The therapist will find the individual with dependent personality disorder challenging, but not because of overt defiance or reticence. “…there are also obstacles to the treatment of people with dependent personality. They may be passive and make unrealistic demands; it may seem that they can never get enough support or reassurance. Suggestibility and respect for authority can also create problems. The therapist must avoid the temptation to become a guru and tell these patients how to run their lives. It’s also important to establish other boundaries to avoid involvement in the patient’s life that might impede emotional growth. Often sustaining the relationship indefinitely is necessary and appropriate, but reducing the frequency of meetings over time may help the patient to become more independent” (Harvard Mental Health Letter, 2007, page 4). Providing therapeutic support must not feed the neediness of dependency. The therapist should have the individual explain his or her justification or logic when accepting the therapist’s input, interpretation, or instruction. Seeking this explanation serves to counter deferential instincts to please. The therapist may consider making nonsensical or illogical suggestions to activate critical thinking and promote self-determination habits otherwise atrophied. When the dependent individual asks what to do, the therapist should flip the question back- “What do you think you should do?” When the individual professes not to know, the therapist can ask, “What will happen if you don’t choose?” Whatever the response (“I don’t know.” “Sometime bad…” “Something else…”), the therapist then should ask, “Is that OK with you?” If the answer is “yes,” then the therapist may state, “Well, you seem to have worked it out already. Is there anything else?” The last question could be ambiguous about something else to consider, about what was brought up, or what to move on to discuss. If the answer is “no,” then the therapist can ask, “So, what’s the problem?” and/or eventually “What are you thinking to do?”
The therapist may point out when appropriate that the individual always knew what or had something in mind to do but was seeking reassurance or permission to do it. In the dynamic between the couple, the therapist can interrupt Johann making any suggestion for example, and interject these questions. Johann can confirm the therapist’s interpretation that Minnie usually already knows what to do or what she wants to do. Despite already knowing, she puts him through verbal shenanigans to get reassurance or permission. The therapist can validate for the partner that it is usually unnecessary and always time consuming and annoying. The partners with the therapist assistance can negotiate ways to interrupt this dynamic. Minnie can begin by saying, “I have an idea how to handle something, and want to run it by you.” This would be a more honest communication rather than go through all the other stuff. Johann can be empowered to ask Minnie at the start or as soon as he becomes aware if she already has something in mind. “Wait a second… seems like you already have something in mind to do. What is it?” Either could address Minnie’s anxiety. Minnie can say, “I’m not sure you’d be ok with this” before running through the circumstances. Or, Johann can say, “You seem to be anxious about getting reassurance or permission. Is that what you want? Are afraid of getting into trouble or do you really need feedback to make a decision?”
The partners engage in their normal dysfunctional communication in the session with the therapist interrupting, focusing and directing them as needed, and also prompting alternative interactions. This is practice for the partners becoming more self-sufficient to improve their dynamics at home. “…as the therapy progresses, the therapist must encourage the patient to play an increasingly active role so as to promote independence and self–reliance. According to Bornstein (1998b) ‘The goal is not to eliminate or suppress an individual’s underlying dependency needs, but rather to help that individual achieve a balance between his or her dependency needs and his or her strivings for independence’ (p. 186). Overholser and Fine (1994) propose a four stage, cognitive–behavioral treatment model for use in the treatment of clients with dependency traits. The stages are: 1) active guidance; 2) enhancement of self–esteem; 3) promotion of autonomy; and 4) relapse prevention. Overholser and Fine suggest that, as therapy progresses, clients generally become more autonomous, allowing therapists to become less directive and to ask their clients to assume more responsibility for managing their lives and problems” (Berk and Rhodes, 2005, page 193). The therapist is professionally empowered to be the third person in the partners' relationship. His or her alternative perspectives alter the dynamics. The advantage of couple therapy is the partner’s ongoing interactions as a participant-observer with the individual with dependent personality disorder. This is also the disadvantage since the partner can be negatively triggered and dysfunctionally reactive in his or her own right. The partner such as Johann can try to establish and maintain a third-person perspective while simultaneously engaged as the second-person to the dependent individual. The therapist can periodically prompt one or both partners to take a step back and comment on what he or she observed in session. With practice, a third-person perspective can hopefully activate interventions therapeutically at home. The dependent individual can develop another third-person perspective that can autonomously interrupt negative dynamics between self and partner as well. This may be the strong Minnie observing and guiding the dependent Minnie. However, the individual with dependency issues has embedded characterological instincts that make that very challenging. Someone such as Minnie already had third-person perspective always giving negative self-critical judgments of her behavior. Minimizing this third-person negativity and promoting a more accepting third-person persona is a goal of therapy. The non-personality disordered partner has less embedded resistance to an accepting third-person persona, and is more likely to activate such a third-person role.
The individual must be guided to accept his or her dependency traits as problematic in some areas of life. Turning a partner into the sun, the moon, and the stars gives up too much individual power. It also puts the partner into a role he or she cannot fulfill. Dependency defines the relationship fundamentally, highly limiting intimacy quality and connection. While identifying and owning ones dependency appears to be an initial or early step in therapy, acceptance may be erratic, transitory and incomplete. Therapy may need to reestablish and reconfirm the individual’s acceptance of dependent instincts and their dysfunctional role for the individual and the relationship. Nevertheless, acceptance enables the therapy and the couple “to help the client manage and modify his dependent behavior. Work in this stage may include helping the client to develop his ability to distinguish between reasonable and unreasonable dependency needs and experimenting with ways of getting reasonable dependency needs met instead of trying to extinguish or deny them. Helping the client to extend his social support system beyond his primary relationship by developing additional supportive relationships can be especially helpful. Also, teaching the client specific decision-making skills, problem-solving skills and encouraging him to risk new behavior while cultivating the ability to withstand the accompanying anxiety during the process of “trial and error” can help him develop confidence in his independent behavior” (Berk and Rhodes, 2005, page 202). A critical goal of couple therapy, therefore is to enable the individual and the partner to accept the reality of dependency habits as a challenge to individual and relationship functioning. If this goal is accomplished, then both partners can join in an alliance against the “enemy” so to speak: the dependent instincts, feelings, and thinking within and the behaviors activated by the individual. Johann is not the “bad guy” anymore. And Minnie is no longer trying futilely to be the “good girl” and becoming the “bad girl.” They are less the targets of therapy and for change. Dependency becomes the target rather than the partner seeing the individual as the adversary… and rather than the individual being adversarial against oneself. This reframing of the problem facilitates redirection of the couple’s energy. They can then work on specific decision-making skills and problem-solving skills and alternative behaviors as their joint task.