Turkat and Carlson reported two behavioral treatments of a patient with dependent personality disorder. The patient initially had been treated with behavioral techniques for anxiety-related complaints but had relapsed immediately after termination. The authors then reformulated the case, focusing on the dependency constructs of excessive reliance on others and deficient autonomous behavior, which resulted from long-standing anxiety over independent decision making. The therapist and patient constructed a hierarchy of situations with which the patient had little experience but about which the patient was required to make independent decisions. The therapist emphasized anxiety management skills, which had been taught previously. Treatment was given every other week over a 2-month period. The patient showed decreasing levels of self-rated anxiety over these situations as treatment progressed; these gains were maintained over a 1-year follow-up interval. Avoidance of situations requiring independent decisions also diminished.
A. T. Beck et al. described cognitive-behavioral treatment for dependent personality disorder, refined and expanded by J. S. Beck. As in dynamic treatments, they viewed the patient-therapist relationship as a microcosm of the patient’s dependent beliefs and behaviors. The therapist must foster the therapeutic alliance early and adjust the therapy to maintain it. For instance, some patients need to begin a session by telling the therapist whatever is on their mind in order to cooperate with the more structured tasks. Treatment is based on a formulation, and each technique is used to foster accurate self-appraisal and independent decision making and behavior. The patient’s dependent behavior is initially accepted, but the therapist encourages self-reflection and agenda setting for sessions.
Independence is first encouraged by setting goals for treatment. A Socratic method is used to avoid directing the patient’s agenda. The therapist continually challenges the patient’s dichotomous thinking (e.g., “If I am not fully successful, then I’m inadequate”) to improve self-evaluation. Successful graded in vivo exposure to anxiety-provoking situations challenges the patient’s belief about being incompetent. A variety of diaries can be used to monitor the patient’s automatic thoughts, especially of inadequacy, highlighting their negative effects. The therapist can challenge the patient to select healthier responses that aid the development of positive schemas. Relaxation training may aid in the reduction of anxiety surrounding independent reflection and decision making. Assertiveness training and role-playing may help if real skills deficits exist.
J. S. Beck recommends a session format that includes checking the patient’s mood, providing a bridge between sessions, setting an agenda for the session, reviewing any homework, discussing the items on the agenda, and then summarizing the session and providing and obtaining feedback. Patients are given worksheets that can help them combine previous work and current situations to prepare for the next session. The formulation or “cognitive profile” plays a crucial role in helping the patient understand connections between early experiences, core beliefs, and compensatory strategies as well as reactions to current situations. Once the therapist and patient have identified maladaptive core beliefs, the patient can fill out a “core belief worksheet” each session that contrasts the old maladaptive belief with disconfirming experiences and substitutes new, more flexible, and more adaptive beliefs. The therapist can use various techniques to help the patient discover and shape new ways of thinking and behaving (e.g., proposing a behavioral experiment to test a belief).
When resistance to change develops, the therapist must help the patient think through ambivalence about changing, with the goal of finding constructive substitutes for the loss of old dependent habits. As treatment progresses, the dependent transference can be reduced by the addition of group therapy. Toward termination, the therapy can be tapered off by reducing the frequency of sessions so that the patient learns to feel competent without frequent sessions. At termination, the threat of loss of the therapist can be mitigated by offering booster sessions at infrequent intervals. Clear guidelines regarding the number of sessions are not yet available.
Marchand and Wapler conducted a retrospective study of cognitive-behavioral treatment for panic disorder with agoraphobia. A chart-review diagnosis of dependent personality disorder did not adversely affect the response to treatment compared with nondependent patients.
Treatment based on a cognitive-behavioral formulation of the mechanisms for a wide variety of dependent features shares much with that based on psychodynamic formulation, minus some specific techniques. Further case studies and treatment trials are needed.
Revision date: June 21, 2011
Last revised: by Jorge P. Ribeiro, MD