In one controlled treatment trial, two types of short-term dynamic psychotherapy (consisting of a mean of 40 sessions) were compared with a waiting-list control condition in patients largely with the anxious-cluster (Cluster C) personality disorders, many of whom had dependent personality disorder. Both treatments were superior to the waiting-list condition on measures of target complaints, symptoms, and social adjustment. Improvement in target complaints was maintained at 1.5-year follow-up.
There is a consensus in the psychotherapy literature about two central aspects of therapy for dependent personality disorder. The first involves allowing the emergence of a dependent transference toward the therapist, which is then dealt with in a way to promote emotional growth. The second is the use of therapist expectations and direct support to promote self-expression, assertiveness, decision making, and independence. If both aspects are not addressed, treatment may be incomplete.
At the outset of therapy, it is important to aid the development of a trusting relationship and allow the patient to begin to transfer dependent wishes onto the therapist. Hill (1970) suggested that the therapist tell the patient that extra sessions may be allowed early on in therapy, especially around the patient’s episodes of panic. This assurance of readily available support helps the patient develop trust. As therapy progresses, the therapist may help the patient find substitute ways of dealing with panic feelings and limit extra sessions.
J. F. Alexander and Abeles found that dependency on the therapist increased from the beginning to the middle of short-term therapy and then remained fairly high until termination. The failure of dependency on the therapist to diminish toward the end of therapy necessitated working through transference right up until termination. In contrast, they found that the patient’s dependency on outside relationships began to diminish from the middle of treatment until termination. They attributed this to a real effect of treatment on the resolution of dependency conflicts.
The hardest work of therapy occurs when a patient experiences increased dependency on the therapist and simultaneously has setbacks in his or her outside life. Offering sympathy for the patient’s misery is not helpful by itself. The therapist also should encourage the patient to express real feelings and wishes; to bear the anxiety of making decisions and accepting pleasurable experiences; and to deal with episodes of anxiety. When the patient experiences frustration over the wish to have the therapist take a more directive role in his or her life, the therapist should clarify and interpret the transference elements and support the patient in finding more self-reliant ways to cope. Leeman and Mulvey limit attention to transference issues in favor of focusing on relationships outside of therapy.
At this stage, the therapist should avoid taking a directive role in the patient’s life; otherwise, a transference-countertransference fixation might result. This requires actively resisting the patient’s attempts to manipulate the therapist into making decisions for the patient, which the patient expects from authority figures.
Saul and Warner described the following optimal circumstances for the therapist to give direct suggestions and encourage various actions or solutions to problems. First, the treatment should have progressed long enough for the therapist to have a good understanding of the patient’s dynamics. Second, the therapist should be aware of the state of the transference and his or her own reaction to it. Third, the patient should be at some impasse out of which a direct therapeutic intervention can mobilize the patient and prevent a repetition of feeling powerless.
Given these circumstances, the therapist should help the patient conceptualize his or her own goals. If the goals are healthy, the therapist should discuss and support them. If there are conflicting goals, then it is helpful to discuss the consequences of each goal and to encourage the patient to bear the anxiety of making choices. Similar to Beck’s cognitive therapy, this approach also makes use of previous insights about the patient’s motivations. The therapist then may urge the patient to commit himself or herself to actions that are within the patient’s reach (e.g., taking a job) or encourage perseverance despite the urge to give up (e.g., flunking out of school). This active intervention presumes that the therapist is using his or her influence in accordance with the patient’s own values rather than the therapist’s.
Covert dependency on the therapist, in which the patient experiences the therapist as a benign, powerful parental figure, can facilitate therapeutic change. Sincere interest and attention and the reliable presence of the therapist may increase the patient’s belief in the benevolent power of the therapist. This affects the patient’s self-esteem in several ways.
First, the patient may identify with the therapist and wish to be like him or her. Idealization leads to a temporary rise in self-esteem. Second, when the patient remembers or experiences for the first time hitherto unacceptable feelings, the therapist should be comprehending and accepting. This will enhance the patient’s self-esteem because the patient can identify with the more benevolent attitudes and responses of the therapist as an authority figure rather than react according to his or her old prohibitions and ideals. This rise in self-esteem is only temporary as long as it relies on the reassuring presence of the therapist. However, if the patient can use this increased feeling of self-esteem to risk trying new behaviors outside the office, he or she may experience other rewards, including approval from others. It is important for the therapist both to communicate genuine pleasure when these outside efforts succeed and to accept failures that inevitably occur. This helps cause a shift in self-perception from dependency toward social self-confidence.
During the final stage of therapy, the therapist gradually increases the level of expectations for autonomous decision making and action and for socially effective responses. This includes reinforcing the individual’s increasing ability to handle crises without extra sessions and to manage panic episodes by soothing himself or herself rather than by seeking someone else to do it. This requires helping the patient to resolve transference wishes to be dependent and instead to accept a more self-reliant position in relationships. If the patient avoids mourning the therapeutic relationship, for instance, by the fantasy that he or she was never really close to the therapist or that the therapist will always be available, then termination will provide a crisis. The patient may feel betrayed that the therapist is not available after all and begin to deteriorate.
The consensus of the literature is that dynamic psychotherapy is usually helpful for the patient with dependent personality disorder. Hill noted that only 2 of 50 treated patients showed no observable improvement. Treatment required several months to more than 2 years. Leeman and Mulvey noted that short-term (3-7 months’ duration), focused psychotherapy was successful in five of six patients, although one patient required a second course of treatment. Hoglend found that more than 30 sessions were needed. Most authors used weekly sessions.
The efficacy of short-term versus long-term treatment has not been adequately addressed. In general, short-term psychotherapies are most likely to succeed when a circumscribed, dynamic conflict or focus is present; the patient can form a therapeutic or working alliance rapidly; and the tendency to regress to severe dependency or acting-out is limited. Unfortunately, many patients with dependent personality disorder will not meet these criteria. Short-term dynamic therapies usually require once-weekly sessions over 3-9 months.
Hoglend found that among patients with personality disorders, the length of treatment was more essential for long-term dynamic improvement than were patient characteristics, such as suitability, cluster category, or initial health-sickness ratings. Significant long-term dynamic changes did not appear before 30 sessions, and the amount of change correlated with the number of sessions (a finding not obtained in subjects without personality disorders). Specific patients, such as those who have failed to improve in short-term treatments or who have multifocal conflicts, do better in longer-term, dynamic psychotherapies or psychoanalysis. These treatments generally require two to four sessions per week over a period of several years to work through the dependent transference.
Revision date: June 14, 2011
Last revised: by Jorge P. Ribeiro, MD