctors she sees."
At that point, Toby hesitantly spoke up: "I see them because I'm sick and can't take most medicines so they don't know what to do with me. Most of them start out being nice, but I guess I discourage them, and I've got to have someone there to call, and they have to get back to me, too." The therapist could hear a note of panic creeping into Toby's voice.
"And another thing that really gets to me," Mel went on, "I just don't understand it. Toby was a professional, a teacher's teacher, and she wasn't clinging to anyone's coattails, as far as I know. I don't know what is happening here, but it's not good for her, and it's not good for me." As his anger became apparent, Toby began quietly to weep.
Toby L. was born and raised in a small midwestern town into one of very few Jewish families. Her father owned a store in the center of town selling blue jeans and work gear. He was a quiet but friendly man devoted to his customers, who in turn, were devoted to him. Business was steady and good. Toby had one brother, 4 years her senior, who was raised and primed to take over the store someday. The family was close and tight, perhaps as protection against the outside, feeling somewhat different from their neighbors. Toby adored her brother. He grew to be tall and good-looking, was a popular fellow and good at sports. With her father working in the store long hours and her mother running the house and functioning as the store's bookkeeper, Toby and her brother spent much time together. He effectively was an auxiliary parent to her, and shepherded Toby through many of the trials of growing up.
Toby was always a frail child, prone to catching everything, and needing much rest. She was not especially pretty and not at all athletic. She was, however, highly intelligent, and much of the attention she received at home and at school rewarded this. She was the smart one but also the fragile one.
When Toby's brother graduated from high school, World War II was being waged. He enlisted in the U.S. Army, which was the patriotic thing to do, with the intention of returning home after the war to work with his father in the store. He would probably marry his high-school sweetheart and raise a family in that same town. However, he never returned from the war. He was killed in action. Toby's mother became a Gold Star Mother, devoted herself to his memory, and idealized his role as a soldier. Toby's father died 6 months after his son was killed. And his father, Toby's beloved Papa, died soon after. Within 1 year, Toby had lost her grandfather, father, and brother, who were collectively her anchor, support, and strength. She was 19 years old and in college that year. She would never return to the family home, and she would never again trust that those she depended on would stay safe and return if they went away.
Toby completed college and went directly on to graduate school to earn an advanced degree in education, specializing in curriculum development. At the university, she met a nice fellow student who was charmed by her intelligence, much superior to his own, in combination with a wispy physical presentation. A big guy with a big heart, he quickly fell in love with Toby and took her under his wing. He would drop her off at school each morning and pick her up at the end of the day. In time she learned to drive, albeit cautiously. They married, and after her first daughter was born, Toby gave up work to devote herself to her husband and their little family. Only when both girls were through school did Toby return to work, joining the faculty of a nearby teacher's college.
Toby's life had two tracks, home and work. At work, she was well respected by her colleagues as well as her students. Somewhat dour and humorless, she was not a beloved teacher, but rather a respected one, being approachable, conscientious, and consistent.
At home, she was competent but always doubting this. She would watch how others did things. She would ask for directions and assistance just to reassure herself that what she was doing was right. She would solicit her husband's advice about most everything, but ultimately came to resent his self-confidence, which she equated with competence, comparatively diminishing her own. When her resentment came to consciousness, at times she would fantasize about divorcing Mel, or that he would die and she could be on her own. Then she would feel very anxious and nearly panic because she knew deep down that she could not make it on her own. She believed that without his help and guidance, she really couldn't get by in the world.
Around this time, in her late 40s, Toby developed a strange collection of symptoms. She became terribly fatigued, lost her appetite and subsequently significant weight, and often felt sweaty and tremulous. She could barely manage to go to work. When she came home, she went to bed. Her husband took over the household chores to allow his wife to rest. She went from one doctor to another, but none could determine the cause of her illness. Many medications were prescribed. Toby tried them all, to no avail. She could not tolerate their side effects and frequently stopped taking the medication after only one or two doses. There was one pill she could tolerate, however, and she came to depend on it. That was a benzodiazepine, which she took before bed to help her sleep, and sometimes a half during the day if she felt especially shaky. This pattern continued over the years. Toby never increased the dosage, but she was never willing to discontinue the drug. A further development during this period was her increased awareness of her husband's presence and accessibility, especially when she felt ill or in distress. Always concerned about where he was going and how long he would be gone, she now experienced a cycle of great apprehension followed by relief when he returned, accompanied by symptoms of autonomic nervous system arousal and recovery.
Toby meets the criteria for a diagnosis of Dependent Personality Disorder. She is submissive, clingy, and profoundly fearful of separation from those on whom she depends. The facts of autonomy and functional independence in an isolated life sphere do not challenge her internalized identity as a passive and timid soul who cannot function without the help of others. Typically, there is a person or two who is internalized as the dependent person's leader. If the leader is lost, the individual with a dependent personality must find a replacement. Toby's brother, father, and grandfather came to be replaced by Mel, whom she relied on for decision making, advice, and reassurance. He served as her protector and guide. She always would need someone on whom to depend, and she would need constant reassurance that this person would be accessible and available. We heard echoes of that when Toby reported that, no matter whether the doctors could help her, she absolutely needed to know that they were there for her.
Frequently, the genesis of this personality disorder includes some life event that triggered a fear of loss or abandonment by the person on whom the child or young adult depended, as happened dramatically in Toby's life. Having been excessively or seriously ill during childhood also adds to the probability that this personality disorder will develop, especially when the label of being a fragile child is applied and independence is discouraged. The message such children get from the family is one of inability to care for themselves and trust that someone will always be there to guide them and care for them. The dominant ego defenses include idealization (of the protector/leader) and reaction formation (to avoid conflict and anxiety emanating from a fear of abandonment).
Comorbid anxiety disorders are often present in individuals with Dependent Personality Disorder as they are inherently anxious and fearful. Their internalized anger, with feelings of resentment and profound inadequacy, puts them into great conflict. They cannot risk confrontation and alienation from those on whom they depend and induce in themselves great suffering when even contemplating this. Their help-seeking and reassurance-seeking behavior can be annoying, but to their protector, this behavior, at least originally, often is gratifying. It is frequently the case, as with Mel and Toby, that what began as a match made in heaven only shifted to living hell when there was a significant change in the system. In this instance, the change was inherent in the aging process. Mel developed a few age-related health problems that were minor, but nonetheless were terrifying intimations of mortality to Toby. Toby also was aging, and was not able to tolerate the usual age-related aches and pains. In addition to an Axis II diagnosis of DPD, she also meets the criteria for an Axis I diagnosis of Undifferentiated Somatoform Disorder. She presents with complaints of fatigue, gastrointestinal disturbances, loss of appetite, and multiple aches and pains that have persisted for years, cause significant distress, and impair her daily functioning. This also increases her clinging and reassurance-seeking behavior, along with her desperate need to be able to contact and access those on whom she depends.
A treatment plan was developed to include four aspects: pharmacological, individual, couple, and group therapies. The pharmacology aspect would suggest a selective serotonin reuptake inhibitor (SSRI) as a first-line medication to reduce the anxiety and treat a probable underlying dysthymia. It would be explained to Toby that this medication was in a different class of drugs from those she had tried before and that it was very well tolerated. Because of her special sensitivity to medications and intolerance of any somatic change, the medication would be introduced and raised to treatment level very slowly, and she would have frequent scheduled contact with the pharmacologist to report her sensations and receive support and encouragement to remain on the medication long enough to give it a chance. As trust in the pharmacologist developed, Toby would be gradually weaned off the benzodiazepine. The SSRI also works on anxiety symptoms, is not addicting, and does not have the side effects of benzodiazepines, which are especially dangerous for older adults.
The individual therapy would be a combination of cognitive, behavioral, and supportive psychotherapies, overall a pragmatic ap proach. The therapeutic alliance would need to engage Toby's trust and also allow and tolerate the initial transfer of dependency. It also would need to provide a context that could reduce her anxious dependency without denying her the secondary gains of this personality disorder, including the protection and attention of her husband. This will be a real challenge, and the clinician can expect to be tested for accessibility. The main goal would be to reduce the dependency/clinging behaviors, but not to eliminate them. A secondary goal would be to link the secondary gains of the unwanted behaviors to the new (less dependent) behaviors. For example, she could be coached to share with her husband her successes, rather than her ineptitudes and deficiencies, and gain his attention and support in that way. She could join her husband on an errand or an outing and offer to drive him. Toby would also be led to understand how she has come to respond with anxiety to the anticipation or fear of aloneness. She would be encouraged to identify the thoughts that lead to the anxiety, her dependency worries, and how many of her dependent behaviors are attempts to reduce this anxiety. Might there be other ways to achieve that? Stress reduction and relaxation training techniques could be introduced at this point.
The couple therapy should be interspersed with the individual therapy, to direct and support positive changes. Their strengths as a couple would be validated and valued. Toby would need to be reassured that should she become less dependent (or more independent), she would not risk her husband's disapproval and thereby increase her fear of his abandonment (equated with less attention and less protection). As she is so concerned about his health and well-being (to ensure his availability), she could be encouraged to understand that allowing him greater breathing room is better for him and therefore for her. For his part, Mel could be coached how best to support his wife's reduced expressions of dependency and reinforce her (relatively) independent behaviors through his greater recognition, attention, and positive regard.
In time, Toby could be transitioned to group therapy. Again, the goal would be to engage and support her independence while accepting the help that becomes necessary as one ages. An older woman's empowerment group would be a good choice at this point. A caution certainly would be the effect that ensuing change would have on the couple. It is therefore important that the couple's therapy continue, at least intermittently, to monitor their adaptation to changes that occur.
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