Professional Psychology: Research and Practice 2005, Vol. 36, No.

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Copyright 2005 by the American Psychological Association 0735-7028/05/$12.00 DOI: 10.1037/0735-7028.36.1.82

The Dependent Patient: Diagnosis, Assessment, and Treatment

Robert F. Bornstein
Gettysburg College
Although dependent psychotherapy patients are compliant and eager to please, they also use more psychological and medical resources than nondependent patients, have more pseudoemergencies, and have difficulty terminating treatment. This article reviews research on diagnosis, assessment, and treatment of dependent patients and offers recommendations for implementing effective diagnostic, assessment, and treatment strategies in inpatient and outpatient settings. Integration is key: Clinicians must combine different types of data (e.g., diagnostic, assessment) and blend different therapeutic modalities (e.g., cognitive, psychodynamic) to work effectively with dependent patients.

Virtually every mental health professional has encountered patients who are highly dependentpatients who alienate those around them with clinging insecurity and seem unable to make even the smallest decision without an inordinate amount of advice and reassurance. Such patients have always presented unique clinical challenges, but in todays health care environment, with its emphasis on time-limited, cost-effective treatment, the dependent patient can be especially difficult. Dependent psychotherapy patients have a greater number of pseudoemergencies (e.g., requests for after-hours contact) than nondependent patients (Emery & Lesher, 1982), use significantly more psychological and medical resources than less dependent patients (ONeill & Bornstein, 2001), and have difficulty leaving therapy, even when termination is appropriate (Bornstein, 1993). In this article, I summarize the literature on effective diagnosis, assessment, and treatment of the dependent psychotherapy patient. I begin by defining dependency and reviewing studies examining the etiology of dependent personality traits. I then discuss research on diagnosis, assessment, and treatment, concluding each section with recommendations for clinical practice.

Research on dependency has been facilitated by the emergence of a consensus regarding the core features of a dependent personality orientation (Birtchnell, 1988; Pincus & Gurtman, 1995). Contemporary definitions of dependency emphasize four components: (a) motivational (i.e., a marked need for support and approval from others), (b) cognitive (i.e., a perception of oneself as powerless and ineffectual), (c) affective (i.e., a tendency to become anxious when required to function autonomously), and (d) behavioral (i.e., use of self-presentation strategies to strengthen ties to potential caregivers). A key corollary of this four-component model is that dependent patients exhibit a much broader range of behaviors than earlier theoretical frameworks recognized. In many situations, dependent patients are indeed passive and compliant, currying favor by presenting themselves as meek and weak. In other situations (e.g., when threatened with relationship disruption), dependent patients can become quite assertive even aggressive using whatever strategies seem necessary to ensure they are not abandoned (see Bornstein, 1995a; Pincus & Wilson, 2001).

The Etiology of Dependency Defining Dependency

During the past several decades, researchers have conducted more than 600 studies examining the antecedents and consequences of dependent personality traits in children and adults. Dependency is associated with cooperativeness, compliance, and interpersonal yielding, and studies show that dependent patients miss few therapy sessions, adhere more conscientiously than nondependent patients to medical and psychotherapeutic regimens, and behave in ways they believe will please and impress the therapist (see Bornstein, 1992, 1993, 2005, for reviews). Culture plays a key role in the etiology of dependency (Johnson, 1993; Neki, 1976). People raised in cultures that emphasize interpersonal relatedness over individual achievement (e.g., Japan, India) report higher levels of dependency than those raised in cultures (e.g., America, Great Britain) that emphasize individual achievement over group harmony (Behrens, 2004; Gjerde, 2001). Beyond culture, several factors contribute to the development of a dependent personality orientation.

Parenting Style
Overprotective parenting leads to high levels of dependency because overprotective parents teach children they are vulnerable and weak. Authoritarian parenting sends a similar message and also fosters dependency. When parental overprotectiveness and authoritarianism are both present, problematic dependency is particularly likely to result (Head, Baker, & Williamson, 1991).

ROBERT F. BORNSTEIN received his PhD in clinical psychology from the State University of New York at Buffalo in 1986. He is a professor of psychology at Gettysburg College. His research interests include personality assessment, personality disorders, and the empirical testing of psychodynamic concepts. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Robert F. Bornstein, Department of Psychology, Box 407, Gettysburg College, Gettysburg, PA 17325. E-mail: bbornste@gettysburg.edu 82

Illness
An early episode of serious illness increases the likelihood that a child will develop dependent traits later in life, in part because it

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contributes to the development of a helpless self-concept and in part because serious illness tends to elicit overprotective parenting (Hoare, 1984; Parker & Lipscombe, 1980).

assessment) is 11% in women and 8% in men (Bornstein, 2005). Although this difference may appear modest, it suggests than a woman is 40% more likely than a man to receive a DPD diagnosis.

Abuse
Childhood physical or sexual abuse leads to high levels of dependency during adolescence and adulthood, primarily because of the feelings of powerlessness that accompany abuse (especially repetitive abuse; see Hill, Gold, & Bornstein, 2000).

Differential Diagnosis and Comorbidity

Table 1 summarizes the differential diagnosis and comobidity information for DPD in the DSMIV (APA, 1994). This comorbidity informationwhile generally consistent with empirical findingsis overly conservative. In addition to the diagnoses listed in Table 1, two other Axis I disorders show high rates of comorbidity with DPD. DPD often co-occurs with substance use disorders, and research shows that dependency levels increase as substance abuse progresses. Thus, DPD diagnoses typically followrather than precedesubstance use disorder diagnoses (OBoyle, 1993). Both anorexic and bulimic women have higherthan-expected rates of DPD, although studies indicate that DPD symptom levels decrease as eating disorder symptoms remit (Bornstein, 2001). DPDAxis I comorbidity data are comparatively straightforward. Axis II comorbidity findings are more problematic because studies indicate that DPD co-occurs with the majority of Axis II personality disorders, including some that bear little resemblance to DPD. For example, in a sample of psychiatric inpatients, Wise (1996) found significant, positive correlations between DPD symptom ratings and symptom ratings of every DSMIV (APA, 1994) personality disorder except histrionic and narcissistic personality disorders. Sinha and Watson (2001) obtained virtually identical results in college students.

Diagnosis
Three issues are germane to diagnosis of the dependent patient: dependent personality disorder (DPD) symptom criteria, DPD epidemiology, and differential diagnosis and comorbidity.

DPD Symptom Criteria

The essential feature of DPD in the DSMIVTR (American Psychiatric Association [APA], 2000) is a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts (p. 725). The DSMIVTR lists eight DPD symptoms, five of which must be present to receive the diagnosis: (a) difficulty making decisions without excessive advice and reassurance, (b) needing others to assume responsibility for most major areas of life, (c) difficulty expressing disagreement, (d) difficulty initiating projects or doing things on ones own, (e) going to excessive lengths to obtain nurturance and support, (f) feeling helpless when alone, (g) urgently seeking another source of protection when an important relationship ends, and (h) being preoccupied with fears of being left to care for oneself. Although these symptoms are a useful index of helpless, submissive dependency, the DSMIVTR (APA, 2000) DPD criteria are limited in two respects. First, they focus almost exclusively on the link between dependency and passivity, and they fail to capture the range of self-presentation styles exhibited by dependent patients (see Pincus & Wilson, 2001). Second, these criteria have questionable external validity: Bornsteins (1997) review of evidence for the DPD symptoms revealed that four of these symptoms (a, e, f, and h) have been supported by the results of empirical studies, two symptoms (b and g) have never been tested empirically, and two (c and d) have been contradicted repeatedly.

Diagnostic Recommendations Do Not Equate Dependency With Passivity

Without question, the DPD criteria in the DSMIVTR (APA, 2000) are essential for accurate diagnosis of problematic dependency. However, because these criteria do not capture the entire range of behaviors exhibited by dependent patients, the practitioner should use caution in making diagnoses and clinical decisions.

Table 1 Dependent Personality Disorder in the DSMIV: Differential Diagnosis and Comorbidity
Differential diagnosis DSMIV Axis I Mood disorders Panic disorder Agoraphobia DSMIV Axis II Borderline PD Histrionic PD Avoidant PD Borderline PD Histrionic PD Avoidant PD Mood disorders Anxiety disorders Adjustment disorder Comorbid diagnosis

Epidemiology
DPD is common in inpatient settings, with researchers reporting prevalence rates between 15% and 25% in psychiatric units, rehabilitation centers, and long-term care facilities (Jackson et al., 1991). The base rate of DPD in outpatients ranges from 0% to 10% (Poldrugo & Forti, 1988), which is comparable to the frequency of DPD in large-scale community surveys (Bornstein, 1996a,, 1997). Cross-cultural data are scanty, but preliminary findings suggest that the base rate of DPD may be somewhat higher in Japan than in North America and Western Europe (Behrens, 2004; Johnson, 1993). Women consistently receive DPD diagnoses at higher rates than men do, and meta-analysis of findings in this area has indicated that the base rate of DPD (collapsing across setting and mode of

Note. Dependent personality disorder differential diagnosis and comorbidity information is identical in the DSMIV (American Psychiatric Association, 1994) and DSMIVTR (American Psychiatric Association, 2000). PD personality disorder.

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Simply because a patient is passive, this does not mean a DPD diagnosis is warranted. Simply because a patient receives a DPD diagnosis, this does not mean the patient will be passive in all (or even most) situations.

Distinguish Primary From Secondary Dependency

It is important to obtain valid information regarding the onset of Axis I and Axis II disorders to determine whether DPD preceded or followed each comorbid diagnosis. DPD may follow certain disorders (e.g., substance abuse) but precede others (e.g., bulimia), and this has important treatment implications. When DPD precedes the onset of a particular Axis I diagnosis, problematic dependency should be a central focus of treatment; in many cases, Axis I symptoms are a product of underlying dependency needs and the strategies used to cope with these urges (Birtchnell, 1988; Nietzel & Harris, 1990). When DPD is secondary to an Axis I disorder, however, the disorder itself should be the focus of treatment; studies show that in these situations, dependency levels often abate as Axis I symptoms remit (Bornstein, 2001).

1994), or the Personality Diagnostic Questionnaire (Davison, Morven, & Taylor, 2001). Hirschfeld et al.s (1977) Interpersonal Dependency Inventory (IDI) has been one of the most widely used self-report dependency tests during the past 25 years and has been validated extensively in inpatient and outpatient settings. The IDI includes 48 selfstatements, each of which is rated on a 4-point scale anchored with the terms disagree (1) and agree (4). The 48 IDI items form three subscales: (a) Emotional Reliance on Others (18 items), (b) Lack of Social Self-Confidence (16 items), and (c) Assertion of Autonomy (14 items). IDI whole-scale scores are calculated by summing the patients scores on the Emotional Reliance on Others scale and the Lack of Social Self-Confidence scale, and then subtracting from this total their score on the Assertion of Autonomy scale. Reviews of evidence supporting the construct validity of the IDI are provided by Bornstein (1994, 1999).1

Assessing Implicit Dependency Needs

Although numerous self-report dependency tests are available, a single projective measureMasling, Rabie, and Blondheims (1967) Rorschach Oral Dependency (ROD) scale has dominated the dependency literature during the past 35 years (Bornstein, 1996b, 1999). In ROD scoring, the patient receives one point for each percept that falls into any of the following categories: (a) foods and drinks, (b) food sources, (c) food objects, (d) food providers, (e) passive food receivers, (f) begging and praying, (g) food organs, (h) oral instruments, (i) nurturers, (j) gifts and gift givers, (k) good luck objects, (l) oral activity, (m) passivity and helplessness, (n) pregnancy and reproductive organs, (o) baby talk responses, and (p) negations of oral percepts. Detailed instructions for ROD scoring and interpretation are provided by Masling (1986); evidence bearing on the construct validity of the ROD scale is summarized by Bornstein (1996b).2

Use Axis IV to Enhance Clinical Prediction

Because dependent persons are sensitive to relationship conflict and disruption (Bornstein, 1995b), Axis IV information can help the clinician anticipate variations in patient functioning. Interpersonal stressors are likely to trigger setbacks in DPD patients, particularly when these stressors involve authority figures and potential caregivers (Mongrain, Vettese, Shuster, & Kendal, 1998).

Assessment
Diagnosis provides a shorthand summary of a patients symptoms, but a complete understanding of dependency-related dynamics requires that diagnosis be supplemented by psychological test data. Numerous self-report and projective measures of dependency are available for use in clinical settings, and as McClelland, Koestner, and Weinberger (1989) noted, self-report and projective tests tap different domains of personality. Most self-report tests assess self-attributed dependency needs, that is, dependency urges that patients acknowledge when asked. In contrast, projective tests assess implicit dependency needsdependency strivings that influence behavior automatically, often without any awareness on the patients part that his or her behavior is affected by these motives. In the following sections, I describe self-report and projective dependency tests and discuss strategies for integrating the results obtained with these tests.

Integrating Data From Different Dependency Tests

Some patients score high or low on both self-report and projective measures of dependency, which indicates convergence between a patients self-attributed and implicit dependency scores (Bornstein, 2002). Alternatively, testing may uncover discontinuities between a patients implicit and self-attributed dependency needs. In one case (i.e., high projective dependency score coupled with low objective dependency score), a patient has high levels of
1 Because the IDI was developed by the National Institute of Mental Health, it is in the public domain. Copies of the IDI and detailed scoring guidelines may be obtained from the author. 2 Although the Rorschach Inkblot Method has been the topic of considerable controversy in recent years, much of this debate has centered on the utility of Exners (1993) Comprehensive System. Even vocal critics of the Rorschach Inkblot Method acknowledge the psychometric soundness of the ROD scale and the strong validity evidence in support of the measure (e.g., Hunsley & Bailey, 1999; Lilienfeld, Wood, & Garb, 2000). As Hunsley and Bailey (1999, p. 271) noted,

Assessing Self-Attributed Dependency Needs

More than 35 self-report measures of dependency and DPD are available today (see Bornstein, 1999, for a review). Many of these measures are stand-alone tests that assess dependency along with one or two other traits (e.g., Pincus & Gurtmans, 1995, 3-Vector Dependency Inventory; Blatt, DAfflitti, & Quinlans, 1976, Depressive Experiences Questionnaire). Other self-report dependency scales are embedded in omnibus personality inventories, such as the Minnesota Multiphasic Personality Inventory (Navran, 1954), the Millon Clinical Multiaxial Inventory (Millon, Millon, & Davis,

One excellent example of a scale that does have scientific support . . . is the Rorschach Oral Dependency scale. The history of research efforts on this scale may serve as a useful guide for future attempts to validate [other] Rorschach scales. (p. 271)

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implicit dependency needs but does not acknowledge them. These patients may be described as having unacknowledged dependency strivings. In the other case (i.e., low projective dependency score coupled with high objective dependency score), the patient has low levels of implicit dependency needs but describes himself as being highly dependent. These patients may be described as having a dependent self-presentation.

Assessment Recommendations Use Assessment Data to Track Progress

As Cates (1999) noted, psychological assessment is best conceptualized as a snapshot of a changing scene, and many patients experience strong feelings of dependency at the start of treatment. Thus, self-report and projective dependency scores are likely to be somewhat elevated at this time, even in patients who are not highly dependent. Periodic reassessment can be used to track changes in underlying and expressed dependency needs. Other useful measures for assessing therapeutic process and outcome in dependent patients include Global Assessment of Functioning ratings (Endicott, Spitzer, Fleiss, & Cohen, 1976), life satisfaction ratings (Diener, Emmons, Larsen, & Griffin, 1985), measures of cognitive distortion and schema accessibility (Ball & Young, 2000), indices of coping and social adjustment (Overholser, 1987), and scores on measures of healthy/adaptive dependency (Bornstein & Languirand, 2003).

dency-related responding (see Bornstein, 2005, for a review). These investigations have used a broad array of outcome measures (e.g., changes in IDI scores, changes in DPD symptoms, Global Assessment of Functioning ratings, behavioral observations, analysis of therapy session transcripts). They have also examined the efficacy of insight-oriented (Alexander & Abeles, 1968), cognitive (Black, Monahan, Wesner, Gabel, & Bowers, 1996; Rathus, Sanderson, Miller, & Wetzler, 1995), and eclectic therapy (Maling, Gurtman, & Howard, 1995). Although some positive findings were obtained (e.g., Alexander & Abeles, 1968; Rathus et al., 1995), no therapeutic modality yielded consistently positive results and emerged as the treatment of choice for dependent patients. Thus, extant data do not provide clear support for a single therapeutic modality in treatment of problematic dependency. In the following sections, I review the core elements of four widely used treatment modelspsychodynamic, behavioral, cognitive, and humanistic/experientialand discuss strategies for integrating these models.

Psychodynamic Treatment
Although Freud (1905/1953) argued that dependency in adults reflects oral fixation (i.e., continued preoccupation with the events of the infantile, oral stage), research does not support this hypothesis (Bornstein, 1996a). Contemporary psychodynamic theorists conceptualize dependent personality traits in adulthood as reflecting unconscious conflicts, which can take two forms: (a) clashes between incompatible wishes and urges (e.g., a wish to be cared for versus an urge to compete), and (b) compromise formations the disguised, distorted end products of unconscious impulses and defenses against those impulses (e.g., when somatic symptoms reflect underlying dependency needs expressed in physical terms). Detailed discussions of psychodynamic strategies for altering problematic dependency are provided by Coen (1992) and van Sweden (1995). Three elements are central to these treatment models. Analysis of core relational themes. Interpretation of patterns in patients stream-of-consciousness verbalizations is central to psychoanalytic treatment. As Luborsky and Crits-Christoph (1990) noted, analysis of core relational themesinterpersonal interactions that share a common dynamic and emerge in different contexts and settingsis particularly useful in helping dependent patients gain insight into maladaptive relationship patterns and distorted perceptions of self and others. Corrective object relations. To supplement interpretation and analysis of core relationship themes, the clinician must create a supportive therapeutic milieu that does not recapitulate the destructive dynamics of other relationships in the patients life (Coen, 1992). The mere experience of a healthy, autonomyfostering relationship with clear and consistent boundaries can have important curative qualities. Transference and countertransference. Dependent patients often idealize the therapist and perceive the clinician as a powerful pseudoparental caregiver. Making this transference reaction explicit during treatment is key to effective psychodynamic therapy with dependent patients. The clinician must also be sensitive to countertransference responses (e.g., frustration, infantilization) that undermine treatment (see Bornstein, 2005, for a discussion of this issue).

Deconstruct Self-Report/Projective Test Score Discontinuities

By administering self-report and projective measures of dependency to the same patient, clinicians can obtain a more complete picture of that persons underlying and expressed dependency strivings. Exploration of these discontinuities may reveal important information regarding the patients personality structure and interpersonal style. For example, patients who are classified as high dependent are diagnosed with DPD at higher-than-expected rates; patients with unacknowledged dependency tend to be diagnosed with histrionic personality disorder (Bornstein, 1998). Patients with a dependent self-presentation show high rates of help seeking in clinical settings; patients with unacknowledged dependency do not (Bornstein, 2002).

Assess the System, Not Just the Person

Dependent people cultivate relationships with individuals who meet their needs for care and support. These individuals (e.g., spouse, siblings, parents) may inadvertently reinforce dependent behavior and propagate pathology in the patient. Thus, it is often useful to supplement traditional testing with assessment of the patients family system and social milieu (see Bowen, 1978; Haley, 1976).

Treatment
During the past century there has been a tremendous amount written about psychotherapy with dependent patients but surprisingly little research. Only eight controlled empirical studies have assessed the effectiveness of psychotherapy in altering depen-

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The basic premise of the behavioral view is that people exhibit dependent behaviors even self-defeating, maladaptive dependent behaviors because these behaviors are or were rewarded (McKeegan, Geczy, & Donat, 1993; Turkat & Maisto, 1985). Within this framework, dependency is conceptualized as a set of responses aimed at obtaining help and support, which are acquired through a combination of conditioning and learning processes. These include (a) direct reinforcement (sometimes continuous, but more commonly intermittent), (b) vicarious reinforcement (through observation of others dependency-based rewards), and (c) modeling (including symbolic modeling). Dependent behaviors are maintained through positive reinforcement (i.e., rewards for exhibiting dependent responses) and negative reinforcement (i.e., anxiety reduction that results from maintaining close ties to a caregiver). The treatment models of Kazdin (1989) and Turkat and Maisto (1985) are particularly useful in altering dysfunctional dependency-related behavior. Several strategies are emphasized in both treatment models. Replacing dependency with autonomy. Although extinction techniques by themselves are of limited value in effecting longterm behavior change, they can be useful in altering problematic dependency when coupled with a treatment program aimed at increasing the frequency of autonomous behavior. Not only is increased autonomy an important goal for dependent patients, but because autonomous behaviors are usually incompatible with dependent behaviors, increasing the frequency of autonomous responding will, by itself, inhibit dependent responding. Using desensitization to facilitate behavior change. To the degree that a patients dependent behavior is exacerbated by concerns regarding embarrassment, abandonment, or rejection, systematic desensitization techniques should be used to manage this anxiety. As Alden (1989) noted, the high levels of autonomic arousal experienced by dependent people in social situations can lead to social crumbling and an inability to implement behavior change strategies in vivo. Maintaining behavior change posttreatment. When autonomous behavior becomes self-reinforcing, the likelihood that this behavior will be maintained increases substantially. As Turkat and Carlson (1984) pointed out, choosing target behaviors that lead to positive outcomes in the patients natural environment can be useful in this regard, as is introducing in vivo training in settings that approximate those wherein the desired behaviors must be exhibited.

thoughts that are cued by perceived or anticipated failure), (b) negative self-statements (i.e., self-blaming statements that exacerbate the patients lack of self-confidence), and (c) attributional bias (i.e., a skewed interpretive style wherein the patient punishes himself or herself for perceived failures, but cannot accept credit for successes). Ball and Young (2000) and Overholser and Fine (1994) outlined cognitive treatment programs designed to alter the self-defeating thought patterns of dependent patients. These programs emphasize several common elements.3 Using active guidance to engage the patient. To foster a therapeutic alliance, Overholser and Fine (1994) recommended that the therapist take an active approach early in treatment, providing considerable feedback and structure. Patients are taught behavioral skills that enable them to make meaningful changes quickly, thereby increasing their sense of control. As the patient gains trust in the therapist and the process of therapy, the clinician gradually places more responsibility on the patient for structuring treatment. Promoting autonomy through problem-solving training. As patients begin to show evidence of increased self-efficacy, the focus of treatment shifts to increasing autonomous behavior outside therapy. To facilitate this shift, the therapist uses Socratic methodsactive, guided questioningto help the patient generate solutions and insights (Overholser, 1987). Self-control strategies (e.g., self-monitoring, self-reinforcement) provide the patient with skills needed to replace reflexive help seeking with mindful problem solving in high-stress situations. Focusing on relapse prevention during the latter stages of treatment. As therapy progresses, the patient is taught to identify high-risk situations and dependency triggers (i.e., external cues that prompt dependent thoughts and behaviors). Alternative ways of coping are discussed, and the patient is encouraged to reframe setbacks so minor backslides are not magnified into global failure experiences (Ball & Young, 2000). If a setback occurs within therapy, this is treated as a learning experience rather than a therapeutic impasse.

HumanisticExperiential Treatment
A key tenet of the humanistic experiential perspective is that various familial and societal factorsmost notably parents conditional positive regard for the child cause the developing person to construct a false self aimed at complying with the perceived expectations of others (Maslow, 1968; Rogers, 1961). To the degree that the parents positive regard was contingent on the childs complying passively with external demands, the child will come to view autonomy as unacceptable and create a false self centered on pleasing other people. Eventually dependency is no longer experienced as a choice, but as a given (Bonanno & Castonguay, 1994; Hassenfeld, 1999). Defenses aimed at obviating
3 As Ball and Young (2000) noted, many cognitive techniques for use with dependent patients (e.g., enhancement of self-efficacy, relapse prevention) were adapted from those used to treat social phobia and avoidance. However, use of Socratic techniques and a deliberate transition from active guidance on the part of the therapist to patient responsibility for structuring therapeutic sessions were developed specifically for work with dependent patients (Overholser, 1987; Overholser & Fine, 1994).

Cognitive Treatment
Cognitive theorists conceptualize dependency as the product of maladaptive schemas (i.e., self-defeating thoughts about the self and other people) that cause patients to doubt their abilities, denigrate their skills, and exaggerate the imagined consequences of less-than-perfect performance (Ball & Young, 2000). Maladaptive schemas not only decrease self-esteem and increase anxiety, they also lead to an array of cognitive distortions that strengthen the persons pre-existing views. Three schema-based cognitive distortions are particularly salient in the intra- and interpersonal dynamics of dependency: (a) automatic thoughts (i.e., reflexive

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alternative ways of experiencing the self become firmly entrenched, and the dependent persons experiences narrow to the point that other-centered behavior becomes the sole means of relating to others (Cashdan, 1988; Schneider & May, 1995). The experiential treatment strategies of Schneider and May (1995) and Yalom (1981) are particularly useful in therapeutic work with dependent patients. These frameworks emphasize several core techniques. Unconditional positive regard. Like Rogers (1961), Schneider and May (1995) see unconditional positive regard as key to helping dependent patients regain access to unacknowledged aspects of the self. By being empathic and nonjudgmental but not flawless or omniscientthe therapist can help the patient experience trust without perceiving the therapist as a pseudoparental guru (Yalom, 1981). A focus on metacommunication. Like psychoanalysts, experiential therapists deconstruct hidden material in the patients verbalizations, but unlike psychoanalysts, experiential therapists focus on metacommunications: pervasive life themes that reflect the patients core fears. Key dependency-related fears include functioning autonomously, taking risks on ones own, and being overwhelmed by unmanageable anxiety (Bornstein, 2005). These fears both reflect and reinforce the dependent persons narrowed sense of self and prevent him or her from envisioning alternative choices and actualizing unexplored potentials. Experimentation within and outside therapy. A core element of experiential therapy is the use of exercises designed to circumvent entrenched defenses, increase emotional awareness, and set the stage for new experiences that help patients reinvent themselves and the world. Schneider and May (1995) provided detailed instructions for a broad array of therapeutic exercises, including writing assignments, skill-building tasks, and role-play scenarios for use within and outside therapy.

modality based on patient needs and therapist expertise, and then (b) to supplement this overarching strategy with interventions derived from other treatment models. Detailed discussions of therapeutic integration strategies are provided by Beitman (1992) and Ramsay (2001).

Conclusion
Integration is key to effective clinical work with dependent patients. To set the stage for effective treatment, the practitioner must integrate diagnostic and assessment data with an understanding of the etiology and dynamics of dependency. To maximize treatment efficacy, the practitioner must integrate strategies from different therapeutic modalities, using an array of interventions to alter dependencys cognitive, motivational, behavioral, and emotional components. Mental health professionals understanding of dependency has evolved considerably since passive dependent personality disorder first appeared in the DSMI (APA, 1952) more than 50 years ago. Empirical findings confirm that dependent patients are not always passive and that underlying dependency needs are expressed in many different ways. By staying abreast of cutting-edge clinical studies, practitioners can enhance the effectiveness of therapeutic work with dependent patients and develop a framework within which they refine their understanding of the intraand interpersonal dynamics of dependency as new findings accumulate.

References
Alden, L. E. (1989). Short-term structured treatment for avoidant personality disorder. Journal of Consulting and Clinical Psychology, 57, 756 764. Alexander, J. F., & Abeles, N. (1968). Dependency changes in psychotherapy as related to interpersonal relationships. Journal of Consulting and Clinical Psychology, 32, 685 689. American Psychiatric Association. (1952). Diagnostic and statistical manual of mental disorders. Washington, DC: Author. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Ball, S. A., & Young, J. E. (2000). Dual focus schema therapy for personality disorders and substance dependence. Cognitive and Behavioral Practice, 7, 270 281. Behrens, K. Y. (2004). A multifaceted view of the concept of amae: Reconsidering the indigenous Japanese concept of relatedness. Human Development, 47, 127. Beitman, B. D. (1992). Integration through fundamental similarities and useful differences among the schools. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 202230). New York: Basic Books. Birtchnell, J. (1988). Defining dependence. British Journal of Medical Psychology, 61, 111123. Black, D. W., Monahan, P., Wesner, R., Gabel, J., & Bowers, W. (1996). The effect of fluvoxamine, cognitive therapy, and placebo on abnormal personality traits in 44 patients with panic disorder. Journal of Personality Disorders, 10, 185194. Blatt, S. J., DAfflitti, J. P., & Quinlan, D. M. (1976). Experiences of depression in normal young adults. Journal of Abnormal Psychology, 85, 383389. Bonanno, G. A., & Castonguay, L. G. (1994). On balancing approaches to

Treatment Recommendations Use Assessment to Guide Treatment

Different problems require different interventions, and flexibility on the part of the therapist is essential. In general, dependent patients with significant comorbid character pathology require more structured, active treatments than do dependent patients without significant Axis II comorbidity. As discussed earlier, different treatment strategies may be required for patients whose problematic dependency preceded the onset of other syndromes and those whose dependency was secondary to one or more Axis I disorders.

Link Autonomy With Healthy Dependency

In the process of fostering autonomy in dependent patients, many clinicians inadvertently go too far and move the patient toward inflexible independence. Healthy dependency (i.e., a blend of autonomy and connectedness coupled with situation-appropriate help and support seeking) should be the ultimate goal of clinical work with dependent patients (Bornstein & Languirand, 2003).

Integrate Mindfully
Messer (1992) introduced the concept of assimilative integration, which requires the clinician (a) to select a baseline treatment

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Received January 16, 2004 Revision received May 24, 2004 Accepted October 19, 2004