8

APPROACHES TO TREATMENT

During the 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 overshadowed 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 during the 1950s, around the same time object relations models gained influence, 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 established they evolved in synchrony, with considerable mutual influence and exchange. The 1970s also saw increased interest in humanistic and existential conceptualizations of dependency (Bugental, 1976,1978), some of which evolved into experiential treatment models that combined an overarching humanistic perspective with object relations principles (e.g., Bonnano & Castonguay, 1994; Cashdan, 1988). In this chapter, I discuss traditional approaches to treatment of the dependent 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 basic elements of an exemplary intervention program derived from that theoretical perspective. These intervention programs can be effective in and of themselves, but they also represent the building blocks of the integrated psychotherapeutic framework discussed in chapter 9.

THE PSYCHODYNAMIC PERSPECTIVE Contemporary approaches to psychoanalytic psychotherapy are discussed by Blatt and Ford (1994), Crits-Christoph and Barber (1991), Luborsky (1984), Messer and Warren (1995), and Weiss and Sampson (1986). As these reviews illustrate, psychodynamic treatment models have become increasingly 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 psychodynamic therapy—a significant departure from earlier psychoanalytic treatment approaches (e.g., Brenner, 1973). Assumptions and Goals: Unconscious Conflict and Insight A core assumption of psychoanalytic theory is that many features of conscious experience are rooted in unconscious conflicts, which take two general forms (Eagle, 1984). Some unconscious conflicts reflect clashes between incompatible beliefs, fears, wishes, and urges (e.g., a wish to be cared for versus an urge to compete). Other unconscious conflicts emerge as compromise formations—the disguised, distorted end-products of underlying impulses and defenses against those impulses (e.g., when hostile humor reflects sublimated aggression). The concept of unconscious conflict is useful in understanding the etiology and dynamics of many personality traits, and it is particularly relevant for dependency. The myriad rules and restrictions of mid- to late childhood— coupled with society's expectation of increased self-reliance—almost invariably cause girls and boys to experience intense ambivalence regarding autonomy and dependency and invoke an array of defenses to manage "unacceptable" dependency-related urges (see chap. 3 for a discussion of this process). Some dependency-related conflicts may be conscious; others are at least 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 examined critically and acted upon mindfully (Brenner, 1973; Eagle, 1984). Thus, a primary goal of psychoanalytic treatment is insight—increased awareness of
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dependency-related thoughts, feelings, and motives that previously operated outside of awareness. For many dependent patients—especially those with unacknowledged dependency needs—insight is a prerequisite to therapeutic change (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 working through to begin, but as working through proceeds, patients gain increased insight as well (Weissmark & Giacomo, 1998). For most patients this means moving beyond superficial awareness of how their dependency needs have affected past and present relationships and gaining a more sophisticated understanding 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).

Luborsky and 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 basic elements of CCRT can be divided into four categories: • The underlying context: Supportive-Expressive (S-E) therapy. Derived from the seminal writings of Lowenstein (1951) and Greenson (1965), S-E therapy combines psychoanalytic interpretation with a milieu specifically designed to enhance the therapeutic alliance. The first task in S-E therapy is to build a collaborative working relationship through empathic communication 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 minimize anxiety and defensiveness, especially in patients with limited insight into their underlying dependency needs (CritsChristoph & 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., language the patient can easily relate to personal experiences and past and current relationships). • Insight through analysis of Core Conflictual Relationship Themes (CCRTs). CCRTs are derived from patient narratives that cenAPPROACHES TO TREATMENT 133

ter on relationship episodes—memorable, meaningful interactions with other people (Luborsky & Crits-Christoph, 1990). As patterns emerge in a patient's relationship episodes, these are analyzed in three broad areas: (a) the patient's wishes, intentions, and fears; (b) the response of the other person; and (c) the patient's reaction to the other person's response. By exploring consistencies in CCRTs across different relationships, the patient's dominant needs and defenses are made explicit, and the trait-like aspects of dependency become clear. By examining inconsistencies in CCRTs across different relationships, the contextual specificity of a patient's behavior can be understood, and the situational features of dependency become apparent (see Crits-Christoph & Barber, 1991; Crits-Christoph, Demorest, Muenz, & Baranackie, 1994). • Obstacles to progress: Ambivalence in the therapeutic alliance. Obstacles to progress in S-E therapy can originate in a number of areas. For the dependent patient, ambivalence is common: As the patient becomes increasingly attached to the therapist, anxiety regarding rejection and abandonment increase and behaviors designed to minimize the possibility of relationship disruption begin to dominate (Kantor, 1992; Lower, 1967; Van Sweden, 1995). Dependency-related resistance is not limited to the patient, however; it can also originate in the therapist (see Ryder & Parry-Jones, 1982). The therapist may fear that the patient's dependency will become increasingly intense over time (the "fantasy of insatiability") and that the patient's dependency will make termination impossible, so treatment can never end (the "fantasy of permanence"). If not managed properly, the patient's and therapist's fears may feed on each other and worsen as therapy progresses: The patient becomes increasingly anxious about the risks and responsibilities of autonomy, and the therapist becomes increasingly anxious about the negative impact of the patient's dependency. • The emotional undercurrent: Transference and countertransference. One way to prevent dependency-related fears from undermining treatment is to explore the patient's transference reaction and the therapist's countertransference response (Bornstein, 1994c, 1998a). Common transference patterns in dependent patients include idealization (maintained through denial of therapist imperfections); possessiveness (which may have a strong narcissistic component or involve feelings of jealousy and competitiveness); and projective identification (wherein the patient unconsciously adopts the therapist's language and mannerisms). Common therapist responses to these transference reactions
134 CLINICAL APPLICATIONS

include frustration at the patient's insatiable neediness; hidden hostility (often accompanied by passive-aggressive acting out); overindulgence (ostensibly to protect the "fragile" patient); and pleasurable feelings of power and omnipotence (which can, on occasion, lead to exploitation or abuse). The key to managing these negative reactions is to seek supervision and guidance from other mental health professionals. This is particularly important for those forms of countertransference that are associated with significant risk of patient harm (Abramson, Cloud, Keese, & Keese, 1994; Coen, 1992).1

THE BEHAVIORAL PERSPECTIVE Reviews of contemporary behavioral treatment techniques are provided by Bellack and Hersen (1993), Hayes (1989), Kazdin (1989), Van Houten and Axelrod (1993), and Wolpe (1990). Although early behavioral interventions aimed at altering problematic dependency were based exclusively on operant conditioning procedures, recent models have combined operant techniques with classical conditioning strategies to maximize treatment effectiveness. Assumptions and Goals: Acquired Behavior and Contingency Change As noted in chapter 1, a basic premise of the behavioral view is that people exhibit particular behaviors—even self-defeating, maladaptive behaviors—because these behaviors are (or were) rewarded. In this context, dependency can be conceptualized as a set of responses aimed at obtaining help and support that are acquired and maintained through a combination of conditioning and learning processes. These include (a) direct reinforcement (sometimes continuous, but more commonly intermittent); (b) vicarious reinforcement (through observation of others' dependency-based rewards); and (c) modeling (including symbolic modeling). Studies show that dependent persons are particularly responsive to subtle social cues (Masling, O'Neill, & Katkin, 1982) and more easily conditioned than nondependent persons in a variety of contexts and settings (Burton, McGregor, & Berry, 1979; Exline & Messick, 1967). Thus, behavioral principles may be particularly useful for understanding the persistence of dependent behavior, even in situations where the rewards for this behavior are not apparent.
'Rather than becoming clingy and needy, some patients cope with dependent feelings by becoming counterdependent, putting forth a veneer of rigid self-sufficiency (Colgan, 1987). This response—which is more common among men than women—creates an additional layer of distortion and defense that must be disentangled before the patient can gain insight into the impact of his dependency within and outside therapy. APPROACHES TO TREATMENT 13 5

Although many behaviorally oriented clinicians conceptualize dependency in terms of positive reinforcement of dependent responding, studies suggest that negative reinforcement also plays a role (see Mowrer, 1950). A two-step process is involved: • Step 1: Acquisition of a fear response. Many children are anxious around unfamiliar people, but in some children this anxiety is especially intense and persistent. Just as certain infantile temperament variables (e.g., high arousal, low soothability) shape parents' responses to the child (Bornstein, 1993), temperament variables may help predict which children are likely to become anxious in the presence of unfamiliar people (Kantor, 1993). • Step 2: Avoidance and anxiety reduction. The overanxious child will tend to avoid unfamiliar people in favor of those who are familiar and predictable. Insofar as avoidance of these interactions reduces the child's anxiety level, this behavior becomes part of her characteristic response pattern (Alden, Laposa, Taylor, & Ryder, 2002). As Ainsworth (1969, 1989) noted, later in life these avoidant responses often persist, although in most cases substitute protectors (e.g., supervisors, friends, romantic partners) replace the parents (see Pincus &. Wilson, 2001; Sperling & Herman, 1991). Turkat's Integrated Behavioral Approach Turkat's (1990) behavioral treatment model is based on the premise that dependent responses persist because they are (a) positively reinforced, in at least some relationships, and (b) negatively reinforced insofar as they enable the patient to avoid anxiety-producing situations. Four techniques, used in combination, are useful in altering the contingencies that maintain this pattern: • Extinguishing problematic dependency. Although extinction techniques by themselves are of limited value in effecting long-term behavior change (Martin &. Pear, 1996), they can be useful in altering problematic dependency. To begin, therapist and patient must identify specific behaviors to be reduced or eliminated. This requires that the components of a patient's selfdefeating dependency be broken into discrete responses, so the contingencies that support these responses can be identified. Using this information, a behavior management program is created aimed at decreasing the frequency of undesired dependencyrelated responses. This process will be enhanced if contingency change first takes place within the context of the patienttherapist relationship, and is then attempted in vivo
13 6 CLINICAL APPLICATIONS

(Overholser, 1997). Studies also indicate that these strategies are most effective when therapist and patient discuss the link between contingency change and behavior change early in the process: When the patient understands the rationale underlying a behavior management program, the likelihood that contingency change will lead to a reactive increase in undesired behavior diminishes (Bellack&Hersen, 1993;Linehan, 1993).2 Replacing dependency with autonomy. At the same time dependency-related responding is reduced, efforts should be made to increase the frequency of alternative responses that are incompatible with the undesired behaviors. For the dependent patient, this means increasing the frequency of autonomous responding (Turkat & Carlson, 1984; Turkat & Maisto, 1985). Just as dependent behaviors that are extinguished must be broken into discrete components, autonomous behaviors that are rewarded must be specific, identifiable, and within the patient's behavioral repertoire (McKeegan, Geczy, & Donat, 1993). When novel or unfamiliar target behaviors are involved, it may be necessary to shape these behaviors incrementally, through a series of narrower subgoals (Deitchman, 1978). To facilitate this process, therapist and patient first identify potentially problematic situations (e.g., being assigned an important project at work), then delineate adaptive responses (e.g., doing background research, seeking feedback from more experienced colleagues). Role-play techniques can be used to increase patient confidence and maximize the likelihood that the newly acquired responses will produce the desired consequences in vivo. Using desensitization to facilitate behavior change. To the degree that a patient's dependent behavior is exacerbated by concerns regarding embarrassment, abandonment, or rejection, systematic desensitization techniques should be implemented to help manage this anxiety and facilitate behavior change. Use of desensitization techniques may be particularly important for dependent patients with co-occurring symptoms of avoidant PD and/or social phobia (Alden, 1989; Alden et al., 2002). For these patients, the high levels of autonomic arousal that accompany social interactions interfere with effective carryover
2 Behavioral treatment of dependency can be used in a variety of contexts, but it is particularly effective with school-age children, hospitalized psychiatric patients, patients in rehabilitation settings, and older adults in long-term care (see Bakes, 1996; Kilbourne & Kilbourne, 1983; McKeegan et al., 1993). Because these individuals are in environments where contingencies are easily managed, effecting behavior change through manipulation of reinforcers is comparatively straightforward (Donat, McKeegan, & Neal, 1991). Dependent patients undergoing behavioral therapy in vivo must be highly motivated for treatment to be effective, and—as discussed in chapter 10—involvement of the patient's family can be invaluable in this regard.

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13 7

of desensitization gains from therapy to real-world settings (Overholser, 1987). Detailed discussions of fear hierarchy construction and deep muscle relaxation techniques for use in this context are provided by Martin and Pear (1996). Maintaining behavior change posttreatment. To the degree that autonomous behavior becomes self-reinforcing, the likelihood that this new behavior pattern will be maintained increases (Linehan, 1993; Wasson & Linehan, 1993). Thus, autonomous behaviors that are targeted early in therapy should be those most likely to bring rewards, especially social rewards (Turkat & Carlson, 1984; Turkat & Maisto, 1985). Four techniques are useful in this context. These are (a) choosing target behaviors that lead to positive outcomes in the patient's natural environment; (b) doing in vivo training in settings that resemble those wherein the newly acquired behaviors must be exhibited; (c) varying training conditions to reinforce different expressions of the target behavior and increase generalizability; and (d) gradually reducing the frequency of reinforcement during the latter stages of therapy so reward dynamics approximate those of the patient's social milieu.3

THE COGNITIVE PERSPECTIVE Contemporary cognitive treatment approaches are discussed by Beck (1994), Ellis and Dryden (1997), Fleming and Pretzer (1990), Freeman, Simon, Beutler, and Arkowitz (1989), and Young (1994). Although these approaches differ with respect to certain principles and techniques, they share an emphasis on effecting behavior change by altering the patient's characteristic manner of thinking about, perceiving, and interpreting the world. Assumptions and Goals: Dysfunctional Thinking and Cognitive Restructuring Cognitive theorists conceptualize dependency as the product of maladaptive schemas (i.e., self-defeating beliefs about the self and other people) that cause patients to doubt their abilities, denigrate their skills, and exaggerate the imagined consequences of less-than-perfect performance (Ball &
3 Linehan's (1993) dialectical-behavior therapy (DBT), which combines traditional behavioral and cognitive intervention techniques with a Zen-like attitude of acceptance and impettutbability on the patt of the thetapist—even in the face of patient acting out—has great promise in the treatment of problematic dependency. Although DBT has been applied most extensively in work with borderline and eating-disordered patients, many DBT principles can be applied to the dependent patient as well (see Linehan, 1993; Wiser & Telch, 1999).

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Young, 2000; Overholser, 1997). Maladaptive schemas not only decrease selfesteem and increase anxiety, they also lead to an array of cognitive distortions that strengthen the person's pre-existing negative views. Three cognitive distortions are particularly salient in the etiology and dynamics of dependency: (a) automatic thoughts (i.e., reflexive negative thoughts that are cued by perceived or anticipated failure); (b) negative self-statements (i.e., self-blaming statements that undermine the person's self-confidence); and (c) negative attributional bias (i.e., a distorted interpretation of causality wherein the person punishes herself for perceived imperfections but cannot accept credit for successes). A primary goal of cognitive therapy is cognitive restructuring—altering dysfunctional thought patterns that foster self-defeating behavior. In the case of dependency, cognitive restructuring focuses on strengthening the patient's self-efficacy beliefs, especially those related to social situations. At the same time, the therapist works to detoxify flawed performance (so the patient does not perceive adequate but imperfect efforts as evidence of incompetence), and provide alternative ways of managing negative feedback (so the impact of everyday criticism is not overwhelming). To accomplish these goals, therapist and patient explore (a) the development of the patient's maladaptive dependency-related schemas; (b) the processes that maintain these schemas over time; (c) the avoidance strategies used by the patient to escape schematriggered anxiety; and (d) the compensatory strategies used to manage this anxiety when it cannot be avoided (Ball, 1998; Young, 1994). Cognitive restructuring techniques run the gamut from gentle reframing of biased perceptions (Ball 6k Young, 2000) to aggressive challenging of irrational beliefs (Ellis & Dryden, 1997). Some cognitive therapies focus primarily on dysfunctional thought patterns (Fleming 6k Pretzer, 1990); others also address problematic emotional responses and self-defeating behaviors (Overholser, 1987, 1997). Increasingly, cognitive therapists have utilized concepts from different treatment models so interventions may be tailored to the patient's overall level of functioning. Thus, several cognitive theorists have delineated specific intervention strategies for use with personalitydisordered patients (Linehan, 1993; Fleming 6k Pretzer, 1990) and other patients with longstanding, change-resistant thought and behavior patterns (Alden, 1989; Ball, 1998). Overholser and Fine's Four-Stage Cognitive Therapy Model Overholser and Fine's (1994) four-stage model is based on the premise that problematic dependency is rooted in active avoidance of autonomy that stems from the patient's belief that she is incompetent, ineffective, and doomed to fail without the guidance and protection of others. Overholser and Fine's model seeks to build patient confidence, teach rudimentary social problem-solving skills, and maximize treatment effectiveness by anticipating
APPROACHES TO TREATMENT ] 39

potential roadblocks and pitfalls. Intervention techniques are implemented in stages to guide the patient through a process of cognitive and behavior change. • Stage 1: Active guidance. To facilitate change and foster a collaborative alliance, the therapist in Overholser and Fine's (1994) framework takes an active approach early in treatment, providing considerable feedback and structure. Patients are taught behavioral skills that enable them to make manageable but meaningful changes quickly, thereby increasing motivation and commitment. During the initial sessions, the therapist takes a more active approach than usual in helping the patient delineate long-term therapeutic goals. Among the techniques used at this stage are (a) assertiveness training; (b) behavioral assignments; and (c) stimulus control (e.g., avoidance of dependency "triggers"). Because dependent patients are highly motivated to obtain approval from figures of authority (Bornstein, 1992, 1993), including the therapist (Overholser, 1996, 1997), reassurance, praise, and encouragement can be effective in helping the patient alter longstanding dysfunctional thought and behavior patterns. • Stage 2: Enhancement of self-esteem. Because the dependent patient's help- and approval-seeking result in part from low selfesteem (Overholser, 1993; Tripathi, 1982), Stage 2 focuses on building self-confidence. This begins with psychosocial exploration aimed at uncovering the roots of the patient's negative self-view and gradually incorporates various cognitive restructuring techniques designed to change this dysfunctional thought pattern (e.g., scrutiny and challenging of maladaptive schemas, logical analysis of biased perceptions and beliefs). Patients are provided with coping self-statements that bolster their selfefficacy and enable them to manage negative affect on their own. Reframing techniques may be used to help patients see dependency-related challenges as opportunities for personal growth (Dryden & Trower, 1989; Marlatt & Gordon, 1985). • Stage 3: Promotion of autonomy through problem-solving training. As patients begin to show evidence of enhanced self-esteem and self-efficacy, the focus of therapy shifts to increasing autonomous behavior within and outside therapy and reducing the patient's dependence upon the therapist. Problem-solving training is used to help the patient deconstruct each challenge into five components: problem definition, problem source, generation of alternative solutions, solution implementation, and verification (D'Zurilla, 1988; D'Zurilla & Goldfried, 1971). As this pro140 CLINICAL APPLICATIONS

cess proceeds, the therapist becomes less active and encourages the patient to take increasing responsibility for structuring the interaction. To facilitate this shift, the therapist may also use the Socratic method—active, guided questioning—which enables the patient to generate her own solutions and insights (Overholser, 1993, 1997). Self-control strategies (e.g., selfmonitoring, self-reinforcement) provide the patient with the skills needed to inhibit reflexive (i.e., "mindless") dependent behavior, even in stressful situations (Ball & Young, 2000; Young & Lindeman, 1992). • Stage 4: Relapse prevention. To maximize the stability of behavior change and prevent minor setbacks from undermining progress, relapse prevention strategies are introduced in Stage 4. The patient is taught to anticipate potential problems and reframe setbacks so that they are not magnified into global failure experiences (Marlatt & Gordon, 1985; Meichenbaum, 1985; Young & Lindeman, 1992). High-risk situations are identified, and patients are taught alternative ways of responding to these situations. If a backslide occurs within therapy, this is used as an opportunity to introduce strategies for moving beyond minor obstacles. Because many dependent patients experience comorbid depression and anxiety (Birtchnell, 1984; Bornstein, 1994a; Overholser & Freiheit, 1994), techniques for managing mood and anxiety level can help maintain therapeutic gain (Overholser, 1997). Studies show that just as increasing patient autonomy diminishes chronic anxiety, using cognitive techniques to dampen anxiety facilitates the acquisition of autonomous behavior (Black, Monahan, Wesner, Gabel, & Bowers, 1996). THE HUMANISTIC-EXPERIENTIAL PERSPECTIVE Although the humanistic—experiential model has been less frequently used than other approaches in treating problematic dependency, useful reviews of humanistic (Bohart & Greenberg, 1997), existential (Schneider & May, 1995), and experiential strategies (Cashdan, 1988) are available. There is considerable overlap in the principles underlying these frameworks, and many practitioners use a combination of techniques derived from all three models when working with dependent patients. Assumptions and Goals: Falsehood, Defense, and Responsibility Beginning with the writings of Rogers (1951, 1961), a key tenet of the humanistic—experiential perspective is that various familial and societal facAPPROACHES TO TREATMENT 141

tors—most notably parents' conditional positive regard for the child—can cause the developing person to construct a "false" (or inauthentic) self. This false self is created to comply with the perceived expectations of other people and obtain their approval and love. Once in place, the false self leads the individual to deny feelings and urges that are incompatible with parental and societal norms (Maslow, 1968). To the degree that the parents' conditional positive regard was contingent upon the child's obeying rules without question and complying passively with external demands, the child comes to view autonomy as unacceptable and creates a false self centered on pleasing other people. Eventually, dependency is no longer experienced as a choice, but as a given. Defenses aimed at obviating alternative ways of perceiving the world become firmly entrenched, and the dependent person's experiences narrow to the point that other-centered behavior is the sole means of managing anxiety and gaining approval (Bonanno &Castonguay, 1994; Cashdan, 1988; Hassenfeld, 1999).4 The existential perspective on dependency—though rooted in humanistic and experiential theory—shifts the focus from the constricting effects of early experience to the core motivating power of existential dread (Bugental, 1976; May, 1972, 1981). As Becker (1973) noted, awareness of death and eventual nonexistence can be overwhelming, and as a result people devote enormous energy (and considerable psychological resources) to denying their own mortality (Pysczynski, Greenberg, & Solomon, 2000). One key strategy in this effort involves externalizing responsibility for choices: The person comes to see himself as a powerless entity controlled by outside forces (e.g., society's rules, other people, a higher power, luck), rather than an autonomous, freely choosing, responsible being (May, 1981; Yalom, 1980). To the degree that an individual becomes committed to this way of coping, he will tend to exhibit a pattern of dependent behavior (e.g., advice-, support-, and protection-seeking) that both reflects and reifies the externalization strategy. May and Yalom (2000, p. 287) described this process well:
[A] major mechanism of defense that serves to block death awareness is our belief in a personal omnipotent servant who eternally guards and protects our welfare A hypertrophy of this particular defense mechanism results in a character structure displaying passivity, dependency, and obsequiousness. Often such individuals dedicate their lives to locating and appeasing an ultimate rescuer.5
4

Although Rogers' (1951, 1961) speculations regarding the dependency-producing effects of conditional positive regard were derived almost entirely from theory and clinical observation, these speculations have since been supported by findings which indicate that parental authoritarianism plays a significant role in the etiology of dependency (Baker, Capron, & Azorlosa, 1996; Head, Baker, & Williamson, 1991; Sroufe, Fox, & Pancake, 1983). 5 Recent research derived from terror management theory suggests that while some people cope with death anxiety through dependent behavior, others cope by distorting their perceptions of self and other people (Pysczynski, Greenberg, & Solomon, 1997). Thus, when individuals are made anxious about their own mortality, they engage in an array of cognitive distortions designed to bolster their

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Schneider and May's Existential-Integrative Approach In Schneider and May's (1995) Existential-Integrative (E-I) framework, therapy is seen as a route to liberation. The goals of treatment are to help the person envision new possibilities, experience aspects of the self that have been distorted or denied, and accept responsibility for choices large and small. To initiate this process, the therapist creates an environment wherein the patient can express feelings openly—even troubling, "unacceptable" feelings. At the same time, the patient is encouraged to experiment within and outside therapy, incorporating new ways of being into real-world relationships. Four strategies are used to guide this process: • Unconditional positive regard. Like Rogers (1961), Schneider and May (1995) see unconditional positive regard as key to helping the patient loosen his defenses and regain access to unacknowledged aspects of the self. In practical terms, unconditional positive regard requires that the therapist avoid being critical or directive. By being empathic and nonjudgmental—but not flawless or omniscient—the therapist can help the dependent patient gain trust without seeing the therapist as a pseudoparental "guru" (Yalom, 1980). When the dependent patient experiences a relationship with an accepting but imperfect figure who communicates empathy and models existential living, he can begin to move beyond his fruitless search for an omnipotent savior-rescuer. • Guilt and responsibility. Whereas narcissistic people are preoccupied with fantasies of greatness, dependent people are preoccupied with fantasies of smallness (Schneider, 1990). A key correlate of the dependent person's smallness fantasy is the belief that without an omnipotent protector standing by, she will be overwhelmed and annihilated (May & Yalom, 2000). The dependent patient's rumination about impending disaster is defensive: It helps protect her from experiencing guilt regarding inauthenticity and abrogation of responsibility. By helping the dependent patient focus on the here-and-now (rather than obsessing about the future) and on immediate emotional experience (rather than what might eventually occur), the thera-

sense that the world is predictable and controllable (e.g., underestimating health risks, overestimating the degree to which other people share their views and values; see Pysczynski, Greenberg, & Solomon, 2000). One recent finding is particularly relevant to the existential perspective on dependency: When college students undergo an anxiety-producing mortality salience manipulation, they compensate by increasing their estimates of their romantic partner's commitment to the relationship (Florian, Mikulincer, & Hirschberger, 2002). This result echoes Simpson and Gangestand's (1991) finding (discussed in chap. 4) that dependent people may overestimate their romantic partner's commitment to allay abandonment fears.

APPROACHES TO TREATMENT

] 43

pist can help break the patient's self-defeating cycle of defense and denial. A focus on metacommunication. Like psychoanalysts, existential therapists deconstruct hidden material in the patient's verbalizations and nonverbal behaviors (Bohart & Greenberg, 1997; Ottens & Hanna, 1998). However, unlike psychoanalysts, whose interpretations focus on unconscious motives and defenses, existential therapists focus on metacommunications: pervasive life themes that reflect the patient's core fears (or "dreads"). Key dependency-related dreads in the E-I framework include functioning autonomously, taking risks on one's own, and being overwhelmed by unmanageable responsibility. These dreads both reflect and contribute to the dependent person's narrowed experience of self and prevent her from envisioning alternative choices and actualizing unexplored potentials. While virtually all patients describe their key dreads in negative terms at the outset of treatment, one goal of E-I therapy is to help patients understand the role these dreads play in protecting them from other, more fundamental fears (e.g., death anxiety). Experimenting within and outside therapy. A core component of E-I therapy is the use of exercises designed to short-circuit entrenched defenses, increase emotional awareness, and set the stage for new experiences that help patients reinvent themselves and the world. Schneider and May (1995) provide detailed instructions for a broad array of such exercises, including writing assignments, skill-building tasks, and role-play scenarios designed to increase insight and interpersonal sensitivity. Once the patient becomes comfortable practicing these exercises in therapy, it is important to consolidate gain by applying newfound skills and perspectives in vivo. As Schneider and May (1995, pp. 164-165) noted, "While experimentation within the therapeutic setting is invaluable, experimentation outside therapy is even more beneficial. . . . Experimenting with the actual gives clients new opportunities to live. Although they may not always seize these opportunities, they are invariably vibrant and edifying."

EFFECTIVE USE OF TRADITIONAL TREATMENT MODELS: A FRAMEWORK FOR THE PRACTITIONER Table 8.1 summarizes the core elements of each psychotherapy model discussed in this chapter. To maximize treatment effectiveness using these models, the therapist must do two things. At the "micro" level, effective
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TABLE 8.1

Psychotherapy With Dependent Patients: Core Elements of Traditional Treatment Models
Model Psychoanalytic Assumptions Dependency is a product of early experiences and unconscious conflicts Dependency is a consequence of learning and conditioning Goals Techniques

Insight followed by Interpretation; working through corrective object within and outside relations therapy Modify contingencies to decrease dependent behavior and increase autonomous behavior Alter self-defeating beliefs and enhance selfefficacy Operant conditioning to alter behavior; classical conditioning to manage anxiety

Behavioral

Cognitive

HumanisticExperiential

Dependency is Cognitive rooted in restructuring; dysfunctional problem-solving thoughts and training maladaptive schemas Dependency stems Re-experience Empathic from neglected aspects connection; inauthenticity/ of self; accept experimentation externalization of responsibility for within and outside responsibility choices therapy

treatment requires that the therapist implement thoughtfully the techniques that are central to whichever theoretical model is guiding her work at that moment, adapting these techniques to accommodate the needs and strengths of each patient (see Bernstein, 1994c, 1998a, for discussions of this issue). At the "macro" level, effective treatment requires that the therapist develop an overarching framework to decide when and how to combine interventions derived from different models. Thus far, our review of traditional treatment approaches for use with dependent patients has focused on the "micro" level application of techniques from each theoretical school. In the following sections, five guidelines are offered to help the practitioner develop the overarching framework necessary to apply this information effectively. Tailor Treatment to the Problem Different disorders demand different interventions, and two considerations are key in tailoring treatment to the problem: • Problem specificity. Narrow problems require focused interventions; pervasive problems demand broader treatment strategies.
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Thus, when patients present with domain-specific dependencyrelated difficulties (e.g., anxiety regarding performance evaluation at work), behavioral and cognitive therapies may be the treatments of choice. When patients describe dependencyrelated difficulties that affect functioning across many areas of life (e.g., generalized lack of assertiveness, dissatisfaction with a broad array of relationships), psychodynamic and humanistic-experiential interventions may be warranted. • Comorbidity. Although some patients seek treatment to deal with problematic dependency, most dependent patients present with other difficulties (e.g., depression, anxiety, relationship conflict; see Joffe & Regan, 1988; Overholser & Freiheit, 1994). Obtaining valid diagnostic information and a detailed clinical history is critical in this context: In some patients problematic dependency was a diathesis for their presenting difficulties, but in other patients dependency only became an issue following Axis I symptom onset (see chap. 6). Even within an individual patient, it is possible for dependency to be primary to certain disorders (e.g., depression) and secondary to others (e.g., agoraphobia). The bottom line: Problem specificity and comorbidity are important considerations when deciding upon a treatment approach, and choice of intervention must be guided in part by the unique combination of difficulties presented by each patient. When problematic dependency predates the onset of symptom-based disorders, the clinician should focus on dependency issues early in therapy, even if this means shifting the focus from present symptoms to longstanding relationship patterns. When problematic dependency followed symptom onset, the clinician should begin by addressing the symptoms themselves; in many patients, dependency levels diminish as symptoms abate (Birtchnell, 1984; Bornstein, 1993; Mavissakalian & Hamann, 1987).6 Tailor Treatment to the Patient Studies show that, in general, dependent patients prefer therapeutic approaches that involve disclosure of personal information and a reasonable amount of feedback from the therapist (Blatt, 1992; Blatt & Ford, 1994; Helweg & Gaines, 1977; Juni & LoCascio, 1985). These findings suggest that—all other things being equal—the dependent patient will respond more
'Beyond these considerations, patients in crisis warrant a different approach than patients with longstanding, relatively stable difficulties. Regardless of which therapeutic modality is used, crises demand structure and a more active stance on the part of the therapist (see Overholser, 1997, and Schneider & May, 1995, for discussions of this issue from the cognitive and existential viewpoints).

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positively to cognitive therapy, humanistic-experiential therapy, or psychodynamic psychotherapy than to behavioral treatment or traditional psychoanalysis. However, some dependent patients are interested primarily in symptom reduction and behavior change and may be more receptive to treatments that focus on current difficulties than those that emphasize internal dynamics and exploration of past and present relationships. Patients with co-occurring dependency and alexithymia tend to fall into this latter category (O'Neill & Bornstein, 1996). Assessment data—especially those derived from the IDI, ROD Scale, QSDOR, and DSQ or DMI—can help determine which therapeutic modality may be best suited to a particular dependent patient (see chap. 7). Although the patient's preferences should not be the primary determinant of psychotherapeutic modality, studies show that in both psychological and medical settings, treatment compliance and patient satisfaction increase when patients are given some say in which interventions are used (see Weissmark & Giacomo, 1998). Moreover, early involvement in determining the nature of treatment will have a particularly positive impact on the dependent patient: It compels the patient to take responsibility at the outset of therapy, disrupts the patient's usual pattern of looking to others for structure, and sends a message to the patient that she—not the therapist—is the ultimate decision maker (Bornstein, 1994c; Overholser, 1997). To the degree that the patient is able to verbalize her feelings regarding the increased autonomy that decision-making entails, this strategy can also provide useful material for the initial stages of therapy. Link Autonomy With Healthy Dependency When working with a dependent patient—especially one who is extremely clingy and insecure—it is easy to overemphasize autonomy at the expense of healthy dependency. Although increasing autonomous functioning is an important goal of clinical work with dependent patients, autonomy is most adaptive when it is expressed in flexible, situation-appropriate ways and combined with a willingness to seek help and support from other people (Bornstein & Languirand, 2003; Colgan, 1987). This has different implications for different treatment approaches: • Psychodynamic. As Blatt's (1990) dependency-autonomy dialectic (Figure 3.2) illustrated, healthy adult development is an ongoing process of integrating strivings for relatedness and selfdefinition. As patients gain insight into the negative impact of their dependency, they may overcompensate by moving too far toward self-definition. To counter this, the therapist must emphasize relatedness concerns throughout treatment. The initial therapy sessions represent an opportunity to discuss these isAPPROACHES TO TREATMENT 147

sues in the context of the patient-therapist relationship. Impending termination provides another useful context for a discussion of relatedness issues. • Behavioral. Because behavioral treatment of problematic dependency focuses on increasing autonomous responding and extinguishing dependent behavior, it is important that the therapist help the patient acquire healthy dependency skills even as she becomes more independent. Western stereotypes notwithstanding, adaptive functioning in adulthood does not mean doing everything on one's own, no matter how challenging the task (Bakes, 1996; Behrens, 2004; Colgan, 1987). The dependent patient must learn to ask for help and support when appropriate, and use this help and support to function more effectively (see chap. 5). • Cognitive. Healthy dependency is implicit in various aspects of Overholser and Fine's (1994) model (e.g., in the therapist's initial tolerance of the patient's dependent behavior), and it is important to structure problem-solving training so that autonomous and healthy dependent functioning are integrated, and the patient does not construct a false dichotomy such that all forms of help-seeking become equated with failure (Ball & Young, 2000). The therapist must distinguish adaptive and maladaptive help-seeking and help the patient understand the cognitive and behavioral differences between these two patterns. • Humanistic-Experiential. As discussed, the goal of most humanistic and experiential treatment approaches is to increase the patient's autonomy and personal responsibility while simultaneously enhancing her capacity for intimacy and connectedness. The therapist can ensure that this balance is achieved by structuring experiments within and outside therapy so the patient experiences autonomy and intimacy as synergistic, not incompatible. Schneider (1990) and Yalom (1980) provide practical suggestions along these lines from an existential perspective; Bornstein and Languirand (2003) provide additional suggestions for interventions to strengthen the intimacy—autonomy link in individuals, couples, and families. Explore Your Own Feelings About Dependency Two patient-therapist dynamics are particularly vexing for clinicians: dependency and control (Barth, 2001). Most therapists are well aware of the ways in which a struggle for control can undermine therapy (especially when

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this struggle revolves around missed sessions or unpaid bills). Fewer therapists are sensitive to the ways in which their feelings about dependency can contaminate the therapeutic relationship. However, studies indicate that many therapists become quite anxious when a patient seems overly dependent (Lower, 1967; Perry, 1989). Not surprisingly, therapists who are themselves dependent are particularly upset by patients who seem helpless, clingy, and needy (Abramson et al., 1994; Browne & Dolan, 1991). Certain reactions to a patient's expressed dependency urges can create difficulties in therapy. Understanding one's reflexive responses to dependency cannot ensure that these reactions will disappear, but in this situation selfawareness is the best defense against subtle (and not-so-subtle) forms of acting out that undermine therapy and harm the patient. Three reflexive responses to patient dependency are particularly problematic: • Infantilization. This occurs when the therapist perceives the dependent patient as childlike and immature. The primary risk here is that the therapist will become fearful of overwhelming the "fragile" patient and fail to set appropriate limits (Hopkins, 1986). Not only does this virtually ensure limited progress in therapy, but it recapitulates the same destructive dynamic that occurs in many (perhaps most) of the patient's other relationships—the very dynamic that helps propagate the patient's dependent behavior in vivo. • Authoritarianism. Some therapists respond to patient dependency by becoming inflexible rather than indulgent (Perry, 1989; Ryder & Parry-Jones, 1982). These therapists take an overly active stance in therapy, set rigid rules, and may inadvertently steer therapeutic dialogue toward issues with which they—not the patient—are concerned. This authoritarian stance is always counterproductive and, like infantilization, it is particularly harmful if it reiterates a dependency-fostering dynamic that is occurring in other areas of the patient's life. • Denigration. In many ways the most problematic response to patient dependency is denigration. Some therapists are so conflicted regarding their own dependency struggles that they reflexively distance themselves from dependent patients by devaluing and belittling them. Even if the therapist does not reveal these feelings to the patient (though many inadvertently do), denigration sets the stage for manipulation, exploitation, and abuse (Gregory & Gilbert, 1992). Oftentimes denigration cooccurs with another problematic therapist response to dependency, forming the subtext for infantilization and/or authoritarianism.

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Integrate Mindfully Some therapists are strongly committed to a single therapeutic modality, but surveys indicate that eclecticism is now the most common therapeutic approach among practitioners; between 25% and 50% of clinicians identify themselves as eclectic (Norcross, Karg, & Prochaska, 1997; Watkins & Watts, 1995). Today's emphasis on eclecticism stands in stark contrast to survey data from 3—or even 2—decades ago, when the vast majority of therapists adhered to a single therapeutic approach. The burgeoning of eclecticism is in part a product of contemporary market forces that demand efficiency and cost-effectiveness in treatment. Increased reliance on formal guidelines for empirically validated treatments has also encouraged practitioners to be flexible in their implementation of different intervention strategies (Beutler, Moliero, & Talebi, 2002; Ramsay, 2001; Sperling et al., 2000). Integration of different therapeutic techniques should be planned carefully; without an overarching framework, it can instead be haphazard. The clinician should be prepared to vary intervention strategies within a single therapy case, adhering to a "baseline" therapeutic modality while judiciously blending aspects of other models into treatment as circumstances dictate. To accomplish this, the practitioner must (a) link each assimilated intervention technique to a specific therapeutic goal and (b) monitor the impact of each intervention on patient functioning as therapy progresses. I discuss this integration process in chapter 9.

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