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Effective treatment of the dependent patient requires an integrated treatment strategy drawing primarily from the psychodynamic and cognitive traditions, but also involving behavioral and experiential techniques. The initial focus of treatment is on helping patients gain insight into the origins and dynamics of their problematic dependency—the history of their dependent coping style and the factors that maintain this style in the present. Once adequate insight has been achieved, cognitive and experiential strategies are introduced to alter dysfunctional cognitions and emotional responses, with the goal of moving the patient from unhealthy (mindless, reflexive) dependency to healthy (mindful, goal-directed) connectedness. The final phase of treatment focuses on strengthening coping skills and implementing relapse-prevention strategies.
Several techniques facilitate this process:
Interpersonal interaction episodes that share a common dynamic and emerge in different contexts can be particularly useful in enhancing insight. Analysis of these core relational themes helps dependent patients understand maladaptive relational patterns and distorted perceptions of self and others.
A three-step process is used to deconstruct each interaction episode:
- exploration of the patient's wishes, intentions, and fears
- scrutiny of the other person's response
- examination of the patient's characteristic manner of coping with this response
To supplement interpretation of core relational themes it is vital that the clinician create a supportive therapeutic milieu that does not recapitulate destructive dynamics from the patient's past and current relationships. Dependent patients often idealize the therapist and perceive the therapist as a powerful pseudoparental caregiver; making this transference reaction explicit is key to effective therapy. The clinician must also be sensitive to countertransference responses (e.g., frustration, infantilization) that undermine treatment.
Self-defeating thoughts regarding the self and other people cause dependent patients to doubt their abilities, denigrate their skills, and exaggerate the imagined consequences of less-than-perfect performance.
Three schema-based cognitive distortions are particularly salient in the intra- and interpersonal dynamics of dependency:
- automatic thoughts (i.e., reflexive thoughts that are cued by perceived or anticipated failure)
- negative self-statements (i.e., self-blaming statements that exacerbate the patient's lack of self-confidence)
- attributional bias (i.e., a skewed interpretive style wherein dependent patients punish themselves for perceived failures but cannot accept credit for successes)
Altering these maladaptive schemas sets the stage for long-term changes in cognitive and emotional patterns.
To foster a therapeutic alliance the therapist should take an active approach early in treatment, providing considerable feedback and structure. When dependent patients develop skills that enable them to make meaningful changes quickly their sense of control is enhanced. To facilitate this shift the therapist uses Socratic methods—active, guided questioning—to help patients generate solutions and insights. Self-control strategies (e.g., self-monitoring, self-reinforcement) provide patients with skills needed to replace reflexive help-seeking with mindful problem-solving.
As therapy progresses the patient is taught to identify high-risk situations and dependency triggers (i.e., internal and external cues that activate dependency-related schemas and prompt dependent behaviors). Alternative ways of coping are discussed, and patients are encouraged to reframe setbacks so minor backslides are not magnified into global failure experiences. If a setback occurs within therapy, this is treated as a potential learning experience rather than a therapeutic impasse.
This integrated treatment approach may be used with a range of clients from late adolescence onward. Common presenting complaints include interpersonal loss (e.g., divorce, death of a family member), assertiveness difficulties, enmeshed relationships with parents and siblings, and conflicts with colleagues and authority figures at work. This treatment strategy may be used with higher-functioning personality-disordered clients, but it is not appropriate for clients with prominent psychotic features, or those with significant organic deficits (e.g., dementia, brain injury).
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