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 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 and
exchange. The 1970s also saw increased interest in humanistic and existen-
tial 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 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 basic
elements of an exemplary 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 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 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 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 gen-
eral 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 compro-
mise formations—the disguised, distorted end-products of underlying impulses
and defenses against those impulses (e.g., when hostile humor reflects subli-
mated aggression).
The concept of unconscious conflict is useful in understanding the eti-
ology 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 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 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

132 CLINICAL APPLICATIONS

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 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).

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. De-
rived from the seminal writings of Lowenstein (1951) and
Greenson (1965), S-E therapy combines psychoanalytic inter-
pretation 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 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., 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 cen-

APPROACHES TO TREATMENT 133

 ter on relationship episodes—memorable, meaningful interactions
with other people (Luborsky & Crits-Christoph, 1990). As pat-
terns emerge in a patient's relationship episodes, these are ana-
lyzed 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 examin-
ing 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. Ob-
stacles 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, anxi-
ety regarding rejection and abandonment increase and behav-
iors designed to minimize the possibility of relationship disrup-
tion 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 de-
pendency will make termination impossible, so treatment can
never end (the "fantasy of permanence"). If not managed prop-
erly, the patient's and therapist's fears may feed on each other
and worsen as therapy progresses: The patient becomes increas-
ingly anxious about the risks and responsibilities of autonomy,
and the therapist becomes increasingly anxious about the nega-
tive impact of the patient's dependency.
• The emotional undercurrent: Transference and countertransference.
One way to prevent dependency-related fears from undermin-
ing 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 thera-
pist imperfections); possessiveness (which may have a strong
narcissistic component or involve feelings of jealousy and com-
petitiveness); 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 oc-
casion, 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 im-
portant for those forms of countertransference that are associ-
ated 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 inter-
ventions 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 behav-
iors—because these behaviors are (or were) rewarded. In this context, de-
pendency can be conceptualized as a set of responses aimed at obtaining help
and support that are acquired and maintained through a combination of con-
ditioning and learning processes. These include (a) direct reinforcement
(sometimes continuous, but more commonly intermittent); (b) vicarious re-
inforcement (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 depen-
dency 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 tem-
perament 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 interac-
tions reduces the child's anxiety level, this behavior becomes
part of her characteristic response pattern (Alden, Laposa, Tay-
lor, & 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 tech-
niques 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 pa-
tient must identify specific behaviors to be reduced or elimi-
nated. This requires that the components of a patient's self-
defeating dependency be broken into discrete responses, so the
contingencies that support these responses can be identified.
Using this information, a behavior management program is cre-
ated aimed at decreasing the frequency of undesired dependency-
related responses. This process will be enhanced if contingency
change first takes place within the context of the patient-
therapist 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 underly-
ing a behavior management program, the likelihood that con-
tingency 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 depen-
dency-related responding is reduced, efforts should be made to
increase the frequency of alternative responses that are incom-
patible with the undesired behaviors. For the dependent pa-
tient, this means increasing the frequency of autonomous re-
sponding (Turkat & Carlson, 1984; Turkat & Maisto, 1985).
Just as dependent behaviors that are extinguished must be bro-
ken 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 prob-
lematic 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, system-
atic desensitization techniques should be implemented to help
manage this anxiety and facilitate behavior change. Use of de-
sensitization techniques may be particularly important for de-
pendent 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 ac-
company 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.

APPROACHES TO TREATMENT 13 7
 of desensitization gains from therapy to real-world settings
(Overholser, 1987). Detailed discussions of fear hierarchy con-
struction 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 environ-
ment; (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 expres-
sions 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 em-
phasis 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 mal-

adaptive schemas (i.e., self-defeating beliefs about the self and other people)
that cause patients to doubt their abilities, denigrate their skills, and exag-
gerate 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).

138 CLINICAL APPLICATIONS

Young, 2000; Overholser, 1997). Maladaptive schemas not only decrease self-
esteem and increase anxiety, they also lead to an array of cognitive distor-
tions that strengthen the person's pre-existing negative views. Three cogni-
tive 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 causal-
ity wherein the person punishes herself for perceived imperfections but can-
not 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, thera-
pist and patient explore (a) the development of the patient's maladaptive de-
pendency-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).
Cognitive restructuring techniques run the gamut from gentle reframing
of biased perceptions (Ball 6k Young, 2000) to aggressive challenging of irra-
tional beliefs (Ellis & Dryden, 1997). Some cognitive therapies focus prima-
rily 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 personality-
disordered patients (Linehan, 1993; Fleming 6k Pretzer, 1990) and other pa-
tients 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 col-
laborative alliance, the therapist in Overholser and Fine's (1994)
framework takes an active approach early in treatment, provid-
ing 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 delin-
eate long-term therapeutic goals. Among the techniques used
at this stage are (a) assertiveness training; (b) behavioral as-
signments; and (c) stimulus control (e.g., avoidance of depen-
dency "triggers"). Because dependent patients are highly moti-
vated to obtain approval from figures of authority (Bornstein,
1992, 1993), including the therapist (Overholser, 1996, 1997),
reassurance, praise, and encouragement can be effective in help-
ing 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 self-
esteem (Overholser, 1993; Tripathi, 1982), Stage 2 focuses on
building self-confidence. This begins with psychosocial explo-
ration aimed at uncovering the roots of the patient's negative
self-view and gradually incorporates various cognitive restruc-
turing 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 self-
efficacy 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 au-
tonomous 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, genera-
tion of alternative solutions, solution implementation, and verifica-
tion (D'Zurilla, 1988; D'Zurilla & Goldfried, 1971). As this pro-

140 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 en-
ables the patient to generate her own solutions and insights
(Overholser, 1993, 1997). Self-control strategies (e.g., self-
monitoring, 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 behav-
ior 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 fail-
ure 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 mi-
nor 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 pa-
tient autonomy diminishes chronic anxiety, using cognitive
techniques to dampen anxiety facilitates the acquisition of au-
tonomous behavior (Black, Monahan, Wesner, Gabel, & Bow-
ers, 1996).

THE HUMANISTIC-EXPERIENTIAL PERSPECTIVE

Although the humanistic—experiential model has been less frequently
used than other approaches in treating problematic dependency, useful re-
views 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 fac-

APPROACHES 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 contin-
gent upon the child's obeying rules without question and complying pas-
sively with external demands, the child comes to view autonomy as unac-
ceptable 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 human-
istic 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 autono-
mous, 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 strat-
egy. 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 mecha-
nism results in a character structure displaying passivity, dependency,
and obsequiousness. Often such individuals dedicate their lives to locat-
ing 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

142 CLINICAL APPLICATIONS

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 out-
side 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 unacknowl-
edged aspects of the self. In practical terms, unconditional posi-
tive regard requires that the therapist avoid being critical or
directive. By being empathic and nonjudgmental—but not flaw-
less or omniscient—the therapist can help the dependent
patient gain trust without seeing the therapist as a pseudo-
parental "guru" (Yalom, 1980). When the dependent patient
experiences a relationship with an accepting but imperfect fig-
ure who communicates empathy and models existential living,
he can begin to move beyond his fruitless search for an om-
nipotent savior-rescuer.
• Guilt and responsibility. Whereas narcissistic people are preoc-
cupied with fantasies of greatness, dependent people are preoc-
cupied with fantasies of smallness (Schneider, 1990). A key
correlate of the dependent person's smallness fantasy is the be-
lief 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 regard-
ing 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 expe-
rience (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 verbal-
izations and nonverbal behaviors (Bohart & Greenberg, 1997;
Ottens & Hanna, 1998). However, unlike psychoanalysts, whose
interpretations focus on unconscious motives and defenses, ex-
istential 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 func-
tioning 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 en-
trenched defenses, increase emotional awareness, and set the
stage for new experiences that help patients reinvent them-
selves and the world. Schneider and May (1995) provide de-
tailed 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

144 CLINICAL APPLICATIONS

 TABLE 8.1
Psychotherapy With Dependent Patients:
Core Elements of Traditional Treatment Models
Model Assumptions Goals Techniques
Psychoanalytic Dependency is a Insight followed by Interpretation;
product of early working through corrective object
experiences and within and outside relations
unconscious therapy
conflicts
Behavioral Dependency is a Modify Operant
consequence of contingencies to conditioning to
learning and decrease alter behavior;
conditioning dependent classical
behavior and conditioning to
increase manage anxiety
autonomous
behavior
Cognitive Dependency is Alter self-defeating
Cognitive
rooted in beliefs and restructuring;
dysfunctional enhance self- problem-solving
thoughts and efficacy training
maladaptive
schemas
Humanistic- Dependency stems Re-experience Empathic
Experiential 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 tech-
niques from each theoretical school. In the following sections, five guide-
lines 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 consider-

ations are key in tailoring treatment to the problem:
• Problem specificity. Narrow problems require focused interven-
tions; pervasive problems demand broader treatment strategies.

APPROACHES TO TREATMENT 145

 Thus, when patients present with domain-specific dependency-
related difficulties (e.g., anxiety regarding performance evalua-
tion at work), behavioral and cognitive therapies may be the
treatments of choice. When patients describe dependency-
related difficulties that affect functioning across many areas of
life (e.g., generalized lack of assertiveness, dissatisfaction with
a broad array of relationships), psychodynamic and humanis-
tic-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., ago-
raphobia).
The bottom line: Problem specificity and comorbidity are important
considerations when deciding upon a treatment approach, and choice of in-
tervention must be guided in part by the unique combination of difficulties
presented by each patient. When problematic dependency predates the on-
set 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 depen-
dency followed symptom onset, the clinician should begin by addressing the
symptoms themselves; in many patients, dependency levels diminish as symp-
toms 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).

146 CLINICAL APPLICATIONS

positively to cognitive therapy, humanistic-experiential therapy, or psycho-
dynamic psychotherapy than to behavioral treatment or traditional psycho-
analysis. However, some dependent patients are interested primarily in symp-
tom 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 thera-
peutic modality may be best suited to a particular dependent patient (see
chap. 7).
Although the patient's preferences should not be the primary determi-
nant 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 determin-
ing 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 struc-
ture, and sends a message to the patient that she—not the therapist—is the
ultimate decision maker (Bornstein, 1994c; Overholser, 1997). To the de-
gree 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 ex-

tremely clingy and insecure—it is easy to overemphasize autonomy at the
expense of healthy dependency. Although increasing autonomous function-
ing 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 implica-
tions for different treatment approaches:
• Psychodynamic. As Blatt's (1990) dependency-autonomy dia-
lectic (Figure 3.2) illustrated, healthy adult development is an
ongoing process of integrating strivings for relatedness and self-
definition. 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 em-
phasize relatedness concerns throughout treatment. The initial
therapy sessions represent an opportunity to discuss these is-

APPROACHES TO TREATMENT 147

 sues in the context of the patient-therapist relationship. Im-
pending termination provides another useful context for a dis-
cussion of relatedness issues.
• Behavioral. Because behavioral treatment of problematic depen-
dency focuses on increasing autonomous responding and extin-
guishing dependent behavior, it is important that the therapist
help the patient acquire healthy dependency skills even as she
becomes more independent. Western stereotypes notwithstand-
ing, 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 appropri-
ate, 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 ini-
tial tolerance of the patient's dependent behavior), and it is
important to structure problem-solving training so that autono-
mous 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 human-
istic and experiential treatment approaches is to increase the
patient's autonomy and personal responsibility while simulta-
neously enhancing her capacity for intimacy and connected-
ness. The therapist can ensure that this balance is achieved by
structuring experiments within and outside therapy so the pa-
tient experiences autonomy and intimacy as synergistic, not
incompatible. Schneider (1990) and Yalom (1980) provide prac-
tical suggestions along these lines from an existential perspec-
tive; Bornstein and Languirand (2003) provide additional sug-
gestions 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

J 48 CLINICAL APPLICATIONS
this struggle revolves around missed sessions or unpaid bills). Fewer thera-
pists 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 depen-
dent (Lower, 1967; Perry, 1989). Not surprisingly, therapists who are them-
selves 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 self-
awareness is the best defense against subtle (and not-so-subtle) forms of act-
ing out that undermine therapy and harm the patient. Three reflexive re-
sponses 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 relation-
ships—the very dynamic that helps propagate the patient's de-
pendent 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 con-
flicted regarding their own dependency struggles that they re-
flexively distance themselves from dependent patients by de-
valuing 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 co-
occurs with another problematic therapist response to depen-
dency, forming the subtext for infantilization and/or
authoritarianism.

APPROACHES TO TREATMENT 149

Integrate Mindfully

Some therapists are strongly committed to a single therapeutic modal-

ity, but surveys indicate that eclecticism is now the most common therapeu-
tic approach among practitioners; between 25% and 50% of clinicians iden-
tify 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 thera-
pists adhered to a single therapeutic approach. The burgeoning of eclecti-
cism is in part a product of contemporary market forces that demand effi-
ciency and cost-effectiveness in treatment. Increased reliance on formal
guidelines for empirically validated treatments has also encouraged practi-
tioners to be flexible in their implementation of different intervention strat-
egies (Beutler, Moliero, & Talebi, 2002; Ramsay, 2001; Sperling et al., 2000).
Integration of different therapeutic techniques should be planned care-
fully; 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 inte-
gration process in chapter 9.

150 CLINICAL APPLICATIONS