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200501370-008

200501370-008

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Published by: Oana Chiru on Jan 22, 2011
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8
APPROACHES
TO
TREATMENT
Duringthe past century
there
has been a tremendous amount of writing
on
psychotherapy, with dependent patients. Until
the
1940s, much
of
this
work
was based on Freud's (1905/1953) classical psychoanalytic model, but
in
recent years traditional Freudian
writings
on
dependency have been over-shadowed
by
contributions
from
object relations theory
and
self psychology
(e.g.,
Kernberg, 1975; Kohut, 1971). Behavioral intervention techniques
for
treating problematic dependency began
to
receive increasing
attention
dur-ing the 1950s, around the same time object relations models gained
influ-
ence,
but it took
another
decade
before
the behavioral perspective played a
significant
role
in
this area. During
the
1970s, behavioral techniques
led to
the
development
of
cognitive strategies
for
treating problematic dependency
(e.g.,
Beck, 1976; D'Zurilla
&.
Goldfried,
1971);
once both
models were
es-
tablished they evolved in synchrony, with considerable mutual influence andexchange.
The
1970s also
saw
increased interest
in
humanistic
and
existen-tial conceptualizationsofdependency (Bugental, 1976,1978), someofwhichevolved
into
experiential treatment models
that
combined
an
overarchinghumanistic perspective with object relations principles (e.g., Bonnano
&
Castonguay, 1994; Cashdan, 1988).In this chapter, I discuss traditional approaches to treatment of the de-
pendent
patient,
focusing
on
four
therapeutic modalities: psychodynamic,
131
 
behavioral, cognitive, and humanistic-experiential.
Within
each domain I
discuss
underlying assumptions
and
therapeutic goals,
then
present
the
basicelementsof anexemplary intervention program derived
from
that
theoreti-cal perspective.
These
intervention programs can be
effective
in and of them-selves,but they also represent the building blocks of the integrated psycho-therapeutic framework discussed in chapter 9.
THE
PSYCHODYNAMIC PERSPECTIVEContemporary approaches to psychoanalytic psychotherapy are discussed
by
BlattandFord (1994), Crits-ChristophandBarber (1991), Luborsky(1984), Messer
and
Warren (1995),
and
Weiss
and
Sampson (1986).
As
these
reviews
illustrate, psychodynamic treatment models have become increas-
ingly
diverse in recent years, incorporating ideas and findings
from
an array
of
domains within
and
outside psychology
(Paris,
1998; Sperling, Sack,
&
Field, 2000).
There
has also been a
shift
toward structured, time-limited psy-chodynamic therapy—a significant departure
from
earlier psychoanalytictreatment approaches (e.g., Brenner, 1973).
Assumptions and
Goals:
Unconscious
Conflict
and
Insight
A core assumption of psychoanalytic theory is
that
many features ofconscious experience are rooted in unconscious
conflicts,
which take two gen-eral
forms
(Eagle, 1984). Some unconscious conflicts reflect clashes betweenincompatible
beliefs,
fears,
wishes,
and
urges (e.g.,
a
wish
to be
cared
for
versusan urge to compete).
Other
unconscious conflicts emerge as compro-
mise
formations
—the
disguised, distorted end-products
of
underlying impulsesand defenses against those impulses (e.g., when hostile humor reflects subli-mated aggression).The
concept
ofunconscious conflictis
useful
inunderstandingtheeti-
ology
and dynamics of many personality traits, and it is particularly relevant
for
dependency.Themyriad rulesandrestrictionsofmid-tolate childhood—coupled with society's expectationofincreased self-reliance—almost invari-
ably
cause
girls
and boys to experience intense ambivalence regarding au-tonomy
and
dependency
and
invoke
an
array
of
defenses
to
manage"unacceptable" dependency-related urges (see chap. 3 for a discussion of thisprocess). Some dependency-related conflicts may be conscious; others are atleast partially
hidden
and
inaccessible
to
conscious awareness (Blatt, 1991;Kantor, 1992, 1993; Ryder
&
Parry-Jones, 1982).The aim of psychoanalytic therapy is not to ameliorate these conflicts,
but
to
make them accessible
to
consciousness, where they
can be
examinedcriticallyand acted upon
mindfully
(Brenner, 1973; Eagle, 1984).
Thus,
a
primary
goal
of
psychoanalytic treatment
is
insight—increased awareness
of
132
CLINICAL APPLICATIONS
 
dependency-related thoughts,
feelings,
and motives
that
previously operatedoutside of awareness. For many dependent patients—especially
those
withunacknowledged dependency needs—insight is a prerequisite to therapeuticchange (Bornstein, 2004; Hopkins, 1986; Snyder, 1963).
Once
the
patient
has
gained insight
into
motives
and
conflicts
that
previously
existed outside awareness,
the
process
of
working
through
—that
is,applying
newfound insights
to
current relationships—may begin (Weiss
&
Sampson, 1986).
Though
insight by definition must precede working through,these processes
are not
separate,
but
synergistic: Insight
is
necessary
for
workingthroughtobegin,but asworking through proceeds, patients gain increasedinsight
as
well (Weissmark
&
Giacomo,
1998).
For
most patients this meansmoving beyond
superficial
awareness of how their dependency needs have
affected
past and present relationships and gaining a more sophisticated un-derstanding of how these relationships have influenced (and in some instances,helped propagate) their dependency-related
feelings,
motives,
and
fears
(see
Bruch,
Rivet, Heimberg, Hunt,
&
Mclntosh,
1999).
Luborskyand
Crits-Christoph's
CCRT
Method
With
these overarching psychodynamic principles
in
mind, Luborksy
and
Crits-Christoph (1990) developed
the
Core
Conflictual
Relationship
Theme
(CCRT)
method, which
has
been used
to
treat
a
variety
of
Axis
I and
Axis
II
disorders,
and may be
particularly
helpful
for
dependent patients.
The
basicelements of
CCRT
can be divided
into
four
categories:
The
underlying
context:
Supportive-Expressive
(S-E)
therapy.
De-rived
from
the
seminal writings
of
Lowenstein (1951)
and
Greenson (1965), S-E therapy combines psychoanalytic inter-pretation withamilieu
specifically
designedto
enhance
thetherapeutic alliance. The
first
task in S-E therapy is to build acollaborative working relationship through empathic commu-
nication on the
part
of the
therapist (Crits-Christoph
&
Connolly, 1998).
The
"holding environment"
of S-E
therapy
may
have curative value
in and of
itself,
but it
also helps mini-
mize
anxiety
and
defensiveness, especially
in
patients with lim-ited insight
into
their underlying dependency needs (Crits-
Christoph
&
Barber,
1991).
Interpretations
in S-E
therapy
are
based
on object relations principles and
framed
in what Mayman
(1976)
termed "experience-near" language (i.e., languagethepatient
can
easily relate
to
personal experiences
and
past
and
current relationships).
• Insight
throughanalysis
of
Core
Conflictual Relationship
Themes
(CCRTs).
CCRTs
are
derived
from
patient narratives
that
cen-
APPROACHES
TO
TREATMENT
133

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