Some dependent patients are needy, clingy, and insecure—unable to make the smallest decisions without inordinate advice and reassurance—whereas others are less easy to recognize. Dependency can be expressed in many different ways: obvious or subtle, maladaptive or adaptive.
Dependent psychotherapy patients are compliant and eager to please but can have difficulty terminating treatment. This article offers recommendations for clinical work with dependent adults to help you:
- assess and diagnose dependent personality disorder (DPD)
- distinguish unhealthy from healthy dependency
- provide effective psychotherapy for DPD in inpatient and outpatient settings.
What is a dependent personality?
DPD is diagnosed when an individual exhibits long-standing, inflexible dependency that creates difficulties in social, sexual, and occupational functioning, according to DSM-IV-TR.1 DPD’s essential feature is a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts. To receive a DPD diagnosis, a patient must show 5 of 8 possible symptoms (Table 1).
Symptoms of dependent personality disorder (DPD)*
|Difficulty making everyday decisions without excessive advice and reassurance|
|Needing others to assume responsibility for most major areas of life|
|Difficulty expressing disagreement because of a fear of disapproval|
|Difficulty initiating projects or doing things on one’s own|
|Going to excessive lengths to obtain nurturance and support from others|
|Feeling uncomfortable or helpless when alone|
|Urgently seeking another relationship as a source of care and support when a close relationship ends|
|Being unrealistically preoccupied with fears of being left to care for oneself|
|* 5 of 8 symptoms required for DPD|
|Source: Adapted from DSM-IV-TR|
Who has DPD? One of the more common Axis II disorders, DPD is not distributed equally across the population. No studies have assessed the impact of age on DPD risk, but variables that affect DPD prevalence include:
- gender (women are far more likely than men to receive a DPD diagnosis)
- practice setting (DPD is more prevalent in rehabilitation and psychiatric inpatient settings than in outpatient practices)
- race and ethnicity (dependency may be less prevalent in African-American than in Caucasian adults).3,4
Interpersonal, intrapsychic dynamics
- Cognitive: A perception of oneself as powerless and ineffectual plus the belief that other people are comparatively confident and competent.
- Motivational: A strong desire to maintain close ties with protectors and caregivers.
- Emotional: Fear of abandonment or rejection; anxiety about evaluation by authority figures.
- Behavioral: A pattern of relationship-facilitating behavior designed to minimize the possibility of abandonment and rejection.
Interpersonal strategies. Dependent persons use interpersonal strategies to strengthen social ties and minimize the possibility of being rejected or abandoned (Table 2). Some strategies involve behavior that is active and assertive—even quite aggressive.8 Therefore, dependency does not necessarily equate with passivity.
used by dependent persons to facilitate relationships
|Supplication||Appear helpless and vulnerable||Submissiveness, self-deprecation|
|Ingratiation||Create indebtedness||Ego-bolstering, performing favors|
|Exemplification||Exploit others’ Guilt||Providing help, emphasizing effort and sacrifices|
|Self-promotion||Emphasize personal worth||Performance claims, exaggeration of accomplishments|
|Intimidation||Frighten and control others||Anger displays, breakdown threats|
What causes DPD?
Three theoretical frameworks have been used to explain the development and dynamics of DPD. Each suggests intervention techniques for dealing with dependency-related problems.
Psychodynamic. Psychodynamic theorists conceptualize problematic dependency in terms of dependency conflicts (such as conflicts between a desire to be cared for and an urge to dominate and compete). Ego defenses used to manage the affect associated with these conflicts (such as denial or projection) help determine the manner in which underlying dependency needs are expressed.9
Cognitive. Cognitive theorists regard problematic dependency as stemming from self-defeating thought patterns,10 including:
- helplessness-inducing automatic thoughts (reflexive thoughts that reflect the person’s lack of self-confidence)
- negative self-statements (self-deprecating internal monologues in which dependent persons reaffirm their perceived lack of competence and skill).
Diagnosis and assessment