Treating the Dependent Personality
Clinical Psychiatry News - Volume 35, Issue 8, Page 23 (August 2007)
Recently, I was running errands across town in Manhattan with Daniel, one of my adult sons. I had to use the cell phone and suggested that he drive. He jumped behind the wheel and asked, “How should I go?” After reminding him that he regularly travels between continents, directs a team of people who work for him, and negotiates his life in a highly organized and positive way, I asked why he needed direction from his father to drive 12 blocks in the city in which he lives.
My guess is that for Dan, that moment took him back to the parent-child relationship of growing up. It took me back to some of the overwhelming issues confronting people with the multiple variations of dependent personality disorder.
Then I returned to my phone conversation, and my son made his way across town without any guidance from me.
So many times in my experience, patients with dependent personality styles or disorders seek treatment for what they describe as depression or uncontrolled anxiety.
Difficulty making decisions and feelings of helplessness, loneliness, and abandonment are often present. The anxiety appears to be part of this system, as the overall helplessness and dependence lead right into this.
Dependent personality disorder was poorly understood until Freud was conceptually able to place the genesis of this disorder into a specific developmental stage in terms of overindulgence during early life. Many variations of these developmental theories have been set forth and have aimed at further advancing our understanding of this often incapacitating disorder.
In treating patients who present with depression symptoms and anxiety disorders, I stay focused on the current symptoms. As patients' personality issues emerge, their level of underperformance, coupled with endless negative expressions of “I can't,” “I'll never be able to,” “I'm no good at it,” “you figure it out,” or “I need help” that keep rumbling into the dialogue, the clarity of dependence emerges and becomes the issues to be addressed. It can be 3 weeks or 3 months or more before this occurs.
In a cognitive model of therapy, however, I believe it's important to let the patient know what you, the therapist, are seeing develop and to create a goal-oriented plan for improvement.
Enter a nice young man in his mid-20s who was referred by his family doctor for depression and “high anxiety.” He was not doing well at work or socially, in that he was being told how difficult it was to be around him. Spending time with him was difficult in the sense that he “needed” so much attention, as some friends had remarked. He was both depressed and anxious at the same time about his failures. By the end of the first visit, it was very clear from the way he spoke that he seemed to need help for many things going on in his life. Almost always, that help came from his “generous” and “kind” family.
At work, he could rarely find what he needed or got confused between incoming and outgoing material. Socially, he needed a lot of attention and was told by one date he went on that he was using up all the “energy” she had.
Interestingly, at the end of the first visit he commented on the TV with multiple VCR hookups I had in my office [for resident teaching] and made it clear that he could never put something like that together. He asked whether I could diagram how I did it for him. (I would use this therapeutically down the road for this young man.)
The patient's presentation was more of helplessness, lack of self-esteem, and a clear understanding that he could not do things at all or well. Dependence was then the central issue to be addressed.
Using my learning, philosophizing, and action (LPA) technique, I decided to focus on learning and action.
First I needed to establish with this young man what I was seeing in him, what I thought was causing the problems, and whether he was willing to work with me in a way to challenge the automatic thoughts he had about himself and his “inabilities.” He agreed.
This is a touchy area, in that the pervasiveness of personality disorders is not always open to discussion, including therapeutic ones. I have found that presenting a goal-oriented plan, including gaining agreement from the patient that his thoughts and behaviors would be challenged to help fix the problem, often works.
I also want to be sure that the patient does not become dependent on me, so I design a plan for improvement in which the patient challenges thoughts and ideas without thinking magically that I will make it better (which avoids fostering dependence on me). This often works.
What is critical in working the cognitive-behavioral model is the patient's motivation to work within the system so that goals can be accomplished successfully and change for the better occurs.
In this part of the process, I'm like the good surgeon who describes the procedure and what is needed to work over the next year.
With this patient, I successfully used Freud's thinking in a relearning mode of “overindulging” and we worked out a nice therapeutic model of how the wrong ideas and signals influenced his style of needing help and feeling incompetent. This was a bright guy, and he did see the learning aspect well. He was able to illustrate to me much of the overindulgence he experienced growing up. Actually, he saw how his dependence grew and was even encouraged.
As learning and insight were gained, there was still the challenge of changing his actions, and a hierarchy of tasks was set in motion, not unlike the hierarchies I have used in dealing with phobic problems (The Psychiatrist's Toolbox, “Conquering Phobias” May 2004, p. 43).
The difference in the phobia treatment is that, therapeutically, I lay out the desensitization plan for the patient. With dependent personality disorder, I had the patient come up with problems or complaints about him in the work world, and together we planned out how, for example, to go out and work the copy machine. If it didn't go well, he would continue to try it. Or he might get the instruction manual or call for technical help and learn it, rather than to repeatedly get coworkers to stop their work and help him.
Over and over, together we developed hierarchies to the point where he actually was able to develop and make presentations on his own, feeling nervous, but not helpless or inadequate.
Clearly, his thoughts about himself were challenged and his behaviors were changed, which allowed a rethinking and reprocessing experience to occur during our therapeutic encounters.
We came back time and again to that first visit and the VCR hookups that he “couldn't do.” It was great to hear the difference between how he sounded then, compared with the end of treatment.
We worked together for about a year and a quarter, more or less weekly, and on the last visit the patient mentioned that he was going to drive upstate to visit an uncle and aunt he hadn't seen in a long time.
He also planned to use the trip to learn more about his family. Then he asked, “What if I get lost?” As I was about to reply, he flashed a big grin and I knew he was joking.
Let me know your experiences with these difficult problems we encounter in treating personality disorders, and I'll try to pass them along to my readers.
PII: S0270-6644(07)70528-3
doi:10.1016/S0270-6644(07)70528-3
© 2007 Elsevier Inc. All rights reserved.