5. Couple Therapy Dependent Partner - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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The Sun, the Moon, and the Stars, Dependency and Histrionics in Couples and Couple Therapy
Chapter 5: COUPLE THERAPY WITH A DEPENDENT PARTNER


The therapist needs to be aware that the dependent client may be hypersensitive consciously or unconsciously to therapist behavior that may replicate a parental pattern of authority and control.  The client may seek a dependent relationship with the therapist in individual therapy as he or she has done with a partner.  In couple therapy, he or she may try to elicit a dependent relationship with the therapist even while his or her partner is complaining about their dependent relationship.  He or she may try to get “excessive nurturance from the therapist.  The therapist can interpret such misperceptions and unconscious wishes to provide concrete examples of the client’s distortions.  If the client perceives the therapist to be an authority figure or if the client idealizes the therapist, he may tend to be overly agreeable with the therapist’s interpretations and suggestions and look to the therapist to rescue him from his pain” (Berk and Rhodes, 2005, page 202).  If the therapist is aware of his or her counter-transference being drawn to care for, guide, rescue, or make unusual exceptions for the client, he or she should find ways to purposely shift from the dynamic.  “In terms of countertransference, the therapist must be careful not to fall prey to the temptation of assuming the role of authority figure the client invites the therapist to take.  The therapist has to be vigilant to not get caught up in feeling flawless, and to pay close attention to encouraging the client to ponder, reflect and participate in the process of self–exploration without deferring automatically to the therapist” (Berk and Rhodes, 2005, page 203).

The therapist can offer to the dependent individual’s partner that he or she has just experienced what the partner has lived with for years.  The therapist should anticipate that the dependent partner replicates in therapy the same dynamics from home.  The dependent partner will often be readily agreeable to the non-dependent partner’s description of home life and the relationship, even though it may be critical of her or him.  As the partner may treat the dependent partner as an immature person, the therapist may feel an instinct to explain things slowly and carefully as would be appropriate for a child.  On the other hand, the dependent partner may try to divert uncomfortable questions by justifying him or herself and accusing the partner of mistakes.  He or she may show irritation or anger briefly, but with trepidation as if anticipating being slammed for daring to contradict or challenge the partner.  Sometimes, the dependent partner may stumble over him or herself trying to be conciliatory in order to avoid discomfort.  Attempts to come to come to some compromise were seen as attacks that require defense (Berk and Rhodes, 2005, page 197).  However, the defensive stance is often intermittent with submissive gestures contradicting any self-assertion.

It can be difficult for the dependent partner to make any definitive self-assertive statement.  What could or should be simple uncontested factual statements are often qualified with insecurity words, tone, or facial or body gestures.  A declarative statement such as “I placed the check on the table…” can be accompanied with a meek “I think…”  “I’m pretty sure…” or with a deprecating widening of the eyes and a shoulder shrug.  The dependent client may appear to be listening carefully and integrating what other people say, including the therapist.  The therapist should have the client verbalize in his or her own words what the therapist has said.  The client should also be required to extend any therapist statements or interpretations with his or her thoughts and specifics.  The therapist should attend not just to the content of the dependent individual’s words but play close attention to the affective communication.  Responding to the affective communication is critical.  “The therapist should encourage the client’s expression of thoughts and feelings while empathizing with the anxiety around the client’s perceived risk of disapproval and rejection by the therapist” (Berk and Rhodes, 2005, page 202).

The individual is driven by anxiety about disapproval and rejection from early experiences in the family-of-origin.  At the same time, he or she tends to dismiss that anxiety as irrelevant or his or her own fault.  Response to the content that ignores the affective anxiety misses the dependent’s core request of “tell me I’m ok.”  The therapist can say “I hear how anxious you are about being rejected by me or displeasing me when you say that.”  The therapist can put the anxiety on the table so that the dependent individual does not have to hide it.  “I’m going to like some things you say and not like some other things.  That’s ok and you being honest is more important than you trying to please or not please me.  You can please me by being honest and not trying to please me.  OK, now go ahead and please me by not pleasing me!  Tell me something you think I won’t like.”  A paradoxical directive such as this is one of many approaches to bring the submissive aspects of the dependency overtly into the therapy and the therapeutic relationship.  Dependency may have been a secret strategy up until now.  Placing overtly it squarely in the middle of the relationship is necessary to evolve from it.

THERAPY
“In assessing for dependency traits, Beck, Freeman, and Associates (1990) suggest exploring four aspects of the patient’s functioning:

1) the patient’s relationship history, particularly the response to the end of relationships;

2) the patient’s decision–making process;

3) how the patient feels about being alone for extended periods of time; and

4) how he handles disagreements with others or the request to perform unpleasant or demeaning tasks” (Berk and Rhodes, 2005, page 188).

Exploring each of these aspects should reveal patterns of dependent relationships, submission to others, tolerance and fear of being alone, and ability to manage conflict with or with being submissive or getting exploited.  As with other personality disorders, the therapist needs to reveal underlying early childhood mechanisms (stress, trauma, and abuse) that fostered this personality style.  Understanding oneself is an important foundation to change.  The dependent personality was developed in order to survive as a fundamentally disempowered individual in a criticizing and dangerous world.  From this perspective, it is not pathology per se, but rather a logical response to extreme conditions.  It “works” or “worked” for the individual as a passive way to gain power and control.  This assertion attacks the basic mythology of helplessness in the dependent personality.  Many of the issues described for the victim personality are relevant to the dependent personality.  Not surprisingly, this personality style may be more common among women who are often culturally less powerful in many communities.  Other groups of individuals that function with social defined limitations on personal power and control, including lower class person may also be more vulnerable to developing dependency tendencies.  Social as well as family circumstances and early and continued training can make overtly asserting choice and seeking control counter-indicated culturally.  Individuals from groups who are historically disempowered may also have a tendency to dependent strategies because of cross-generational transmission.

The therapist should investigate the individual’s developmental relationship experiences.  Minnie had a pattern of dependent relationships starting with her parents.  Her separation anxiety was intense upon attending preschool, then kindergarten and continued through her early years in elementary school.  She would cry and cling to her mother until school staff physically separated them.  Then she refused to separate from early teachers- the substitute caregivers.  Minnie followed her preschool and kindergarten teachers everywhere.  They had to get someone to restrain her so they could use the restroom.  She eventually improved in the first and second grade by attaching herself to a best friend.  She had difficulty sharing her best friend with others and would be loss if her friend did not come to school.  Eventually, she found a group of girlfriends and could shift from one to another when someone was absent.   She was overwrought with anxiety and sadness when she was the scapegoat or designated “yucky” girl by the group at the end of one school year.  Fortunately for her, summer came and with summer play dates, the group forgot she was the “yucky” girl and chose another target to be ostracized for their girl bullying.  Minnie lived in fear for the rest of her school career that she would antagonize the “queen bee” and be on the outs again.

When boys began being interested in her, she switched her allegiance and energy to a boyfriend.  Her boyfriends were always the sun, the moon, and the stars- her entire universe.  Minnie completely catered to their needs.  Not surprisingly, the first boyfriend that wanted to be sexually active with her got what he wanted.  He threatened to break up with her.  Fourteen years old and terrified that she would lose him, she loss her virginity to him.  For the rest of their relationship, she remains terrified, but now because she feared that her parents would find out that she was not a “good girl.”  She hated herself for being weak… she condemned herself for being a “bad girl.”  It was a relief when he broke up with her except that she was again terrified that she would stay alone.  Within two weeks, she had a new boyfriend.  This became the pattern of her relationships.  The longest she ever went without being in a relationship was two months.  Minnie tried drugs and did some kinky sex for one of her boyfriends that disgusted her.  She felt she had to please him.  She met Johann the week after a college age breakup.  Within two weeks… by the third date they were sexual.  They were a couple right away in her eyes.  Johann knew a bit about her dating history and saw himself as her gallant knight riding to the rescue.  Minnie was a great damsel in distress for him until he got tired of the burdens of on-demand chivalry.

RAPPORT AND DEPENDENCY
Successful therapy is usually based on the establishment of a strong therapeutic rapport with the client.  This portends to be relatively simple with the dependent client such as Minnie whose pathology strongly desires relationship with an authoritative figure.  By definition, the role of the therapist often duplicates the paternal and/or maternal caregivers that fostered the individual’s dependency in the beginning.  However, the individual’s desire for a relationship that duplicates his or her extreme dependency is not an effective or productive therapeutic relationship.  Initial exploration of individual and couple’s dynamics may draw enthusiastic cooperation, but the dependent individual often lacks insight and deeper substance.  The therapist needs to both join the pattern of relationship the dependent individual desires and is comfortable with, yet simultaneously recruit him or her in a collaborative process to allow discomfort exploring dependency anxiety.  The therapeutic relationship needs to be constantly examined to maintain rapport and collaboration without duplicating dependency.  Unlike many other types of clients, the dependent individual is unlikely to complain about the therapy and the therapeutic relationship, especially in individual therapy.  The therapist seeks to reassure Minnie that he or she will be gentle and caring while also being direct and honest.  The therapeutic holding environment is akin to the parental nurturing dynamics that allow and facilitate the child risking discomfort in experimenting and exploring new behaviors and interactions.  The rapport is established where the therapist is kind enough, intuitive enough, wise enough, strong enough, in control enough, and supportive enough for Minnie to risk being her real self.

An advantage in couple therapy is the availability of the non-dependent partner to comment, criticize, and complain- that is, give feedback about therapy, the therapist, and the relationship!  The partner may well had been deluded into thinking everything was fine in lieu of the dependent partner’s complaining much as the therapist may be deceived.  Bringing this experience and history to therapy counters the dependent partner’s tendencies.  For example, Minnie's behaviors can be revealed in session to be non-confrontational and to please the therapist.  Johann can be prompted and guided by the therapist to reveal Minnie’s real self and to confront her when she is not genuine.  Rapport with the non-dependent partner such as Johann comes from two processes.  One rapport building process is relatively standard in therapy.  Rapport develops with the therapist honoring and being in tune with his emotional/psychological process- that is, to give feedback that shows that the therapist does “get him.”  The second process happens when the therapist shows that he or she also “gets” the dependent partner’s process and is not co-opted by it.  Partners of individuals with personality disorders have themselves been seduced and manipulated by them.  Only over time have they come to this realization.  If the therapist notes and manages the personality disorder driven machinations without being deceived, the partner gains immediate confidence that he or she and the relationship may be helped.

QUALITY OF MOTIVATION
Within the components for positive therapeutic rapport are the motivations of the client or of two partners to change.  The quality of the dependent individual may be inconsistent.  “...little is also achieved without motivation and a commitment to change.  However, motivation is complex, multidimensional, and ever changing” (Livesley, 2008, page 220).  The dependent individual may be “highly motivated to attend sessions, but not highly motivated to work on critical problems.  Anger and a tendency to see others as responsible for... difficulties, and hence as the ones who needed to change, hindered therapeutic work.”  This more aggressive/defensive behavior is often a reaction to the sense of having been a victim for so long.  It can be a rare or occasional outburst or a habitual part of the dependent personality.  Loud aggressive victimhood comes from a sense of entitlement given enduring suffering helplessness.  “I am completely dependent on the good or ill will of others and having been screwed over constantly, I have the right to express and aggress angrily... in fact, I cannot help but rage.”  Although, it appears and is experienced as powerful and assertive, these behaviors are actually expressions of deep hopelessness and vulnerability. This style is probably more acceptable and common for male dependents as opposed to female dependents.

In one sense it can be relatively simple to access initial motivation for the submissive dependent.  His or her need to please and be accepted is the primary motivation and life strategy.  This is directed towards the partner and now to the therapist.  The challenge of therapy is to foster motivation and commitment in the individual for fundamental change instead of reverting to flawed ineffective dependent strategies.  The therapist can take a non-judgmental stance that the dependent person is not good or bad, but instead is ineffective.  Practically speaking, the therapist feeds back that the dependent person does not gain acceptance but elicits rejection.  The therapist should simultaneously present or coordinate such feedback with psychodynamic, family-of-origin, and cultural exploration of the person’s development of dependent behaviors, strategies, and identity.  This also removes a moral judgment about dependency and replaces it with identifying and respecting how dependency had been a compelling survival strategy, given early environments.  The therapist offers as motivation the opportunity not merely and barely surviving, but to actually flourish in the intimate relationship.   The therapist may throughout the course of therapy need to constantly assess the motivation of the dependent partner.  He or she can easily revert to pleasing submissive dependent motivations.  Consistently reintroducing and reinforcing alternative healthier motivations should be intrinsic the process of therapy.

INTROSPECTION
Livesley also feels that “the ability to reflect upon oneself and the development of an interest in one’s own mind as opposed to a focus on immediate experience seems critical.”  The individual client, parents of child or teen clients, the couple, and the family often have immediate urgencies if not crises are presented as the target of therapy.  Fix this or that however may ignore critical foundational experiences and learning that makes the fixing difficult or impossible.  The ability for introspection- to self-reflect may be stymied by fear about what one may see or remember.  It may take some time before a person can willingly and skillfully be introspective and insightful.  Minnie was aversive to self-reflect because her internalized highly critical self-image.  She had been told in words and actions and experienced failing to please her parents that she was inadequate and deficient.  Getting Minnie to explore these feelings in order to re-examine how they developed was painful for her.  She easily slid into self-hatred.  Woe is Minnie.  Johann been drawn initially to her self-deprecation and had been supportive validating her positive attributes.  Minnie had simultaneously eaten this up while continuing to dismiss any praise.  Worse for her own sense of self and for Johann’s identity as a nurturer/supporter, she denigrated who and what she was and her prospects for growth and fulfillment.
An essential element of therapy is for the individual and the couple to believe that they can create a life worth living.  Livesley described a client in these terms.  “For many years, like most patients with complex conditions, she was primarily motivated by negative goals- things she was not prepared to do, situations and people she wanted to avoid, a lifestyle that she was not prepared to adopt, problems that she was not prepared to work on, and so on.  She had few positive goals.  Yet positive goals are important.  They give direction, purpose, and meaning to life.  Long-term goals also integrate different aspects of personality because traits, talents, interests, and values need to be coordinated in the interests of goal attainment.  Substantial change only occurred when Sandra identified work that she enjoyed and found fulfilling” (Livesley, 2008, page 220).  Minnie may have characterized herself as trying to support and please Johann, but her actual orientation was to not displease him, not fail him, not be rejected, not be abandoned, and not replicate the negative dynamics between her and her parents.  Pleasing and submitting to Johann however as her primary strategy for avoiding these negative goals did not work over the long haul.  Therapy can propose merging the positive goals of being a great partner to Johann and being more true to herself (which both pleased and served him by being a great partner).  Thus, Minnie might conceive possible a life of fulfillment and reciprocal nurturing and care might become viable rather than a life of tension and anxiety avoiding rejection and abandonment.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
office: (510) 582-5788
fax: (510) 889-6553
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