Journal of Contemporary Psychotherapy, Vol. 34, No.

4, Winter 2004 (
C 2004)

Integrating Cognitive and Existential

Treatment Strategies in Psychotherapy
With Dependent Patients
Robert F. Bornstein

A dependent personality orientation is associated with increased risk for a broad

array of Axis I and Axis II disorders. Although traditional treatment interventions
have modest ameliorative effects on problematic dependency, the multifaceted na-
ture of dependency suggests that integrated treatment strategies may hold more
promise than traditional treatment approaches. This article outlines one poten-
tially useful integrated treatment strategy, combining elements of cognitive and
existential therapy to alter dependency-related thought, behavior, and emotional
responding. Procedures for implementing an integrated cognitive-existential treat-
ment model are outlined, and challenges in use of the model are discussed.
KEY WORDS: interpersonal dependency; cognitive; existential; psychotherapy integration.

During the past several decades there have been more than 600 studies of
interpersonal dependency, a personality style wherein the person habitually looks
to others for protection and support, even when autonomous functioning is possible
(Bornstein, 1992, 1993, in press). High levels of dependency are linked with an
array of Axis I disorders including depression (Nietzel & Harris, 1990), eating
disorders (Bornstein, 2001), anxiety disorders (Stewart, Knize & Pihl, 1992), and
somatization disorder (Hayward & King, 1990). On Axis II, dependent personality
disorder diagnoses are associated with elevated risk for borderline, histrionic,
and avoidant symptoms (Barber & Morse, 1994; Ekselius, Lindstrom, Knorring,
Bodlund & Kullgren, 1994).
Given its clinical significance, it is not surprising that dependency has been
conceptualized from a variety of theoretical perspectives, including classical psy-
choanalytic (Coen, 1992), neo-analytic (Horney, 1945), object relations (Bornstein,

Address correspondence to Robert F. Bornstein, Ph.D. Box 407, Gettysburg College, Gettysburg,
Pennsylvania, 17325; e-mail: bbornste@gettysburg.edu.

293

0022-0116/04/1200-0293/0 
C 2004 Springer Science+Business Media, Inc.
294 Bornstein

1996), behavioral (Turkat, 1994), cognitive (Overholser, 1997), humanistic

(Bonanno & Castonguay, 1994), and existential (May, 1981). Each model has
enhanced psychologists’ understanding of the dynamics of dependency, but no the-
ory can explain completely this complex personality style (see Pincus & Wilson,
2001).
Researchers today conceptualize dependency as a multifaceted construct in-
volving four core components: a) cognitive (i.e., a perception of oneself as power-
less and ineffectual, coupled with the belief that others are powerful and potent); b)
motivational (i.e., a marked need for support and approval from others); c) affec-
tive (i.e., a tendency to become anxious when required to function autonomously);
and d) behavioral (i.e., use of relationship-facilitating self-presentation strategies
to strengthen ties to potential caregivers). This model integrates the major etiolog-
ical factors in dependency (i.e., parenting style, gender role socialization, cultural
milieu), explains situational variability in dependent behavior, and accounts for in-
dividual differences in the expression of underlying dependency needs (Bornstein,
1996; Pincus & Wilson, 2001).
Figure 1 illustrates links among the four components of dependency. Three
aspects of this model are noteworthy. First, cognitive elements play a central role:
Not only do dependency-related motivations, behaviors, and affective responses
stem from a schema of the self as powerless and ineffectual, but events that prime
this helpless self-schema lead to state-related variations in dependent behavior
(Bornstein, in press). Second, dependency-related affective responses can them-
selves prime the helpless self-schema, producing feedback loops that increase
dependency-related responding. Third, this model accommodates the range of
passive and active behaviors exhibited by dependent persons by recognizing that
these behaviors serve a common goal of strengthening ties to others.1
Research on treatment of problematic dependency has focused on insight-
oriented therapy and cognitive or cognitive-behavioral treatment, and results in
both domains have been modest. Thus, researchers reported small positive effects
in clinical trials of time-limited (Alexander & Abeles, 1968) and long-term (Blatt,
1992; Blatt & Ford, 1994) psychodynamic therapy for dependent patients with an
array of comorbid diagnoses. Five studies assessed the effectiveness of cognitive or
cognitive-behavioral treatment for dependency, with two producing positive results
(Nelson-Gray, Johnson, Foyle, Daniel & Harmon, 1996; Rathus, Sanderson, Miller
& Wetzler, 1995), and three producing nonsignificant results (Black et al., 1996;
Moore & Blackburn, 1996; Rector, Bagby, Segal, Joffe & Levitt, 2000).
These modest treatment efficacy findings, coupled with the multifaceted na-
ture of dependency, suggest that integrated treatment approaches may be needed
to maximize therapeutic effectiveness in clinical work with dependent patients.

1 Although most investigations have focused on the environmental antecedents of dependency, twin and
adoption studies suggest that approximately 30% of the variance in dependency levels is attributable
to genetic factors (Bornstein, in press).
Dependency Treatment Strategies 295

Fig. 1. A Four-Component Model of Interpersonal Dependency. As this figure

shows, dependency-related cognitions help produce dependency-related motiva-
tions, behaviors, and affective responses. Dependency-related affective responses
may then “prime” the dependent self-schema, increasing dependency-related mo-
tivation and behavior.

Given the centrality of the self-concept in the etiology and dynamics of depen-
dency, integration of the cognitive and existential frameworks may be particularly
fruitful. To a greater degree than other frameworks, the cognitive and existential
models emphasize exploration of the self as a route to positive change (Beck, 1976;
Ottens & Hanna, 1998; Overholser & Fine, 1994).
Only one study has compared these two therapeutic modalities in a sin-
gle sample of patients. Watson, Gordon, Stermac, Kalogerakos, and Steckley
(2003) assessed changes in depression, self-esteem, level of distress, and problem-
focused coping in matched groups of outpatients receiving 16 weeks of cognitive-
behavioral or process-experiential therapy for depression. Significant gains were
296 Bornstein

found on each dimension, with patients in the two groups reporting virtually iden-
tical outcomes.2
This paper offers recommendations for an integrated cognitive-existential
approach to treatment of problematic dependency. I begin by discussing the cog-
nitive and existential strategies, and convergences and divergences between the
two models. I then outline a framework for integration of cognitive and existential
treatments, and discuss unresolved issues and future directions.

COGNITIVE TREATMENT OF DEPENDENCY

Cognitive theorists conceptualize dependency as the product of maladap-

tive schemas (i.e., self-defeating beliefs about self and others) that cause peo-
ple to doubt their abilities and exaggerate the imagined consequences of less-
than-perfect performance (Ball & Young, 2000; Overholser, 1987). Maladaptive
schemas decrease self-esteem, increase anxiety, and lead to an array of cognitive
distortions that strengthen pre-existing negative views. Three such distortions are
particularly salient in the dynamics of dependency: a) automatic thoughts (i.e.,
reflexive thoughts that are cued by perceived or anticipated failure); b) negative
self-statements (i.e., self-blaming statements that undermine self-confidence); and
c) attributional bias (i.e., a distorted interpretation of causality wherein the person
punishes herself for imperfections but cannot accept credit for successes).
A primary goal of cognitive therapy is cognitive restructuring—altering dys-
functional thought patterns that foster self-defeating behavior. In the case of depen-
dency, cognitive restructuring focuses on strengthening the patient’s self-efficacy
beliefs, especially those related to social situations (Overholser & Fine, 1994). To
accomplish this, therapist and patient explore: a) the development of maladaptive
dependency-related schemas; b) the processes that maintain these schemas over
time; c) the avoidance strategies used by the patient to escape schema-triggered
anxiety; and d) the compensatory strategies used to manage this anxiety when it
cannot be avoided (Ball, 1998; Young, 1994).
Overholser and Fine’s (1994) four-stage model is the most fully developed
cognitive framework for treatment of dependent patients. This model seeks to build
patient confidence, teach social problem-solving skills, and maximize treatment ef-
fectiveness by anticipating potential roadblocks. Overholser and Fine recommend
that the therapist take an active stance early in therapy, providing considerable
guidance and structure. As therapy progresses the patient assumes a more active
role and the focus shifts to practicing relapse prevention techniques to minimize
post-therapy backslides. Thus, Overholser and Fine’s model is divided into four

2 Although existential and process-experiential treatments are not identical, they share many common
elements, and findings obtained with one modality have often been used to draw conclusions regarding
the other (see Elliott, 2002).
Dependency Treatment Strategies 297

stages: a) active guidance; b) enhancement of self-esteem; c) promotion of auton-

omy through problem-solving training; and d) relapse prevention.

EXISTENTIAL TREATMENT OF DEPENDENCY

Existential therapists regard the central issue in dependency to be a constricted

phenomenal experience characterized by the belief that life’s key events are outside
one’s control. A central tenet of the existential perspective is that familial and
societal factors cause the person to construct a “false” (or inauthentic) self, created
to comply with the perceived expectations of others and obtain their approval and
love.
To the degree that the parents’ conditional positive regard was contingent upon
the child obeying rules without question and complying passively with external
demands, the child is likely to create a false self centered on pleasing other people.
Defenses aimed at obviating alternative ways of perceiving the world become
firmly entrenched, and the person’s experiences narrow to the point that other-
centered behavior is the primary means of managing anxiety and gaining approval
(Hassenfeld, 1999).
Existential therapists regard existential dread as central in the dynamics of de-
pendency. As Becker (1973) noted, awareness of death and eventual nonexistence
can be overwhelming, and as a result, people devote considerable psychological
resources to denying their own mortality. One strategy in this effort involves exter-
nalizing responsibility for choices: The person comes to see himself as a powerless
entity controlled by outside forces (e.g., other people, a higher power), and exhibits
a pattern of dependent behavior that both reflects and reifies the externalization
strategy.3
As Schneider and May (1995) noted, dependent persons fear that without an
omnipotent protector standing by, they will be overwhelmed and annihilated. This
anxiety is in part defensive: It helps protect the dependent person from experiencing
guilt regarding inauthenticity and abrogation of responsibility. By helping the
patient focus on the here-and-now (rather than obsessing about the future), the
therapist can help break the patient’s self-defeating cycle of defense and denial.
The goals of existential treatment are to help the person envision new pos-
sibilities, experience aspects of the self that have been distorted or denied, and
accept responsibility for choices large and small (Corrie & Milton, 2000). To set

3 Terror management theory suggests that when people are made anxious about their own mortality,
they engage in an array of cognitive distortions to bolster their sense that the world is predictable
and controllable (e.g., underestimating health risks, overestimating the degree to which others share
their views and values; 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).
298 Bornstein

this process in motion, the therapist creates an environment wherein the patient
can take risks within and outside therapy, and incorporate new ways of being into
real-world relationships. Writing assignments, skill-building tasks, and role-play
scenarios are among the techniques used to loosen entrenched defenses and open
up new ways of experiencing.

COGNITIVE AND EXISTENTIAL PERSPECTIVES ON DEPENDENCY:

CONVERGENCES AND DIVERGENCES

Cognitive and existential practitioners agree that the construction of personal

meaning is central to personality development and dynamics, and that the recon-
struction of personal meaning is key to positive change (Ottens & Hanna, 1998).
As Edwards (1990) noted, transformations of consciousness are also central to
both approaches. Existential therapists seek to expand consciousness by loosen-
ing entrenched defenses and helping patients experience aspects of the self that
have been distorted and denied. Cognitive therapists seek to broaden the patient’s
perspective by opening up new ways of thinking, and replacing “mindless” (i.e.,
reflexive) responding with mindful (i.e., deliberate) responding. In the follow-
ing sections I explore convergences and divergences between the cognitive and
existential strategies for treatment of problematic dependency.

Key Aspects of the Self

The cognitive and existential models both emphasize the role of self-distor-
tions in the dynamics of dependency. Although cognitive theorists describe these
distortions in terms of a maladaptive self-schema and existential theorists describe
them in terms of an inauthentic self, both frameworks trace dependent behavior to
a perception of oneself as weak and ineffectual, and recognize that dependency-
related emotional responses (e.g., fear of abandonment) result from this distorted
perception of self.

Assumptions Regarding Causality

Cognitive and existential therapists both view problematic dependency as

stemming from distortions in the self, but they disagree regarding the factors that
underlie these distortions. Cognitive therapists contend that dependency is rooted
in maladaptive schemas and the strategies used to cope with them (Overholser,
1996, 1997). Existential therapists shift the focus from early learning to defense
and coping as central to the etiology of dependency (May & Yalom, 2000). Both
models recognize that help- and nurturance-seeking eventually become reflexive
ways of responding to threat and challenge.
Dependency Treatment Strategies 299

Interpretive Focus

Existential therapists deconstruct hidden material in the patient’s verbaliza-

tions and nonverbal behaviors by focusing on metacommunications: pervasive life
themes that reflect the patient’s core fears (e.g., isolation, being overwhelmed
by unmanageable responsibility). Cognitive interpretations of dependency involve
uncovering the roots of the patient’s negative self-view, and use of restructur-
ing techniques to make explicit dysfunctional thought patterns (e.g., scrutiny of
maladaptive schemas, logical analysis of biased perceptions and beliefs).

Change Processes

In cognitive therapy, the patient’s experience of self and other people is pre-
sumed to change as she practices new ways of thinking and processing information.
Enhanced reality testing is a primary goal. In existential therapy, change is thought
to result from experiencing emotional patterns which create new possibilities for
thought and behavior. A more open experience of self and others—not enhanced
reality-testing—is paramount.

Experiential Learning

In both the cognitive and existential models, the therapist encourages the
patient to practice new ways of responding outside therapy. For cognitive therapists,
in vivo experiences reify changes that occur during treatment by generalizing these
changes to real-world situations. For existential therapists, experiential learning
helps loosen entrenched defenses and trigger new emotional patterns.

Role of the Therapist

By being empathic and nonjudgmental—but not flawless or omniscient—the

existential therapist helps the patient gain trust without seeing the therapist as a
pseudo-parental “guru” (Yalom, 1980). The patient can begin to move beyond
his fruitless search for an omnipotent savior/rescuer. The cognitive therapist, in
contrast, provides considerable feedback and structure. Patients are taught self-
monitoring and self-control strategies that enable them to make meaningful chan-
ges quickly, increasing motivation and commitment (Overholser & Fine, 1994).

ASSIMILATIVE INTEGRATION OF COGNITIVE AND EXISTENTIAL

TREATMENT STRATEGIES

Messer (1992) introduced the concept of assimilative integration as a method

for combining treatment strategies to maximize therapeutic outcome. Messer
300 Bornstein

recommended selecting an overarching (“baseline”) therapeutic modality based

on the patient’s personality and presenting problem, then supplementing this ap-
proach with interventions derived from other treatment models. As Beitman (1992)
pointed out, the timing of new interventions is as important as the interventions
themselves. Conceptualizing therapy as a series of four stages—engagement, pat-
tern search, change, and termination—Beitman argued that the optimal point for
introduction of new interventions is during stage three. In other words, the thera-
pist’s overarching strategy should be used to engage the patient, provide her with
a conceptual framework to understand her current difficulties, and elucidate long-
standing patterns in cognition, behavior, and emotional responding. Once these
goals have been achieved, the stage is set for therapeutic shifts to be introduced as
needed.
In the following sections I discuss assimilative integration of the cognitive
and existential treatment approaches in therapeutic work with dependent patients,
using Beitman’s (1992) four-stage model to structure this integration process.

Engagement

The goals of engagement are to help the patient understand her strengths and
limitations and encourage her to become invested in treatment. Three strategies
are useful in attaining these goals.

Choosing a Starting Point

The patient’s pre-existing conceptualization of her presenting problem should

be one factor (though not the only factor) in selecting a “baseline” engagement
strategy. Certain dependency-related difficulties (e.g., assertiveness problems at
work) are amenable to interpretation in cognitive terms (Overholser, 1996); other
dependency-related difficulties (e.g., a history of exploitation in a broad array of
relationships) may be more amenable to existential interpretation (Schneider &
May, 1995).
Whatever language is used to describe the patient’s situation at the outset,
cognitive and existential interpretations can still be used in parallel to deconstruct
problematic dependency. Cognitive interpretations are useful in uncovering dis-
tortions in thinking whereas existential interpretations are useful in uncovering
distortions in emotional responding, but both types of interpretations help link the
patient’s private experience with interpersonal problems, and concurrent use of
both strategies can engage the patient on multiple levels (Corrie & Milton, 2000).

Dual Interpretation of Fears and Fantasies

Although older patients, grieving patients, and patients who have experienced
a serious illness or injury may describe fears and fantasies related to death and
Dependency Treatment Strategies 301

mortality at the outset of treatment, most dependent patients focus primarily on re-
jection, abandonment, and other dependency-related themes (Bornstein, in press).
These themes represent genuine concerns experienced by dependent patients, who
may be convinced that without the support of others, they cannot survive, but they
also serve a defensive purpose, preventing them from focusing on fundamental
concerns regarding poor choices and missed opportunities (Yalom, 1980).
Just as the therapist should follow the patient’s lead in framing the presenting
complaint, in most cases it is useful to interpret the patient’s fears and fantasies on
the level at which they are presented. By exploring these concerns using experience-
near language, the patient can be engaged more deeply in therapy. Reinterpretation
and reframing should be done later, during the pattern search and change phases.

Assessment as Engagement

Psychological assessment is not only useful for gathering information, but

the assessment process—and the feedback that ensues—can also help engage the
patient and provide insight regarding current functioning and experience (Finn,
2003). To set the stage for cognitive-existential treatment of problematic depen-
dency, assessment should focus on understanding the self.
As clinical and social psychologists have noted, the self is a complex construct
that serves multiple functions. Among the key ways of conceptualizing the self
are: a) as the phenomenal locus of private experience; b) as an object of scrutiny
(e.g., during periods of self-reflection); and c) as a psychological structure that
guides perception, thought, and emotional responding.
Two measures of the self are particularly useful in the context of cognitive
and existential treatment. Higgins’s (1987) Selves Questionnaire makes explicit
inconsistencies among the patient’s actual, ideal, and ought selves (i.e., the self
as it is currently experienced, the self one would like to be if freed of current
constraints, and the self one believes one ought to be based on familial and societal
expectations); it is a useful bridge to a cognitive interpretation of maladaptive
schemas. Markus and Nurius’s (1986) measure of Possible Selves makes explicit
the patient’s expected, hoped-for, and feared future selves (i.e., the self one expects
to become if life goes as planned, hopes to become if things go very well, and fears
becoming if things go badly); it is a useful bridge to existential interpretation of
dependency-related dreads.4

Pattern Search

The goals of pattern search are to discover consistencies and inconsistencies

across different life domains. This involves exploring the contrasting manifesta-
4 Existentialtherapists typically utilize experiential techniques to uncover hidden aspects of the self,
but formal assessment techniques can complement these strategies and provide additional avenues for
insight.
302 Bornstein

tions of dependency in different contexts (e.g., romance, friendship, parenting,

work), and the patient’s unique configuration of dependency-related thoughts, be-
haviors, and emotional responses.

Making Patterns Explicit

To maximize the effectiveness of pattern search, concurrent exploration of

these distortions within and outside therapy is needed. Uncovering distortions
outside therapy involves examining the antecedents and consequences of key
dependency-related events. These include relationship conflict and disruption,
abandonment or rejection by a valued other, episodes of help- or nurturance-
seeking, and evaluation by a figure of authority (Bornstein, Bowers & Robinson,
1995). For patients who have difficulty recalling these events a diary can be used to
record dependency-related experiences over several days or weeks (see Bornstein
et al., 1995, for suggestions in this area). Using this diary material the variability
in dependency-related responding across different contexts can be examined.
Transference analysis is particularly useful for uncovering cognitive and phe-
nomenological distortions that occur within the therapy session (Crits-Christoph
& Barber, 1991). Although the therapist in cognitive-existential treatment takes a
more active stance than the traditional psychodynamic therapist, there is enough
ambiguity in the patient-therapist relationship that most patients will attribute a po-
tentially revealing array of traits and motives to the therapist. Once described, the
patient’s attributions can be explored from cognitive (i.e., information processing)
and existential (i.e., experiential) viewpoints.

Interpreting Patterns from Cognitive and Existential Perspectives

As Ball and Young (2000) noted, exploration of schemas—and the processes

that maintain them—are the core of cognitive therapy. By examining the patient’s
beliefs regarding the self, other people, and self-other interactions, distortions
in other areas will naturally emerge (Overholser, 1997). Assessment data can
facilitate this process and serve as a springboard for more in-depth discussion
of longstanding patterns that propagate self-defeating behaviors and emotional
responses.
When a patient describes experiences related to isolation and externalization
of responsibility (e.g., feelings of vulnerability, fear of abandonment or rejection),
the therapist should shift the focus to the here-and-now, so the patient can dis-
cover whether these feelings also emerge in the therapeutic relationship. As May
and Yalom (2000, p. 287) noted, “a major mechanism of defense that serves to
block death awareness is our belief in a personal omnipotent servant who eter-
nally guards and protects our welfare . . . A hypertrophy of this particular defense
mechanism results in a character structure displaying passivity, dependency, and
Dependency Treatment Strategies 303

obsequiousness. Often such individuals dedicate their lives to locating and appeas-
ing an ultimate rescuer.”

Change

The process of change in cognitive-existential treatment of dependency in-

volves analyzing resistance, exploring the roots of dysfunctional patterns, and
using homework assignments to facilitate change in vivo.

Conceptualizing Resistance

To the cognitive therapist, resistance results from automaticity: Certain pat-

terns of responding are so well-learned that they occur with minimal awareness, and
are difficult to control or inhibit (Bargh & Chartrand, 1999). These well-learned
patterns lead to reflexive (“mindless”) information processing, and prevent the
patient from construing themselves and other people in new, more adaptive ways.
To the existential therapist, resistance results from defense. Overwhelmed by
autonomy and the responsibility that goes with it, the dependent patient cannot
acknowledge that she has chooses to engage in behaviors that are ostensibly un-
satisfying and unfulfilling. By narrowing her phenomenological experience and
focusing primarily on dependency-related anxiety, the patient protects herself from
other, more fundamental fears and regrets.
An important step in therapeutic change is to label the patient’s resistance, and
bring it into the open. Labeling resistance provides the patient with a conceptual
framework, and helps detoxify a key obstacle to therapeutic change. Thus, the
words used to describe this phenomenon should be clear enough that the patient is
able to understand the ways that resistance propagates dysfunctional responding,
but not so pejorative that the patient experiences guilt or shame for having engaged
in a process that is nearly universal, largely unconscious, and difficult to inhibit
without considerable feedback and support.

Overcoming Resistance

In both the cognitive and existential perspectives overcoming resistance be-

gins with self-awareness. Processes that were carried out mindlessly (i.e., reflex-
ively) must become mindful (i.e., deliberate and conscious). Only after mindful
responding replaces mindless responding can the patient alter dysfunctional habits,
thoughts, and emotional patterns (Baer, 2003).
As mindless processes gradually become mindful, changes occur in two ar-
eas. Cognitively, the patient learns to replace fixedness with flexibility: Ritualized,
stereotypic ways of processing information give way to thoughtful, deliberate ways
304 Bornstein

of thinking about the self and other people (Overholser, 1997). Phenomenologi-
cally, the patient learns to replace defensiveness with openness: Narrow, constricted
experience gives way to a willingness to take risks and experience the world in a
different way (Hassenfeld, 1999; Yalom, 1980). To maximize the likelihood that
these changes will be mutually supporting and synergistic, within-session inter-
ventions should be supplemented by between-session homework assignments that
foster experiential learning.

Within-Session Interventions

Interpretation of choicepoints in the patient’s life—points where decisions

were made based on well-rehearsed habits or entrenched defenses—are key to
therapeutic change in the cognitive-existential framework. These need not be ma-
jor life decisions, but can be unnoticed everyday events that reflect and reify
longstanding cognitive distortions and defensive processes.
Interpretation of choicepoints within the therapy session is also important.
Two treatment-related events lend themselves especially well to concurrent inter-
pretation from cognitive and existential perspectives: pseudo-emergencies and ter-
mination concerns. When the dependent patient requests between-session contact
to cope with a crisis, it is useful to explore the cognitive basis of this request (e.g.,
thoughts regarding the consequences of the crisis, beliefs regarding the power of the
therapist), as well as the existential aspects of the request (e.g., fantasies regarding
impending catastrophe, feelings of safety that accompany being rescued).
Termination concerns are another rich source of insight, and studies suggest
that many dependent patients become anxious regarding termination after a few
therapy sessions—sometimes after only one (Hopkins, 1986). In most cases it is
useful to focus on the cognitive underpinnings of termination fears early in therapy,
and shift to a more phenomenological focus as termination nears.

Experiential Learning

Overholser (1997) offered several suggestions for in vivo assignments that

help alter dysfunctional thoughts and behaviors. Using a hierarchy of increasingly
challenging tasks, Overholser’s approach begins with self-monitoring to clarify the
patient’s reflexive reactions to different life events. Once dependency-related cues
(or “triggers”) are identified, the patient can practice stimulus control techniques
(including avoidance of high-risk situations), and self-control techniques (e.g.,
anxiety management) that help replace dysfunctional ways of responding with
more adaptive patterns. Problem-solving strategies which are initially practiced
within therapy can be extended to real-world situations. Social skills training within
therapy (or in adjunct group therapy) can also be practiced in vivo so the patient
becomes comfortable with new ways of responding.
Dependency Treatment Strategies 305

Schneider and May (1995) offer a broad array of suggestions for in vivo
assignments aimed at promoting choice and responsibility, making unrecognized
defenses explicit, and helping the patient experience long-avoided emotional pat-
terns. Many of these exercises involve deliberately taking risks so the patient can
experience the feelings that come from meeting a challenge rather than avoid-
ing it. Other assignments involve activating and tolerating unpleasant emotional
states (e.g., anxiety regarding rejection) so these emotions become less frightening.
Like Overholser (1997), Schneider and May (1995) recommend that experiential
learning take place gradually, beginning with less challenging tasks before more
difficult tasks are confronted.
To build synergy between cognitive and existential learning experiences, the
therapist should return periodically to the patient’s experience of self. This can
be approached from the cognitive perspective (by focusing on self-esteem, self-
confidence, and self-efficacy), and from the existential perspective (by exploring
self-awareness, self-focus, and openness to experience). When significant shifts
in thought and emotional patterns are accompanied by positive changes in the
patient’s experience of self, termination can begin.

Termination

The goals of termination are to solidify changes that have taken place in
earlier phases of therapy, provide the patient with strategies to manage backslides,
and set the stage for continued growth and positive change.

Finding Balance

As Bornstein and Languirand (2003) noted, many therapists become so fo-

cused on minimizing problematic dependency that they overemphasize self-reli-
ance, which may lead some patients to become counterdependent. As changes
occur in the patient’s characteristic way of thinking and experiencing, it is im-
portant to help the patient find a balance between dependency and autonomy.
Making explicit the negative consequences of “underdependence” can be useful
in this regard (Colgan, 1987). In addition, patient and therapist can explore the
importance of blending autonomy with relationship-facilitating support-seeking
in various situations and settings (e.g., romance, parenting, friendship, work).

Reifying Changes in the Self

Impending termination provides an ideal context for revisiting the patient’s

initial assessment data and evaluating the degree to which the goals implicit in
these data have been reached (Finn, 2003). Ideally, the gap between the patient’s
306 Bornstein

actual and ideal selves should be narrower at the end of therapy than at the out-
set; readministration of Higgins’s (1987) Selves Questionnaire can help evaluate
changes in this area. It is also useful for patient and therapist to review the patient’s
descriptions of Possible Selves (i.e., hoped-for, expected, and feared future selves;
Markus & Nurius, 1986). Successful cognitive-existential treatment should lead
to movement toward actualization of the patient’s hoped-for self, and away from
the feared self.

Relapse Prevention

As Overholser and Fine (1994) noted, backslides during the latter stages of
therapy can be valuable learning experiences. They provide opportunities for ther-
apist and patient to discuss dependency “triggers” and confront the inevitability
of occasional slips. Existential therapists agree that confronting backslides during
therapy can help the patient deal more effectively with backslides after therapy
ends (Schneider & May, 1995). Development of skills to identify and overcome
dependency-related backslides is key to relapse prevention. These include: a) learn-
ing to detect mindless information processing and replace mindlessness with mind-
fulness; b) becoming sensitive to internal signals (e.g., fluctuations in anxiety level)
that signal defensiveness and narrowing of phenomenal experience; c) identifying
relationships that are associated with regression to dysfunctional ways of think-
ing and feeling, and taking steps to change those relationships; and d) becoming
proactive, engaging in activities that set the stage for continued growth and gain.

CONCLUSION

As Corrie and Milton (2000) noted, there are limits to the degree to which
cognitive and existential treatment models can be combined. These models are
based on contrasting epistemologies, and the goals of these approaches will always
differ to some degree. In the applied realm, many existential therapists are opposed
to “universalizing” treatment strategies, preferring to work within the context of
the moment; cognitive therapists have been at the forefront of the manualized
treatment movement.
Despite these limitations, an integrated cognitive-existential approach to prob-
lematic dependency has several advantages over existing treatment models. It can
enhance understanding of the current situation by conceptualizing this situation
from multiple perspectives, and provide a framework within which dependent re-
sponding can be altered by intervening at different levels. Given the centrality of
dependency-related thoughts and emotional responses, intervening in these areas
may yield more lasting gains than those produced by traditional treatment models.
Though promising, an integrated cognitive-existential framework is also
associated with certain practical challenges. Some patients (and some therapists)
Dependency Treatment Strategies 307

might not find it easy to move back and forth between different levels. Even those
therapists who are comfortable with this process may find it difficult to build syn-
ergy between cognitive and existential interventions. For those patients who do
not benefit from a cognitive-existential approach, the therapist must be prepared
to utilize other intervention strategies in conjunction with—or in lieu of—those
described here (see Crits-Christoph & Barber, 1991; Linehan, 1993; Turkat, 1994).
Finally, it is important to recognize that integration can take place in several
different ways, and need not be limited to the introduction of new therapeutic tech-
niques within a single course of treatment (Stricker & Gold, 1993). Psychotherapy
researchers group integration strategies into three categories: a) integration within
a single session (e.g., when patient and/or therapist approach an issue from a new
perspective); b) integration across sessions (which is usually initiated by the ther-
apist to provide fresh perspective on an issue); and c) integration across treatment
episodes (which is almost always initiated by the patient, who may seek different
types of therapy during different stages of coping with a problem).
Integration across treatment episodes sometimes reflects a patient’s dissatis-
faction with an earlier therapy experience, but it can also stem from a conscious
decision to reconceptualize a longstanding issue from a new vantage point. Thus, it
is important that new interventions be planned with the patient’s treatment history
in mind. To maximize treatment effectiveness in therapeutic work with dependent
patients, the therapist must recognize that regardless of his or her goals and agenda,
the integration process may already be underway.

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