2. Expanse of Problems - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
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2. Expanse of Problems

Therapist Resources > Therapy Books > SunMoon DependentHistrionic-Cple

The Sun, the Moon, and the Stars, Dependency and Histrionics in Couples and Couple Therapy

Minnie’s problems in her relationship with Johann are the most recent of reoccurring symptoms and issues from having dependent personality disorder.  Livesley (2008) categorized dependent personality disorder as having:

1. Symptoms such as anxiety, depression, and self-harming acts

2. Situational problems involving difficult life circumstances, problematic relationships, and friendships that tend to encourage maladaptive behavior

3. Problems with the regulation and control of impulses and emotions

4. Maladaptive traits such as anxiousness, sensation seeking, and cognitive dysregulation

5. Interpersonal problems linked to traits such as dependency and submissiveness

6. Self or identity problems, in this case, a fragmented sense of identity and low self directedness (page 211).

The expanse of problems indicates the severity of dependent personality disorder affecting life functioning.  Each area requires being addressed, perhaps separately if necessary as opposed to unilaterally in therapy.  Within an intimate relationship, there exists a dynamic balance of dependence, independence, and interdependence that may be more or less functional.  Dependence implies both intimacy and vulnerability.  Independence implies freedom from dependence- freedom from constraints, greater safety and control, but may also preclude closeness, connection, and thus, intimacy.  Interdependence implies some mutual reciprocal process of contractual dependence exchange between equal or unequal partners.  Pincus and Wilson (2001) offer components within the concept of dependence that can be used to distinguish healthy functioning versus development of dependent personality disorder.  Each component depends on others to provide distinct psychological and instrumental resources: love dependence, exploitable dependence, and submissive dependence.  “…love dependence reflects the need to obtain and maintain proximal relationships with nurturant others (i.e., attachment figures) as suggested in the item, ‘Having close bonds with other people makes me feel secure.’  Love dependence appears related to more adaptive functioning (e.g., secure adult attachment style, lower scores on aspects of pathological attachment, and lower scores on loneliness for males).  Additionally, love dependents exhibited more affiliative parental representations.  Finally, love dependence is also positively related to Conscientiousness and Openness to Experience (Pincus & Gurtman, 1995).  An integration of these results suggests that underlying object-relations of love dependents reflect the view of others as friendly and available and the self as loveable.  Love dependents successfully bond with attachment figures in adaptive ways and appear open to mutual shared experiences and commit to relationships readily.  Their internal object relations generate inner dialogue supportive of approaching others and expecting care in turn, effectively buffering the individual from loneliness” (page 242-43).  The degree that the relationship between Minnie and Johann includes love dependence strongly influences the health of their dynamics.  Although, Minnie’s dependent characteristics are problematic, she intuitively desires love dependence or a secure attachment with Johann.  Johann may have love dependence with or for Minnie but be stymied by her insecure attachment behaviors.

When Johann expresses some need, Minnie is quick to try to satisfy him.  When she has done something that pleases Johann, she is often like a puppy dog eager for approval.  Rather than considering how convenient it may be or what it may cost in terms of time and effort, Minnie will jump high although he is not or has not asked her to do anything.  An idle bit of wishful thinking can trigger Minnie spending extensive energy and resources to get Johan what he had not really asked for.  Earlier in their relationship, Johann would be pleasantly surprised and very appreciative when Minnie would surprise him with these seemingly “random” acts of kindness.  When he told her that she didn’t have to do such things, Minnie said that she just liked to do nice things for a nice person.  Johann thought it was so charming and sweet; until over time he realized that Minnie did not just like to do nice things for a nice person.  Once in a while, when Johann was not effusively thankful and did not adequately acknowledge her effort, Minnie would pout.  At first, he did not know why she seemed upset.  When he figured out she wanted acknowledgement, he was more conscientious about expressing appreciation.  Eventually, Johann recognized over and beyond that, he was supposed to…that he had to respond or else.  Johann was a relatively caring partner and in tune with and balanced about his selfish instincts, so he consciously tried not take advantage of her.  Minnie desperately wanted acceptance and appreciation for doing nice things beyond what others’ need for acceptance and appreciation.   Minnie could be so automatically compliant even when Johann has not specifically requested her to do anything, that Johann often censored himself so not to exploit her dependence.  Sometimes, Minnie did things anyway for him.  As a result, his sense of debt increased as her “gifts” and “kindness” accrued against his less compulsive and less frequent acts of kindness.  Johann said that it made him feel lesser in the relationship.  He both felt and resisted the obligation to do things for Minnie.

“Exploitable dependence reflects the need to obtain and maintain acceptance and appreciation from others and to avoid conflict, as suggested in the sample items, ‘I do things that are not in my best interest in order to please others,’ and ‘I worry a lot about offending or hurting someone who is close to me.’  In most analyses, exploitable dependents exhibited intermediate scores on psychosocial variables, consistent with circumplex logic.  Their object relations and inner dialogue reflect a view that others will be available and appreciative if they are pleased by the exploitable individual.  Exploitable dependents do seek care compulsively in a conflict-avoidant way.  For example, Newes, Pincus, Claudius, Jones, Skinner, and Wilson (1998) found that individuals high in exploitable dependence were less able to refuse unwanted sexual petting and intercourse the submissive and love dependents.  While this strategy of pleasing others to obtain relatedness is successful, exploitable dependent males report significant loneliness, suggesting that such relationships may be much more satisfying for the other person involved” (Pincus and Wilson, 2001, page 243).  Minnie had told Johann about previous boyfriends, family, friends, and colleagues who had exploited her.  He wanted to be a better person than them, so he resisted exploiting her dependence.  However, over time he began to wonder this was another form of manipulation on Minnie’s part.  While it may have been a manipulation, Minnie’s need for appreciation and approval was sufficiently strong that she clearly had exhibited exploitable dependence with less conscientious or kind partners.

Johann’s biggest complaint about Minnie was her seeming inability to make almost any decision on her own.  “What should I order for dinner?  Which television show should I watch?  Is this nice enough?  Is this sweet enough?  Where should I put this?  How much should I spend on the present?  Do you think this is a good price?  Should I wait for a sale?  Is this a good color?  Is this feature important?”  And on and on.  It was kinda cute when they were first dating.  Johann admitted that it appealed to his male-as-master instincts when he was in college.  Eventually, it began wearing him down.  “I have my own life to live.  I have to make my own decisions.  And I don’t care what she orders for dinner!  What television she watches! And for sure, I don’t give a damn… I don’t know if it’s a ‘good’ color!  She’s a grown-up.  She has a Bachelors degree in Accounting.  She oversees accounts for her company in the millions of dollars.  We have grown kids, that she raised a heck of a lot without my input about minutia!  Why does she need me to decide piddly stuff?!” Minnie was more than smart enough and more than competent but she had a profound lack of confidence in her decision-making.  She was terrified of being wrong, even when there seemed to be no tangible consequences that Johann could see or that she could articulate.  As a result, she continually submitted herself to Johann greater knowledge, experience, and skills- even when he did not possess greater knowledge, experience, and skills.  Johann hated that Minnie depended on him for such trivial decisions.  Minnie had strong submissive dependence.

“Submissive dependence reflects the need to obtain and maintain instrumental support from others, as suggested by the sample item, ‘I have a lot of trouble making decisions by myself.’  Submissive dependence was consistently related to higher scores on maladaptive constructs (e.g., fearful adult attachment style, angry withdrawal, compulsive careseeking, total pathological attachment score, and loneliness in males).  Additionally, submissive dependence was related to recollections of lower parental affiliation and higher maternal control.  Finally, submissive dependence was also negatively related to Conscientiousness and Openness to Experience (Pincus & Gurtman, 1995).  An integration of these results suggests that underlying object-relations of submissive dependents reflect the view of others as controlling and less available and the self as ineffective and weak (see also Bornstein, 1996).  They seek out others for instrumental guidance in compulsive ways and feel angry when needed others do not respond.  This pattern in males is particularly likely to lead to loneliness as social bonding in males typically involves shared activities (Eagly, 1987; Maccoby, 1990; Stokes & Levin, 1986), which submissive males are more likely to avoid due in part to passivity and inner dialogue reinforcing negative representations of self and other”  (Pincus and Wilson, 2001, page 243).  When Johann got tired of Minnie’s incessant demands for guidance and direction, he often became short-tempered and sarcastic.  Minnie felt rejected and hurt, but also upset with Johann for “not being as helpful like he had been before.”  Feeling abandoned, Minnie’s instinct was to intensify her submissive dependence and become more helpless and infantile trying to draw more of Johann’s involvement.

“Dependent personality disorder may be conceptualized as a rigid reliance on behaviors expressing any or all component traits in situations that are not congruent with such expression.  Further, extremely intense expressions of love dependence (e.g., a clinging need to absolutely maintain physical proximity to a nurturant figure) might be just as maladaptive as extreme expression of exploitable and submissive dependence” (Pincus and Wilson, 2001, page 245-46).  Minnie did not just have trouble making decisions by herself, she had difficulty being alone.  Without Johann present or Johann’s advice, she was prone to emotionally reactivity and distress.  Normal or healthy dependency includes some emotional reactivity and vulnerability to distress but in less severe and disturbing fashion.  It is possible that “dependent personality disorder is associated with higher levels of Neuroticism.  That is, individuals with the core motive to obtain and maintain nurturant and supportive relationships, who are also highly reactive and distress-prone, might experience greater impairment when those on whom they depend for needed psychological and instrumental resources are unavailable or unresponsive” (Pincus and Wilson, 2001, page 246).  Ironically and sadly for Minnie, her fundamental strategies to gain the reassurance and nurturing that she craved, eventually caused Johann to become increasingly unavailable and unresponsive.  Fortunately for Minnie, Johann was aware of his growing intolerance for Minnie’s neediness and the damage to their relationship.  Rather than rejecting or abandoning her in a break up, Johann instigated couple therapy to heal the relationship.

Minnie had gone to a few sessions of therapy previously to deal with feelings of unhappiness and empty nest issues about the children leaving for college.  Her therapist had picked up on Minnie’s eagerness for guidance but had attributed it to anxiety about finding a new role in the family dynamics with the children getting more independent.  Minnie had flattered the male therapist with praise when he offered suggestions to manage her feelings and activities that might offer some fulfillment.  Unbeknownst to either of them, they had executed a classic male savior and damsel-in-distress cultural dance.  She submitted to his authoritative wisdom as a “good girl” should.  Being a compliant good girl was a pattern that she had learned in her family.  Dependent personality disorder can present as other conditions and/or coexist with other conditions.  It is “particularly intimately associated with depression; separation anxiety, the fear of being apart from a loved person (see Mental Health Letter, January 2007); somatoform disorders, unexplained physical symptoms with an emotional basis; and social anxiety disorder, the crippling dread of personal encounters and social situations.  People with dependent personality disorder develop separation anxiety because they feel abandoned when not in the presence of those they rely on.  They are at risk for social phobia because they don’t like to leave familiar people and surroundings.  They may use physical symptoms as a way to receive sympathy, protection, and care.  All of us feel some distress when we don’t receive the support we believe we require, when we lose a close relationship, or when we must assume responsibilities for which we feel unprepared.  But the risk of depression is much higher in people with dependent personality, especially if they lack the social skills needed to maintain relationships with others” (Harvard Mental Health Letter, 2007, page 1).

With intermittent or short-term interaction, an individual with dependent personality disorder may appear to be functioning normally.  Or they exhibit symptoms or behaviors that may be viewed as separate issues or diagnoses rather than part of the disorder.  Minnie could legitimately qualify for one or another of these diagnoses at different times.  Minnie’s individual therapist considered her anxiety and depression as normal given life transition issues with her children’s growing up.  Her role and identity as a mother was changing.  If pressed to make a diagnosis for billing managed care coverage, he might have used an Adjustment Disorder diagnosis- excessive reaction to an identifiable psychosocial stressor.  If they had focused on Minnie’s physical responses, he could have made a somatoform diagnosis of some sort.  If she had complained excessively and focused on her physical reactions, she may have been considered to be a hypochondriac.  “Additionally, the findings of Skodol, Gallaher, & Oldham (1996) link excessive dependency to acute depression and also to other types of psychopathology.  These include eating disorders and anxiety disorders, especially multiple anxiety disorders and anxiety mixed with depression (Bornstein, 1995)” (Berk and Rhodes, 2005, page 192).  Therapy follows diagnosis, including incomplete or inaccurate diagnosis.  Diagnosis in of itself may be problematic.  “Categorical diagnoses do not capture the complexity or range of psychopathology relevant to treatment planning.  They are global constructs that only provide broad treatment guidelines with limited value in selecting interventions because most interventions target specific behaviors such as self-harm, emotional lability, and impulsivity.  An additional problem encountered with complex cases is that clinicians usually make a single personality diagnosis and neglect the other personality disorders and traits” (Livesley, 2008, page 209).

Misunderstanding or misdiagnosis of Minnie can further ignite a dependent personality disorder symptom of self-directed negativity.  “Blatt (1974) and Blatt and Shichman (1983) described a number of interpersonal correlates of dependency and self-criticism  They proposed that dependent people possess strong needs to be loved, cared for, and protected, and that they fear abandonment and loss of love  If they can establish need-gratifying relationships, they are relatively satisfied and may idealize the gratifying other.  Blatt and Shichman (1983) suggested that self-critics are fundamentally concerned with ‘issues of self-definition, self-control, self-worth and identity’ (p 203).  They are ambivalent about interpersonal relationships because, while they desire approval and admiration, they fear disapproval, loss of control, and loss of autonomy.  Relationships are valued and chosen for their contribution to the self-critic's sense of identity and self-esteem  Even when they receive approval, self-critics remain ambivalent and dissatisfied with their relationships” (Zuroff and de Lorimier, 1989, page 826).  Early in their relationship, despite Johann openly adoring and praising Minnie, she continued to be very insecure about how and what she did.  Minnie craved Johann’s approval but more feared his disapproval.  Despite almost absolute and unconditional favor from Johann, Minnie constantly scrutinized her behavior and performance with a negative critical fine toothcomb.  She regularly found herself failing to do something or not doing more or less of something else.  She luxuriated in Johann’s attention and appreciation, but felt guilty that she did… and terrified that it was somehow insufficient or not enduring.  Or, she feared and condemned herself that over-confidence would cause her to miss any whiff of disappointment in Johann’s tone, face, or body language.  Try as she might, she thought herself as a “bad girl.”

Minnie was intrinsically tied into Johann, his life, and his successes.  It was no accident that she had been so supportive of Johann and his career.  She needed his success to build her own highly vulnerable and fragile sense of self.  Johann was more than a partner.  He was not an equal partner, but a superior partner to attach to.  “Many of the extrinsic rewards they described could serve to bolster the self-critic's self-esteem or solidify her sense of identity, and therefore would be highly valued.  A well-chosen boyfriend could provide the self-critic with approval and respect from her family and social circle, social status and admission to prestigious social circles, and access to business or career connections” (Zuroff and de Lorimier, 1989, page 827).  Minnie’s motivation differs fundamentally from intrinsic motivation based on shared or reciprocal mutual benefits.  A mutually reciprocal relationship itself is worthy for both partners: feelings of intimacy and closeness, shared interests, and mutual satisfaction.  Minnie always secretly felt that she got more from Johann in the relationship than Johann got from her.  She needed more than Johann.  Johann had a sense of a worthy self that Minnie did not have.  She needed his worth to gain worth for herself.

Zuroff and de Lorimier (1989, page 841-42) found that women who were both dependent and self-critical had greater needs for intimacy than those that were dependent but not self-critical.  However, despite this greater need, they still “feel unlovable or unworthy because of their self-critical aspects.  They may feel that only an extremely loving man with a high need for Intimacy will provide them with the affection they need…”  A self-critical woman such as Minnie anticipate that an achievement-oriented man like Johann would approve of her achievement urges and understand her needs and fears.  Minnie had internalized her parents’ standards that someone like Johann was the kind of achievement-oriented man that she should be with.  “Women who are both dependent and self-critical may find intimate relationships to be inherently conflictual, and are willing to endure the conflict only for a partner who has a great deal to offer in terms of extrinsic rewards” (Zuroff and de Lorimier, 1989, page 842).  Johann was a prize for many reasons, and Minnie was willing to “pay” for it.  She however did not realize what the price really would be and how hard it would be.  And, that she would not really get all she hoped to buy.

3056 Castro Valley Blvd., #82
Castro Valley, CA 94546
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
office: (510) 582-5788
fax: (510) 889-6553
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