Both the therapist and Johann instinctively knew that Minnie did not arbitrary come to her personality. It had to come from somewhere and through some impactful experiences. Early domination in the family-of-origin (emotional and psychological neglect or abuse, if not also physical and sexual) is likely in development of dependent personality disorder. It was dangerous to assert oneself in relationships within their family of origin. The result is “an unassertive hyperacquiescent interpersonal style, and… a poor self-concept with limited personal resources for coping with problems and stresses” (Litman, 2003, page 773). Dependent personalities continue this dynamic with new relationships. They have many experiences being made unimportant, being silenced, and being disempowered. They often have extremely low self-esteem. Unable and inexperienced to confirm for self his/her basic worth, subsequently, the dependent personality is always looking to others for confirmation, including from the couples therapist. However, when a dependent personality gets confirmation, he or she is unable to retain any lasting sense of self-worth. Therapist’s or anyone’s praise is only (if is at all) momentarily effective. It may be useful feedback to that the individual with dependent personality that he or she seems unable to take praise.
Personality has its first or important early roots in biological dispositions that are inherited. Individuals with dependent personality disorder tend to have cautious temperaments including a fear of novelty starting as children (Harvard Mental Health Letter, 2007, page 2). Generalized anxiety disorder, phobias, and avoidant personality are more prevalent in their families of origin. However, temperament does not directly and solely define adult outcomes. “The most popular explanations are psychodynamic and behavioral. Psychodynamic theorists and therapists believe that unconscious emotional conflicts- experiences and feelings out of awareness- and the unconscious defenses we erect against them shape personality traits. Disorders are thought to arise if, for example, problems in early relationships lead a person to develop defenses that are not effective, adaptive, or useful.” One psychodynamic theory, proposes that someone with dependent personality disorder is defending against unconscious hostility directed “against overbearing parents, so they submit to others as a way to avoid showing or even acknowledging anger.” These internalized parental images continue to affect current functioning. Poor early attachment between the young child and parents rather than developing healthy attachment with positive secure experiences with reliable intimate caregivers undermines a solid foundation to deal with life. “If parents are unresponsive, inconsistent, or abusive, children may develop a fearful or insecure form of attachment, which they internalize as a model and adopt in later relationships. They also have more trouble soothing or calming themselves when they are frustrated, angry, or anxious. One result of this pattern of development is dependent personality.”
Behavioral and social learning theory proposes that children learn through conditioning (automatic associations) and reinforcement (reward and punishment). Dependent personality may develop from the child being rewarded for making excessive demands for care. Others’ expectations may reinforce dependence. Inconsistent parents teach the child that life is not only unpredictable but also not in his or her control. If independent action is not rewarded or instead punished, the child will learn to avoid independent behavior and be more likely to behave dependently. “One possibility is that dependent personality begins with a gentle and easily frightened temperament that evokes protective feelings. Overanxious parents, who discourage independence, or a bullying brother or sister, reinforce the tendency. Constantly sheltered, the submissive child becomes still more passive, and others develop expectations that make the behavior and attitudes difficult to change. It then reappears repeatedly in later childhood and adult relationships” (Harvard Mental Health Letter, 2007, page 3).
The genesis of unhealthy dependency in adulthood can be examined in the process of normal dependency needs of the infant and young child. Attachment theory proposes that the baby and young child need positive experiences with their initial caregivers- parents. If the caregivers are available and meet the individual’s needs: basic care needs and nurturing, then healthy or secure attachment develops. With repeated caregiver proximity and caregiver soothing during distressful experiences, the child becomes ever more secure that his or her needs will be met. The natural and healthy outcome is that the child is able to experiment with letting go of his or her dependence on the caregivers and venture forth more independently. The individual continues with exploring a balance between dependence and independence. Eventually, childhood attachment styles are hypothesized to become adult attachment styles that affect subsequent relationships. Rather than demonstrating secure attachment and independence, Minnie’s reactions and behavior with Johann are very similar to that of an insecurely attached child. Her emotional reactivity and intense submissiveness mimic the anxiously attached child. “Ainsworth (1969) states that the overall quality of the infant–caregiver relationship during infancy and early childhood is the primary determinant of dependency traits in adulthood. She further states that dependence implies immaturity, and that, although normal in the young child, dependence should gradually give way to a substantial degree of independence. The word dependence refers to the extent to which one individual relies on another for his existence, dependence being at its maximum at birth and diminishing steadily as maturity is reached (Bowlby, 1969). As the child grows and moves toward independence, he develops the means for doing without actual direct physical care. This is accomplished through the accumulation of memories of care and the development of confidence in the environment (Davis & Wallbridge, 1981). Problems can arise when accessibility and responsiveness of the principle attachment figure is not forthcoming because of emotional absence for one reason or another (Bowlby, 1973), thus inhibiting the accumulation of memories of care essential for the development of independence… object constancy, is characterized by the unfolding of complex cognitive functions. During this phase, the child can establish a mental representation of the self as distinctly separate from representations of the object, thereby paving the way for object constancy through the internalization of the caregiver object. If separation–individuation is successfully achieved, the child no longer needs the actual presence of the mother to feel secure and is capable of functioning independently” (Berk and Rhodes, 2005, page 189).
Minnie’s parents were inconsistent as caregivers. Her father was a charismatic minister with a large church full of evangelical spirit. He was adored by his flock of parishioners and had political and economic clout in their community. At home however, he was short-tempered, critical, and domineering. The entire family tiptoed in the house terrified that he would go off at any moment. Minnie’s mother joined the “congregation” when her father was a young seminary student. She was intelligent enough, had the right pedigree (daughter of another minister), and best of all, she looked appropriately deferential and reverential standing slightly behind and next to him. Her mother knew that when she hitched her wagon to his train, that he was going to be the leader and her job was to support him. And, that clearly meant deferring and submitting to him no matter what sacrifices she was to endure. Minnie got a first-hand model of how to submit herself to a husband from her mother. Minnie tried hard to please both her parents. That clearly meant trying to anticipate what they wanted even before knew themselves. If she did something they didn’t like or she hadn’t anticipated what they wanted, they made it abundantly clear that it was her fault. Minnie would scramble to atone for her transgression and make it up somehow. No matter how much she tried however, she could not anticipate the unpredictable mood swings of her father. Her older sister was more willing to tell the “emperor” that he had no clothes. Unlike the townspeople and the emperor, who realized the truth of the confrontation and were shamed, her father became infuriated. He beat Minnie’s sister and emotionally ostracized her. Minnie’s mother did not dare to contradict her husband and did little to support Minnie’s sister. Minnie did not dare either to align with her sister in any way. Submission was the safest strategy. Johann’s strong religious faith and his dedication to his family, work, and community reminded Minnie of her father in a positive manner. And, his kindness and gentle manner seemed to be the antithesis of her father’s cruelty. He was father and the not-father.
Joining with a life partner or any partner involves giving up a degree of independence and allowing for a degree of dependence. Fear of being dependent and becoming vulnerable to harm- that is, losing control may prevent some individuals from risking intimate relationships. Or, cause some individuals to seek and create rigidly truncated relationships for self-protection. On the other hand, fear of and the desperation of being alone may be so compelling that someone such as Minnie will engage in highly problematic and fundamentally unfulfilling relationships. Minnie was fortunate that Johann was a decent person and did not exploit or abuse her. However, the relationship was still unfulfilling in large part because of her immature dependency. “...there has been recognition that dependency may be expressed in immature and mature forms (Blatt et al., 1995; Rude & Burnham, 1995). Both these investigations suggested that measures of dependency reflected two facets. The first typified immature dependency and was labeled ‘neediness,’ reflecting ‘a generalized, undifferentiated dependence on others and feelings of helplessness and fears of desertion and abandonment’ (Blatt et al., 1995, p.334). The second facet typified mature dependency and was labeled ‘connectedness’ or ‘relatedness,’ reflecting ‘a valuing of relationships and a sensitivity to the effects of one’s actions on others’ (Rude & Burnham, 1995, p. 337)... One approach to reconceptualizing dependent personality disorder is to consider the arc from submissive dependence to love dependence as a maturational dimension... Adults expressing immature forms of dependency would then be considered as having dependent personality disorder. This is consistent with our results suggesting that submissive dependence is associated with higher scores on maladaptive constructs, lower levels of parental affiliation, and higher levels of maternal control” (Pincus and Wilson, 2001, page 244-45).
Minnie manifested consistent needy behavior. Her helplessness and fears grated upon Johann’s sense of personal competency as her husband. He had committed to care for her as her life partner. Try and try as he had, her continued neediness insinuated that he was a failure as a husband. Minnie essentially refused to be sufficiently “helped” and Minnie continued helpless stance challenged Johann’s sense of self as a caring giving partner. Johann had expected that his faithful attention and support for Minnie would build the connectedness of a mature dependent relationship in Minnie towards him, and for him towards her. He thought that they would have a healthy interdependent mutually connected and supportive relationship. Minnie’s dependent personality disorder proved problematic to his hopes despite his best intentions. Minnie’s developmental process balancing dependence and independence was corrupted. “Birtchnell (1988), elaborating on the work of Mahler, Winnicott and Kohut, presents five principal processes of maturation into adulthood: 1) separation, 2) individuation, 3) the acquisition of competence, 4) the acquisition of self–worth, and 5) acceptance into the adult world. He asserts that a failure during any of these five processes can lead to dependency in adulthood… Bornstein (1992) states that both parental authoritarianism and over–protectiveness are linked with dependent personality traits. An authoritarian style of parenting prevents the child from trial-and-error learning critical to the development of autonomy and feelings of self–efficacy (McCranie & Bass, 1984). An overprotective style of parenting prevents a child from developing a belief that he or she can function in the absence of help, guidance and support from others (Parker & Lipscombe, 1980)” (Berk and Rhodes, 2005, page 189-90).
Not only was Minnie unable to become appropriately dependent and independent in her family-of-origin, but her five processes of dependency maturation in the couple’s relationship with Johann was likewise stunted. Minnie could not separate herself from Johann. She did not individuate as a whole viable persona outside of her mother-to-children and wife-to-husband identities. In fact, as her children grew up and away diminishing her mother-to-children identity, it intensified her identity as being a part of Johann. Minnie was competent in many areas of her life- in particular in her profession, as a mother-caregiver, and as a friend. However, she remained or felt incompetent at what she felt most important- pleasing Johann perfectly. As a result, she was never worthy enough for Johann in her mind as she was never good enough for her father. She remained the scared little girl. Although Johann tried to draw, invite, and accept her as an equal, he struggled to see her as mature adult as she continually acted so needy and submissive. Even when Johann was able to hold her as an equal partner, Minnie could not accept herself as a mature adult.
CULTURE, GENDER, AND DEPENDENCY
Johann initially considered Minnie’s deferential and submissive behavior part of her personality- appropriate for a young woman. Minnie’s individual therapist also thought her behavior as within expectations for female cultural standards. Gender expectations for greater female dependency initially appear validated by research “Studies conducted to date suggest that women do in fact show higher levels of dependency than men when dependency is assessed via self-report measures (Birtchnell & Kennard, 1983; Chevron, Quinlan, & Blatt, 1978; Ederer, 1988; Fujihara & Kurokawa, 1981; Golightly, Nelson, & Johnson, 1970; Lao, 1980; Singh & Ojha, 1987). These sex differences in dependency are consistent across community subjects, psychiatric patients) and across different objective dependency measures (e.g., Blatt, D’Afflitti, & Quinlan’s Depressive Experiences Questionnaire [DEQ] Dependency scale, 1976; Navron’s MMPI Dependency scale, 1954; the Hirschfield et al. Measure of Interpersonal Dependency [MID; 1977]; the Golightly et al. Children’s Dependency Scale, 1970). Moreover, American, Canadian, British, German, Dutch, Indian, Israeli, and Japanese subjects show comparable gender differences on objective dependency measures (Bornstein, 1992)” (Bornstein, et al., 1993, page 170). This difference that appears in objective measures may be a consequence of women being more open about acknowledging dependent traits, attitudes, and behaviors than men, rather than an actual difference between genders. “A very different pattern of results is obtained when dependency is assessed via projective measures such as Masling, Rabie, and Blondheim’s (1967) Rorschach Oral Dependency: (ROD) scale, Thematic Apperception Test measures of dependency (Kagan & Mussen, 1956), sentence completion tests (Sinha, 1968), the Hand Test (Wagner, 1983), or the Blacky Test Oral Dependency scale (Blum, 1949). On these (and other) projective measures, men and women typically obtain comparable dependency scores (Bornstein, Leone, & Galley, 1988: Gordon & Tegtemeyer, 1983; Greenberg & Bornstein, 1989; Juni, Masling, & Brannon, 1979; Mills & Cunningham, 1988; O’Neill & Bornstein, 1990; Shilkret & Masling, 1981; Weiss, 1969; Weiss & Masling 1970)” (Bornstein, et al., 1993, page 170).
Gender differences in personally identified dependency may be attributed to differences in socialization based on traditional cultural expectations. Since childhood, males may be strongly discouraged from freely showing dependent feelings and needs which are considered signs of weakness incompatible with the strong male persona. On the other hand, girls and women are more likely within cultural standards to be allowed and even encouraged to show dependent feelings. Being passive, deferential, and dependent was considered appropriate and desirable exhibitions of femininity. Adults including parents and teachers, other family members, as well as reservoirs of cultural models in literature, and various media outlets present with relative subtlety to gross promotion that boys and girls should conform to models for traditional men and women. “To the degree that a woman views herself as departing from the traditional female sex role, she should be less willing to acknowledge dependency needs on self-report measures. Conversely, to the degree that a man regards himself as departing from the traditional male sex role, he should show higher levels of dependency on self-report tests. A number of investigations have examined the sex-role orientation-dependency relationship (e.g., Anderson, 1986; Birtchnell & Kennard, 1983; Chevron et al., 1978; Welkowitz, Lish, & Bond, 1985). These studies produced highly consistent results, confirming that self-reported dependency is positively related to femininity scores in both women and men and inversely related to masculinity scores in subjects of both sexes” (Bornstein, et al., 1993, page 177). Both Johann and Minnie tended to adhere to traditional gender models. Johann however tried to stretch himself to be more open with his feelings. His willingness to engage in couple therapy was somewhat atypical of male gender models. He was able to admit that he could have an appropriate and healthy dependency relationship with Minnie.
Different gender expectations change parental interactions with boys and girls. “With boys, a mother feels torn between maintaining the attachment with her son while affirming the differences between them, versus helping her son achieve individuation and independence by pushing him away. A father’s attitude and behavior toward his son reinforces the pressure on the mother to encourage aggressive behaviors and separateness in the son and pressures the son to negate his wishes to maintain more open and continuous contact with his mother. As a result, boys are generally discouraged from openly expressing dependent feelings and needs (Bornstein, 1992)” (Berk and Rhodes, 2005, page 191). Johann was encouraged by both parents to be more independent. Although, he shared a bonded relationship with his mother, she held the expectation that for a boy to become a man, he had to be nudged away from being too close with her. His instincts to be assertive and aggressive with taking risks and exploring beyond the parental sphere were tolerated and encouraged. Boys will be boys, especially when their behavior is sufficiently “boy-like” according to social gender norms. “Be my little man” was how his mother communicated that he was to take risks and be independent. Johann’s father was a gentle and kind soul, but he also was steeped in the post-World War culture of stoic manliness. He had been chided and then challenged to be tough, especially during his military service during the Korean War. He encouraged Johann’s toughness even when it denied his feelings and sensitivities- even when he hurt for Johann’s distress. Telling Johann to “man up” and to learn how to “fight your own fights” discouraged Johann from being dependent.
Johann’s sister was raised differently despite having the same parents, the same household, and a very similar temperament to Johann. Johann saw and often envied the difference. She was allowed to stay emotionally closer to their mother. She was “momma’s little helper” who shared the feminine roles of mutual communication and nurturing. She was encouraged to be empathetic and be dependent and interdependent. Being like mom was acceptable and encouraged. She was “momma’s little clone.” As a child, Johann did not always meet the expectations he was given, especially about staying connected and being close versus separating. Eventually he learned to expect different treatment as the boy, rather than the girl in the family. He knew he was supposed to be strong and more independent, while his sister was supposed to be “girly,” close, emotional, and deferential. “Bar–Yam (1991) agrees that yearnings for separateness on the one hand and inclusion on the other are not inherently masculine and feminine traits respectively but, in reality, are salient for both sexes. In addition to the impact parents have on the expression of dependency needs in their children of either gender, she adds that society’s demands and expectations, personal experiences, cultural values, and life conditions greatly affect the inclination to express one type of yearning or the other” (Berk and Rhodes, 2005, page 191). More than once, Johann recalled how uncles or aunts or other adults commented approvingly on his “manliness” or his sister’s “femininity” or discouraged his “sensitivity” or his sister “acting like a boy.”
The symptoms of dependent personality disorder can be split into two groups. One group concerns issues assuming responsibility, making decisions, and showing disagreement. The other group is about fears of being abandoned and helpless. Men who do not have trouble asserting themselves would not therefore be diagnosed with dependent personality disorder. However, they may have significant anxiety about needing nurturing and support, which “is compatible with a surprising degree of aggression. The need for care and support can lead to abusive behavior, intimidation, and violence. A jealous man who abuses his wife or partner may be displaying this kind of dependency. Dependent men are especially at risk of becoming abusers when they fear that the partner is about to leave or getting too close to another person” (Harvard Mental Health Letter, 2007, page 3). The therapist should be vigilant for abusive behavior in men with dependent personality disorder. While women with the same diagnosis may be similarly prone to abusing partners, gender cultural standards may direct them to more passive-aggressive rather than overtly aggressive behavior. The therapist should be sensitive to any type of relational violence and the potential: emotional, psychological, verbal or non-verbal. However, physical assault requires a greater level of ethical and legal requirements over and above clinical requirements.
As may happen with other males, Johann could not deny his dependency needs, or minimize them sufficiently despite family and cultural training enough to be unaffected. However, like many men he did not identify his dependency traits as such but expressed them in other ways. “The results of several studies reveal a strong correlation between dependency traits in men and Axis I disorders, particularly depression. Nietzel and Harris (1990) assert that dependency needs appear to predispose individuals to depression. Researchers offer several possible explanations for this correlation. Bornstein (1992) suggests that when a dependent person experiences a stressful life event that threatens his dependency, he is more vulnerable to depression. Overholser (1996) proposes that high levels of interpersonal dependency correlate with maladaptive social functioning, which plays a role in vulnerability for depression. Birtchnell (1988) asserts that dependent individuals are vulnerable to withdrawal, denial and rejection and, in response to such actions, often become depressed. Chodoff (1974) believes that patterns of personality, the dependent personality for example, predispose to depression. Brown and Silberschatz (1989) found a correlation between dependency and self–criticism and that both are related to depression” (Berk and Rhodes, 2005, page 191-92).
The fear of losing the intimate figure is a central theme for dependent individuals. It is consistent with seeing oneself as a failure, self-condemnation, and self-criticism. Ownership of such feelings while often intense however is also verboten for many men. This creates a bind that has potentially harmful consequences. “Another interesting finding is the comorbidity of dependency traits in men and spousal abuse. Controlled studies and clinical accounts strongly suggest that men who perpetrate spousal abuse are often highly dependent on their partners (Murphy, Meyer, & O’Leary, 1994; Sonkin, Martin, & Walker, 1985). In a more extreme example of the relationship between dependency traits and violence, Ainslie, in his book The Long Dark Road: Bill King and Murder in Jasper, Texas (2004), explores the dynamics that drove Bill King to join a racist group and eventually to commit murder. His book suggests that, in an effort to satisfy their need to be accepted and to defend against their terror of abandonment, some men will go so far as to engage in antisocial behavior to maintain their sense of belonging to a group” (Berk and Rhodes, 2005, page 191-92).
Dependent men may have the same emotional and cognitive experiences fearing disapproval and becoming submissive trying to please partners to avoid abandonment. However, gender role standards may result in some important behavior differences. Frequent and constant practice behaving differently than their true self- acting according to a false self is a risk for both men and women. If getting angry is not egosyntonic with ones sense of self, depression may be the result. Although, the anger offers some relief, guilt and shame may follow. Rather than reconciling the discrepancy between the true or ideal self with the real self through compassion and understanding ones process, the false self asserts instead to avoid the emotional and psychological stress of addressing it. Other non-productive behaviors may arise to avoid dependency anxiety. “Dependent men have a pattern of quickly moving into a new relationship following the loss of a previous relationship. We believe this is the result of the inability of men with dependency traits to tolerate the absence of a physical caregiver object. In case example #2, R. was aware of his anxiety when away from his girlfriend and that he was unable to keep a mental image of her, consequently feeling unloved and unlovable. This is an example of the failure to attain the subphase of object constancy (Mahler & La Perriere, 1965). The fear of loss of the caregiver object can be so extreme in some men with dependent traits that it can result in the use of physical violence in an effort to prevent abandonment” (Berk and Rhodes, 2005, page 199). A man with a history of physical violence would be more likely to commit domestic violence if his anger and aggression are not redirected in some fashion. For some men, it is directed towards anyone or anything that threatens losing the caregiver or intimate partner. If the threat comes from the intimate partner, then domestic violence becomes more likely since the dependent person is unable to otherwise self-soothe.
ATTRACTION TO NARCISSISTS
Similar to dependent women such as Minnie’s mother who picked a narcissistic partner, “When dependent men choose mates, they are frequently attracted to narcissistic women and narcissistic women are often attracted to them. The dependent partner’s submissiveness is a perfect fit with the exploitive, entitled behavior of the narcissist (Nurse, 1998). In return, the dependent partner gains a ‘borrowed identity,’ guidance, compensation for areas in which he is incompetent and affirmation of worth.” This is a gender reversal of Minnie’s mother and father’s roles, where the female was dependent and submissive, while the male was the dominating narcissist. “Bird et al. (1983) report a trend in which the men they identify to be ‘collapsible men of prominence,’ men who show significant dependent characteristics, often have powerful, controlling mothers and weak fathers who occupy peripheral positions in their families” (Berk and Rhodes, 2005, page 200). Again, this is a gender reversal of Minnie’s parents. While there is a cultural standard that encourages male narcissist dominance and female dependence, the individual composition of a pair of parents with a narcissist dominant/dependent polarity tends to promote dependency in the family’s children. It however remains important to consider, although not to be tied to the gender expectations and limitations that males versus females are subject to, and the stereotypical manifestations that the therapist may see in couple therapy.
Men are probably less likely than women to present for therapy around issues of dependency. The reason for therapy is more likely to be issues with anxiety or depression after experiencing a significant loss or in anticipating a loss of the intimate relationship. The therapist should be aware of several criteria that may be indicative of unhealthy dependency. “These include a client reporting guilt for feeling unhappy in his primary relationship, a pattern of establishing a new primary relationship as quickly as possible when the existing one ends or is threatened, reports of severe anxiety about the possibility of being alone, physical discomfort when alone, difficulty making decisions without reassurance, and difficulty expressing any form of disagreement. When any of these are apparent, the therapist needs to determine if they are merely symptomatic of the Axis I disorder or, in fact, indicate underlying dependency traits” (Berk and Rhodes, 2005, page 210). These issues were not essentially different than what Minnie presented to her individual therapist. While her individual therapist did not consider a dependent personality disorder, many therapists would be more likely to make the diagnosis for a woman than for a man. There has been some increased presentation by men for therapy around dependency issues. “The traditional marriage of several decades ago was more conducive to nurturing men with dependency traits. Stiver (1991) asserts that the man could assume maternal care-giving by his wife and therefore never had to acknowledge his own neediness or the extent of his dependence on her. As the nature of the role of women in society has changed, men with dependency traits may be baffled by the feeling that something is missing in their primary relationships. This may be reflected in the Axis I diagnoses that bring them to therapy” (Berk and Rhodes, 2005, page 201).
Men may expect to be “babied” by female partners and get a regular dosage of “TLC” (tender loving care) as part of the relational contract as long as they hold up their end as the traditional provider. With increased gender equality and feminist challenges to traditional roles, some women in heterosexual couples expect a more egalitarian and mutually reciprocal relationship. As this has evolved, women have become less likely to be the automatic nurturer in the couple. Men may have been expected to step up both as household engineers and emotional caregivers. However, as much as some men have had difficulty learning new roles, other men have had difficulty getting the nurturing that they had not had to ask for previously. Or, they have yet to learn how to arrange a conscious reciprocal nurturing process. If they have not been consciously aware of how to ask and give, they may also not been aware that they depended such emotional sustenance. Without the automatic female nurturance, some men could only recognize that something was not quite “right” or something was “off.” Unarticulated unidentified dependency needs intensified without institutionalized male venues to address them. Therapy becomes an option often for the first time.
While therapy or couple therapy has become an acceptable option for some men, the therapist should be aware that a dependency diagnosis for male clients or individuals from certain cultural groups may be socially or culturally stigmatizing. “Once the therapist has established the existence of dependency traits, treatment can be difficult. The male client may be reluctant to explore a painful dependency issue for several reasons. These may include the belief that such feelings are unacceptable, a fear of being judged negatively by the therapist, and a fear that the anger underlying the dependence could come out in uncontrollable ways. At this initial stage, the task of the therapist is to provide a safe environment in which the man can explore his dependency and the shame, fear, grief and anger around it. To do this, the therapist must draw the client’s attention to the issue and help him to maintain focus on it. When working with men, this process may be considerably more difficult than when working with women, given the social stigma attached to dependency in men leading to additional shame which men may have to overcome prior to addressing the core material. Normalizing dependency needs as something everyone has can be helpful at this stage” (Berk and Rhodes, 2005, page 201). “Additionally, the gender of the therapist may play an important role in the transference with these clients. These men may feel more comfortable expressing their dependency needs to a female therapist based on a belief that women have a better understanding of dependency needs” (Berk and Rhodes, 2005, page 202-203). Cautions may be as relevant for a particular female who has similar aversion to being dependent for psychodynamic reasons other than from social gender norms. In addition, ethnic, nationality, religious, or class standards may be as compelling if further intensifying shame about dependency. For example, someone who has a privileged upper class or aristocratic background used to commanding others, may find it extremely humiliating to admit being subservient to another. The therapist may be drawn to other cross-cultural issues or attribute aggressive or entitled behavior to narcissism rather than to dependency fears the client cannot culturally acknowledge. It is arguable that many personality disorders are based on dependency fears or attachment anxiety, but express cognitively, emotionally, and psychologically in different patterns of behaviors otherwise labeled.