6. Phases & Goals in Therapy - 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 6: PHASES AND GOALS IN THERAPY


Livesley asserts the five phases: safety, containment, control and regulation, exploration and change, and integration and synthesis.  This “sequence is consistent with research evidence of the stability of personality pathology that suggests that symptoms are the least stable aspects of personality disorder and hence fluctuate over time.  An early focus on symptoms therefore tends to produce change early in therapy, which could be used to build motivation.  It also produced more stability that enabled (clients) to deal with other issues and to learn new skills.  Emotion and impulse control problems, maladaptive interpersonal patterns, and the consequences of trauma form an intermediate level of stability.  Hence, attention was given to increasing emotion control before dealing with more traumatic material.  Finally, core beliefs about self and others are often remarkably intractable.  Although these beliefs inevitably arise throughout therapy, they only became a major focus when less intractable problems have been addressed” (2008, page 213).  Minnie and Johann’s therapy should be a coherent treatment process conceptualized as progressing through the five phases.

“The safety and containment phases are largely concerned with crisis management. Here the concern is to ensure the patient’s safety and contain emotions and impulses” (Livesley, 2008, page 212).  Minnie arrived in therapy with major anxiety that she would be found “wrong” and be finally rejected by Johann.  She feared that the therapist would join in Johann’s condemnation.  She was hypersensitive to any criticism, which intensified all her dependency driven survival mechanisms.  Johann was frustrated and starting to resign himself to the impossibility of change.  The therapist needs to create a therapeutic holding environment to modulate the emotional reactivity while validating each partner’s feelings and perspectives.  The therapist’s confidence can be demonstrated through the initial interview process, empathy, and insight.  This helps the partners gain hope that their intense emotions can be addressed safely, contained, kept from getting out of control, and regulated with learned strategies.  This may be the most critical aspect of successful therapy.  It duplicates healthy parental holding and is core to building rapport.  The therapist should not rush to problem solving or neglect building and maintaining a safe therapeutic container during the ensuing problem-solving parts of therapy.

When reactivity is controlled sufficiently, therapy can begin to address problematic couple’s dynamics.  Therapy may next work on controlling and managing dependent emotional reactivity and impulsive behavior.  The therapist can interview Minnie and Johann to identify what and when Minnie’s insecurity gets triggered.  The emphasis is not on whether her reactions are necessary, good or bad, but on how and what happens, while avoiding judgments.  As the trigger, assumption, prior trigger, anxiety/fear reaction, and behavior sequence is identified, Minnie and Johann are guided how to recognize these parts and how to interrupt them.  “The therapist must… begin encouraging each partner to own his or her respective behaviors.  From the outset, the pursuer must take individual responsibility for pursuing and the distancer for distancing” (Betchen & Ross, 2000, page 20).  The goal is to interrupt disruptive behaviors.  They can be Minnie’s compulsive dependency behaviors or they can be Johann’s reaction to them.  Since most problematic behaviors have multiple cycles or layers of action and reaction, either or both partners can and are responsible to break the cycle.  Whoever can do it must do it.  The cycle may be:

1. Johann showing frustration about a work situation,

2. Minnie becoming anxious that Johann is upset,

3. Minnie fearing that Johann will be mad at her,

4. Minnie doing or saying something to minimize or distract Johann from the upset,

5. Johann feeling his upset being dismissed,

6. Johann getting angry at being dismissed,

7. Minnie feeling Johann’s anger and getting more anxious,

8. Minnie trying to assuage her anxiety by trying to submit to Johann with apologies,

9. Johann feeling shame for Minnie getting anxious about him.

10. Johann getting angrier that now he has Minnie’s anxiety added to his original upset,

11. Minnie feeling incompetent and guilty that Johann has gotten more angry/upset,

12. Minnie repeating response #2 at a more intense level,

13. and so on and so forth.

BREAKING THE CYCLE
Therapy can identify this cycle or similar cycles as representative of Minnie as the dependent personality and Johann as the partner.  It is their unsuccessful dynamics that repeat over and over.  The therapist can point out where one or the other partner can interrupt the cycle of compulsive behavior.  Both partners can be encouraged to problem-solve alternative language and behaviors that may work better.  Some interventions can directly incorporate awareness of and insight about dependency instincts.  Any shift from the negative pattern potentially may improve the cycle.  Even if a shift or change in the communication or behavior in the short term proves ineffective or even may cause additional issues, the couple begins to practice behavior other than those in the same cycle that have been proven to be perpetually dysfunctional.  As Minnie and Johann develop the ability to act differently, they may develop eventually the ability to act differently and more effectively.

For example after behavior #1 from the cycle listed above (Johann showing frustration about a work situation),

Johann can say to Minnie, “This isn’t about you.  You don’t have to do anything but listen.”  

Or, Minnie can ask, “What do you want me to do?  I’m feeling like I’m supposed to do something.”  

Or, Minnie can be aware of her anxiety and ask herself, “I’m getting anxious.  What’s that about? It doesn’t have to be about me.”  

Or, Minnie can say soothingly to herself, “Johann is upset about work.  This is NOT me messing up and getting into trouble like when I was a kid!  I’m OK.”

After #4 (Minnie doing or saying something to minimize or distract Johann from the upset),

Johann can say, “You don’t have to do anything.  Don’t do that.  You don’t have to because it’s not about you.  Don’t distract me.  Just listen to me and care.”

Or, Minnie can say, “Oh, I just said that because I was trying to please you... take care of my being anxious about you being upset.  Opps, I’ll stop.  What did you say?”

After #6 (Johann getting angry at being dismissed),

Johann can say to himself, “Now I’m mad at Minnie instead!  What’s that about?  Oh yeah, I stirred up her anxiety about keeping me happy.  Take a deep breathe... and now reassure Minnie it’s not about her and tell her to listen to me instead w/o ‘helping’ me.”

After #6 (Johann getting angry at being dismissed) or #7 (Minnie feeling Johann’s anger and getting more anxious),

Minnie can say to herself, “Johann just got angrier... I got more scared!  What did I do wrong?  Oh yeah, I just did my worry worry thing and tried to make sure Johann was OK.  He’s OK, but just upset.”

Minnie can say to herself, “Johann just got angrier... I got more scared!  What did I do wrong?  Oh yeah, I just did my worry worry thing and tried to make sure I was OK for Johann.  I’m OK even though he’s upset.”

After #8 (Minnie trying to assuage her anxiety by trying to submit to Johann with apologies),

Minnie can say to herself, “I just apologized.  Damn... there I go again apologizing for being alive!  I’m OK... breathe!”

Johann can say, “You don’t need to apologize.  I wasn’t angry at you at first.  Now I’m getting frustrated that you feel you have to do something.  You don’t.  Relax.  I’m OK, you’re OK... and my job sucks!”

After #9, #10, #11, #12, #13, or whenever appropriate,

Johann can say, “It’s your parents fault!”

Minnie can say, “It’s my parents fault!”

After #9, #10, #11, #12, #13, or whenever appropriate,

Either can say, “This isn’t working.  What did we just do?  We’re doing the same thing again. Let’s start over.  We’re missing each other... again!”

Interrupting the cycle or blocking compulsive reactions may be very difficult for Minnie because of her embedded dependency instincts.  Depending on his instincts, it may be difficult also for Johann.  In individual therapy, the therapist works with the dependent individual to interrupt his or her internal dialog of shame and recriminations along with submissive or shameful gestures and communications towards the therapist.  In couple therapy, the therapist engages in the same process with the dependent individual, while also facilitating changing the dependent individual’s comparable process with the partner.  This involves not only revealing the dependent individual’s internal dialog but also the external dialog with the partner. In session, the therapist can interrupt Minnie and Johann’s communication process when it veers off course for example, when Minnie apologies unnecessarily.  “Minnie, there was nothing to apologize for unless you feel you must apologize for existing.  That’s not healthy.  Say it again with apologizing.”  The therapist can interject when she looks towards Johann for approval by asking, “What are you looking to Johann for?  You need his approval for your opinion?”  This prompts revelation of Minnie’s internal dialog of anxiety about rejection.  “Cognitive therapists question the patient’s thinking, exposing and correcting unrealistic judgments based on false implicit beliefs.  They emphasize that the opposite of submission is not control over others but independence and confidence.  They examine and question self-denigrating internal monologues and thoughts of helplessness” (Harvard Mental Health Letter, 2007, page 3).  Therapy can delve deeper into Minnie’s internalized logic (that is, illogic) that drives her self-concept and her result behavior.   If Minnie can consider that she does not have to submit and still have relative control, she may consider greater autonomy in her processing.

Or, when Johann responds verbally to the content of Minnie’s words while also commenting non-verbally, the therapist can ask Johann, “What was that face about?”  This prompts Johann to reveal his internal thoughts or feelings, while verbalizing an internal question Minnie has not expressed.  The therapist can ask for more from the partners as they gain more awareness of their habits and process.  “Johann, what did Minnie’s face and body language just said?”  “Minnie, what were you worried that Johann might think?”  The therapist can prompt them to assess their own process.  “Tell me about what just happened… not the words but the feelings- yours and his (her) feelings.”  As they become more aware of their process, the therapist can encourage them to problem-solve.  “What would have worked better?  What could you have done or said differently?” After eliciting and discussing their suggestions for self and the partner, the therapist then directs them, “OK, try saying that and see how it works.”  Communication assessment, practice, and evaluation in therapy offer a model to duplicate at home without the therapist.  The hope is that the partners can transfer experiences and learning from the session and interrupt their negative communication cycles at home.

In individual therapy, the therapist may initially work primarily within the session on the dependency reactivity.  However, therapy is not the real world and the therapist is not a “real” person or relationship.  The advantage and challenge of couple therapy is the partner is very real and the couple’s relationship very real.  Working on dependency tendencies and then relationship interactions can at least, conceptually be approached as a sequential process in individual therapy.   However, practically speaking it happens all at once in couple therapy.  Skills are not developed first, and then treatment moves on to deal with maladaptive interpersonal behaviors associated with dysphoria and self-harm as Livesley (2008, page 213) describes in working with an individual.  Skills are developed as depression, anxiety, and interpersonal communication are demanding improved skills in the couple therapy.  Livesley also sees progression in therapy eventually moving onto the phase of integration and synthesis.  For the individual, he or she needs to “‘get a life’ and to develop a more coherent and adaptive sense of self.”  For the couple, this would also require developing a sense of the couple including the future they will have together.  

NAME THE DYNAMICS
Partners and other intimate people can get tired of the dependent individual’s neediness and will often become rejecting.  They then become uncomfortable and have a hard time justifying being rejecting of the “sweet” and “nice” partner.  The therapist should ask partner such as Johann how it is to be trapped and/or manipulated by the constant demand for reassurance and permission.  This line of question exposes the dependent strategies.  The dependent personality often is super-nice… super-sweet.  Being super-nice/sweet is his/her “thing” or methodology to gain some control of life.  By being sweet, others will like them and will tend to do things for them and/or will cut them a lot of slack.  Ask the partner how it feels to be trapped and manipulated specifically by the dependent’s niceness.  The dependent personality sometimes may show more passive aggressive behavior than any overtly aggressive behavior.  Minnie, in fact is often able to successfully drive Johann crazy with passive aggressive behavior.  Her mistakes sometimes seem purposely intended to bother him despite her protestations.  Sometimes, Johann could not tell if her behavior was accidental or some underhanded way for Minnie to annoy him while having plausible deniability.  She professed to do anything for him and that he was not in any way negatively affecting her. After all she claimed, Johann was a good person and would never be hurtful.

“Although studies show that DPD persons have considerable insight into the ways that underlying dependency needs motivate and direct their behavior (Bornstein, 1992, 1993), two defenses—rationalization and denial—nonetheless play a prominent role in this disorder.  First, DPD persons tend to deny interpersonal difficulties and conflicts, to maintain the façade that important relationship are never at risk (Birtchnell, 1988; Bornstein, 1995b).  Second, DPD persons often rationalize neglecting or abusive behavior exhibited by nurturers and caregivers because acknowledging neglect or abuse requires disengaging from the abuser and functioning autonomously (Murphy, Meyer, & O’Leary, 1994; Sperling & Berman, 1991).  Both of these defensive strategies serve to mask interpersonal conflict but still allow underlying dependency needs to reach conscious awareness” (Bornstein, 1998, page 10).  Johann admitted that he lost his temper with Minnie.  Sometimes when Minnie was the most submissive and adoring of him, he could be mean.  He knew he was an asshole at such times and Minnie’s denial of his negativity both shamed him and made him more frustrated.  Johann’s anger was the epitome of failure for Minnie.  Despite making him the sun, the moon, and the stars, the universe exploded in a cataclysmic explosion…again, as she had always feared.

The therapist can name and reveal this dynamic, in addition to other dependent processes in the couple in therapy.  Revealing Minnie’s dependent personality passive aggressive behavior puts the couple on a more equal footing.  Johann has criticized and attacked Minnie, but with the therapist’s reframing of Minnie’s behavior both partners are exposed as purposely attacking and hurting the other, although with different styles.  Minnie is no longer the victimized blameless innocent and Johann the big bad wolf so to speak.  The therapist must challenge Minnie while managing her dependent instincts so she does not deeply descend into characteristic self-recriminations and guilt.  On the other hand, the therapist must still hold Johann accountable to modulate his hurtful treatment of Minnie.  When the therapist can establish this greater equality of negative behavior, it defuses moral superiority.  This allows for more mutually empowered negotiations between the two partners.  Johann circumvented healthy negotiation with his anger and frustration at Minnie’s victim stance and his subsequent attempts to counter-balance a bad guy identity.  The therapist can essentially agree with him but take it to a deeper level beyond their immediate dynamics.  “You’re right… she’s got it made!  Her ‘niceness’ really screws you up.  Where do you think she learned this?” Johann, like many partners is aware of the family-of-origin dynamics at the origin of personality of the spouse.

To Minnie, the therapist asks, “This works pretty well.  Being nice is a great way to ‘get’ him!  Where did you learn this?”  Minnie may reveal that being nice and sweet was the only for females to get any semblance of power and control in her family.  Overt attempts were considered too aggressive or not feminine, and were punished severely.  Continuing to work with her individually while Johann watched, the therapist asks, “What were the consequences of doing life this way?  What was the downside?”  Usually, the individual with dependent personality disorder is quite aware of negative consequences having lived them all his or her life.  At this point, the personality will still re-assert itself when she says, “Oh, I’m so messed up!  What should I do?  Tell me what to do?”  Pointing someone like Minnie to other people and personalities can be a way to promote change while not falling into the same pattern of dependency.  “What would so and so do?  What would the angry part of you do?  What would the strong part of you do?  The powerful part?”  Enlist the partner in her process, “You would like her to fight back, huh?  It’d be better than all this sweetie sweetie stuff, wouldn’t it?”  Often, a frustrated partner such as Johann would confirm this, “At least she’d be real, instead of being all fake about it.”  The therapist seeks their agreement to train the couple and especially, the dependent personality how to “fight” in the session.  

PRACTICE NON-DEPENDENCY
The dependent person has very little experience in being assertive or confrontational.  Any rudimentary attempts at self-care were probably squashed in childhood.  Like teaching a brand new skill, the therapist may need to promote rudimentary practice to develop emotional and verbal muscle memories for Minnie.  Well versed and virtually with robotic response, the dependent person is highly used to dependent feeling, thinking, communication, and behavior.  Non-submissive self-affirming language and actions will be foreign and awkward.  The therapist can have Minnie repeat assertive words he/she models.  The therapist can prompt her to make “I” statements.  In all likelihood, Minnie would instinctively pervert “I” statements from “I want…” “I need…” or “I like or don’t like…” into submission or apologies such as, “I’m sorry…”  “I should have…”  “I can’t…”  The therapist may need to provide purposely provocative and emotionally charged phrases for her to repeat that have her experience ownership of her feelings.  For example, “Minnie, tell Johann, you’re pissed that he took your seat.  Repeat that exactly, looking directly at him.”  “Tell him, you hate that…”  “Tell him, you can’t stand being corrected.  Look him in the eyes and use a firm voice.  Don’t look down at the floor.”  The dependent personality is likely to continually try to revert back (like most individuals with a personality disorder) to habitual communication and behaviors.  Maintaining the behavior that validates his or her core identify is compulsively instinctive however dysfunctional it may be.  The dependent personality may try to deny the therapist’s invitation to join in the trying on a different relationship.

In this situation, the therapist can get the partner such as Johann to also invite the new behavior and attempt to change the relationship.  The therapist can prompt Johann to make a paradoxical intervention by having him say, “Minnie, if you want to please me, you need to repeat what the therapist is saying.  You need to say those negative things about me… about what you want.  I’m going to be mad at you if you don’t come up with some bad stuff I do… if you don’t tell me what you don’t like.”  If Minnie is not willing- probably declaring that she cannot say anything or otherwise avoids cooperating, the therapist can interpret and identify her behavior/non-behavior as effectively passive-aggressive.   “So Minnie, you’re ‘saying’ screw you Johann, I’m not going to cooperate.  It works pretty well.  So that aggravates you Johann, right?”  As Johann agrees, Minnie is likely to protest, “But I’m not saying screw you and don’t want to upset you.”  The therapist can feedback and get quick confirmation from Johann, “But you are doing it to him.  If you want to not upset him, then tell repeat what I’ve say… ‘I get upset when you are upset Johann.’”  This is an easier prompt that she is more likely to repeat.  The therapist then continues, “Ok Minnie, now say ‘I get real upset when you’re upset Johann.”  Once she repeats that, the therapist can intensify the statement to be modeled to “I hate upsetting Johann.”  Next, “I get really annoyed when Johann is upset,” and then, shift to “I get annoyed at Johann when he is upset.”  If Minnie is able to repeat this statement of overt non-submissive feelings towards Johann, it becomes her initial practice of non-dependent communication and behavior.

Minnie might be unable to repeat any assertive statement of feelings or thoughts despite requests, permission, encouragement, and pressure by the therapist and Johann.  The therapist then feeds back to the partners that her dependent issues are deeply embedded in her character.  The therapist should assert that for the relationship to progress, that Minnie will have to be more assertive and non-dependent sooner or later.  And that she runs the risk that if she cannot or if she does it too late, their relationship will be broken.  The therapist should make a clinical judgment to continue or discontinue pursuing Minnie experimenting with such language.  It may be more beneficial to inform her and Johann that they will return to it, but for the time being explore how Minnie had become so disabled about caring for herself.  This would be psychodynamic and family-of-origin investigation.  Or, therapy can explore Minnie’s emotional and psychological consequences from her dependency.  “…dependent individuals who do not communicate verbally in adaptive, relationship-facilitating ways are at increased risk for depression.  In particular, deficits in social control appear to be most strongly associated with depression in dependent individuals” (Huprich, et al., 2004, page 13).  While possibly denying it, Minnie is likely to denigrate herself for being depressed or anxious.  Being depressed or anxious fits into a dependent strategy as expected from being deficient.  Therapy would need to emphasize depression and anxiety as intrinsic to dependent personality and all of these issues consequential to childhood experiences, rather than depression, anxiety, and dependency as indicative of Minnie’s identity as being inherently flawed.

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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