Problems Arising in Psychotherapy

Five types of transference and countertransference problems often arise in the treatment of dependent personality disorder (

Table 88-2). First, the patient entering therapy may make many demands or requests of the therapist for advice, succor, or concrete help, which the therapist is unable to meet. One study showed that such patients often terminated therapy early and were rated as having had unsuccessful outcomes. The therapist should give special attention to helping modulate these patients’ demands early in treatment to prevent overwhelming disappointment and dropout. These patients also invite a countertransference response of emotional withdrawal, which reinforces neurotic guilt about needs.

A second problem may occur when the patient repeatedly attempts to have the therapist both take responsibility for all decisions and tell the patient how to run his or her life. If the therapist assumes this directing countertransference role, he or she may become an external substitute for the patient’s own will. A therapist may do this because of feeling exasperated by the patient’s protestations of helplessness or because of a personal wish to assume an idealized role as wise and all-knowing. This reinforces the patient’s emotional reliance on the therapist without helping the patient learn more independent ways of coping. Directive approaches may have a useful, but limited, role during crisis interventions, but even cognitive-behavioral therapies require the therapist to foster the patient’s independent decision making.

A third problem results when the patient avoids making real changes but stays in therapy to maintain the emotional attachment to the therapist. The patient’s compliant attitude toward the therapist may be mistaken for cooperation with the goals of therapy. Such individuals have tacitly refused to accept responsibility for making changes and may have their passivity reinforced if the therapist does not recognize and deal openly with this problem.

A fourth problem may occur with patients who have unsatisfying, punitive relationships, commonly referred to as masochistic or self-defeating. The patient’s repeated stories about mistreatment may evoke in the therapist a desire to control the patient’s self-defeating pattern or even to punish the patient. If the therapist challenges the patient to leave or to assert himself or herself in the relationship, this may be very anxiety-provoking because of the strength of the emotional attachment or because of the realistic threat of a punitive response from the patient’s partner. Such a challenge may make the patient feel trapped between pleasing the therapist and being punished by the patient’s partner. It may result in panic or early termination.

A fifth pattern is found in the patient who refuses to deal with separation issues in therapy, which often involve mourning past losses or disappointments. This may lead the patient to avoid anticipating the loss of the therapist at termination and mourning appropriately. The therapist may tacitly collude with this avoidance because of a countertransference fantasy of always being available or a fear of provoking separation panic. Failure to confront the avoidance may result in a failure to make lasting, dynamic changes, leaving the patient at risk for a sense of betrayal after termination, followed by deterioration.

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Revision date: July 4, 2011
Last revised: by Sebastian Scheller, MD, ScD