What Is Psychotherapy? Proc. 9th Int. Congr. Psychother., Oslo 1973 Psychother. Psychosom. 25: 36-42 (1975)
Brief Psychotherapy of the Dependent Personality. Specific Techniques Cavin P. Leeman and Catherine H. Mulvey
The life style of many patients who apply for psychiatric treatment is characterized by dependency in interpersonal relationships, by apathy and lack of initiative, and by feelings of helplessness, resentment and rage. Although these patients are not psychotic, the predominance of dependent longings in their character structure makes their treatment difficult. Traditional psychotherapy may become a prolonged stalemate in which the patient acts helpless and de pendent in still another relationship, while doing nothing to modify his depen dent way of relating outside of therapy. Indeed these patients sometimes are regarded as hopeless prospects for treatment, especially if they already have undergone one or more unsuccessful courses of psychotherapy. Perhaps greater therapeutic success with this group of patients could be obtained if the psychotherapy were tailored to fit the character structure of these patients, so as to serve their particular needs. If specific therapeutic tech niques were developed, a relatively short period of psychotherapy might prove beneficial. With this objective in mind, several innovations in the treatment of certain patients with dependent personality were decided upon, in order to minimize dependency in the therapeutic relationship and to help the patient to alter his dependent relationships to others. The following specific therapeutic techniques were employed: (1) the patient was informed early that the treat ment would be brief; (2) the therapist (a psychiatric social worker supervised by a psychiatrist) emphasized that she would not assume responsibility for manag ing the patient’s life; (3) the treatment was focused primarily on the patient’s relationships outside of therapy, rather than on the transference; (4) the thera pist actively encouraged the patient to change his behavior, not merely to under stand it; and (5) the therapist conveyed an expectation of strength on the part of the patient, both to tolerate unpleasant feelings, and to behave in more adaptive and self-satisfying ways.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
Boston University School of Medicine and Framingham Union Hospital, Framingham, Mass.
Leeman/Mulvey
(349) 37
Mr. E. was one of the four patients who changed markedly as a result of treatment. He was a 36-year-old married engineer and father of two boys, who was referred to the clinic because of recurrent anxiety attacks, obsessive ruminations and difficulties at work. He was the veteran of 10 years of psychiatric treatment, including 2 years of psychoanalysis, with four different psychiatrists. At each interruption of treatment his symptoms returned. Be cause the patient ‘used it like a crutch’, his last therapy was terminated with the understand ing that he would not call his therapist again for at least 6 months. Promptly 6 months after termination he called his therapist, who referred him to the clinic. Mr. E. was the older of two sons in a family from which the father was often absent, working at a profitable business. Mr. E’s father regarded himself as right about everything, and criticized and belittled his sons. His mother was extremely controlling of her children’s lives, conveying the attitude that her way was the only way to do anything. She criticized whatever the boys did on their own, and repeatedly appeared to rescue them from the brink of disaster. The patient’s only friend during his childhood and adolescence was his brother; when his brother was killed in an accident during late adolescence the patient became more passive and timid than before. Mr. E. had many problems. At his job, he volunteered good ideas for his colleagues to develop, while he sat unproductively with his own projects for weeks at a time. He resented the younger men who advanced beyond him into positions of authority; yet he did not feel ready to assume administrative responsibility. At home, he had trouble setting limits with his sons, and difficulty in his sexual performance. His main complaint was the failure of his treatment; although he had gained considerable insight, his panic and despair returned whenever he was not in therapy. In the initial interviews, patient and therapist discussed the patient’s strong tendency to look for other people on whom to depend, rather than assuming responsibility for himself. They agreed to limit treatment to this aspect of the patient’s problems rather than trying to solve everything. The therapist recommended that they examine the patient’s
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
Six patients who applied to the outpatient psychiatric clinic of the Beth Israel Hospital, and whose diagnostic evaluation concluded that they were suffer ing mainly from problems related to dependency, were selected for brief psycho therapy, using the specific techniques already listed. Patients were seen for 50 min once a week. The duration of treatment was decided individually, and varied from 3 to 7 months. All six patients were white middle-class Americans, between 31 and 44 years old. Three of the four women and both men were married; their educational achievement varied from high school graduation to a master’s degree. Four of six patients had prior experience with psychiatric treatment, ranging in duration from 16 months to 10 years. Their complaints included a variety of long-stand ing anxious, phobic, and depressive symptoms, and generally were not clearly circumscribed. In fact, these patients seemed almost globally dissatisfied with their lives. The results of treatment were assessed both at the time of termination and again 2.5 years later. Of the six patients, four made significant improvements in their characteristic patterns of behavior, self-esteem, and satisfaction with their lives; one improved only after an additional course of brief psychotherapy; and one reported only minimal gains.
Leeman/Mulvey
(350) 38
dependent behavior together, and that the patient begin actively to change this behavior whenever he recognized it. They agreed to limit therapy to approximately 3 months, in order to circumvent the patient’s becoming overly dependent on the therapist. Shortly after this agreement, the patient became furious at the therapist for being late for an appoint ment. He called her unprofessional, disorganized and indifferent. The therapist attributed part of the patient’s rage to her previous statement that he should learn to stand on his own rather than depending on her, which he seemed to take as a rejection. She pointed out his fantasy, threatened by her lateness, that she was perfect, and his wish that she make him perfect, too. During the next few sessions, the patient gradually recognized that his depen dent position was maintained by his angry demands, and that he might not really be incompetent. At this point Mr. E. very emotionally described how his mother had encour aged him to depend on her rather than rely on his own resources. He had depended on his previous therapists in the same way. It should be noted that the examination of this patient’s relationship with the therapist was somewhat more important than in the other five cases, perhaps because of his long experience in psychotherapy. Nevertheless, the major part of the therapy consisted of examining his past and present dependent relationships outside of treatment. Soon he began to try out new ways of relating to people, and to discuss his efforts with the therapist. He found himself more effective at work, more independent of his wife and parents, and better able to discipline his children. He was much less anxious, and was able to discontinue weekly visits as planned, without great distress. The patient returned for 12 maintenance sessions during the next 18 months, using them mainly to report on his progress. He found he could make many observations and most decisions alone, without asking his therapist, his wife, or his friends for advice. He began to speak of his maintenance appointments as a ‘security blanket’ that he would like to do without. They gradually were spaced farther apart, and then discontinued. In a follow-up interview 2.5 years after termination, and 1 year after his last mainte nance session, Mr. E. reported that his treatment was ‘very successful’. He was doing much better at work, and was feeling much happier, more self-confident, ‘more of a man’, and less dependent on his wife. Although he admitted to some residual symptoms (e.g. premature ejaculation and biting his nails) he stressed that ‘my attitude toward them has changed drastically. 1 feel that I am “cured” and can handle my symptoms myself.’
A depressed 34-year-old housewife, who deprecated herself and related in a subservient way to her husband and children, became able to set limits for her family, embark on some
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
This case illustrates not only the utilization of the specific psychothera peutic techniques already enumerated, but also the importance of limiting the goals of treatment. For the treatment to succeed, therapist and patient must strive for improvement, not for perfection. As a result of treatment, the patient’s attitudes about some of his symptoms may change more than the symptoms themselves (4, 7, 8). The most incapacitating attitudes and patterns of behavior are identified at the outset, and therapeutic effort is concentrated on these. This is another way in which the short course of successful therapy differs from the much longer unsuccessful treatment which the patient already has experienced. Three other patients made comparable gains in treatment. Only one of them was seen for a single maintenance session 6 months after termination. All three reported maintenance of improvement after 2.5 years.
(351) 39
projects of her own, and feel better about herself. A 31-year-old, single female office worker, who complained of depression, obesity, and inability to go out with men, lost weight, developed new relationships, and got a better job. She said that she could under stand herself better and that she felt more confident. A 4!-year-old married male artist, who complained of depression, inability to make decisions, an explosive temper, and sexual problems, made improvements in all these areas. A fifth patient, Mrs. G., a 44-year-old phobic housewife and mother of two adolescent children, who was afraid to be alone, seemed not to benefit from 5 months of therapy. Two prior courses of treatment elsewhere, totalling almost 3 years, allegedly had made her worse, apparently because she had become intensely dependent on each of her therapists, and then more phobic and depressed following termination. This time, the therapist repeatedly pointed out the patient’s unrealistic expectation that the therapist would intervene for her in real-life situations, especially in relation to her husband, mother-in-law, and children. The therapist explained that she could not create a beautiful life for the patient, and emphasized the necessity for the patient to take responsibility for herself. This effort got nowhere, since although the patient began to feel a little better, she continued to complain and to plead helplessness. Termination of treatment was scheduled arbitrarily at 5 months, as the thera pist was planning a 2-month absence from the clinic. As soon as the therapist returned, the patient called for an appointment, saying that she again was as fearful as ever. She had been waiting for her therapist to return to champion her cause with her family. The therapist again pointed out the patient’s unrealistic expectation, and proposed that they meet inter mittently with the specific goal of helping the patient to take responsibility for herself. As they met eight times over the next 2 years, the patient experienced no further relief, and made no changes in her relationships. At the 2.5-year follow-up interview, Mrs. G. said that in treatment she had come to understand that 'most of my fears came from anger from my childhood’. Nevertheless, she remained paralyzed. Asked about this discrepancy, she said, ‘I haven’t tried to apply my understanding’. At this point, Mrs. G. still seemed essentially unchanged. She returned a few months later, however, saying she wanted to try again, and was seen six times over a 2-month period. She took a part-time job, which she found gratifying, and began doing things that frightened her, such as driving a car alone and going out to dinner with her husband. Through tears she said, 'It might not seem like much, but nothing ever worked out for me before. I’m so happy I have to pinch myself.’ Although the initial treatment at the clinic had seemed meaningless, in retrospect it was apparent that there was value in the therapist’s persistence in reiterating what treatment could and could not accomplish, and what the patient would have to do for herself. The 2.5-year follow-up interview appeared to catalyze the reaction by which the patient finally applied her understanding to changing her behavior. One patient, Mrs. T., a 31-year-old housewife and mother of three children, made only minimal gains from treatment. She was one of only two patients in this group who had not had previous psychiatric treatment. Mrs. T’s symptoms were depression, anxiety attacks and phobias. She had an overprotective mother (typical for this group), and her childhood history included numerous fears which tied her even more closely to mother. In treatment Mrs. T. examined her idealization of her mother, and began to see how her mother had undermined her independence. As she confronted her anger toward her mother, she became more anxious in the therapy hours, and less phobic outside of treatment. She then began to explore her current conflicts with her husband, but when sexual material intruded into the sessions, Mrs. T. left treatment rather abruptly, after 4 months. Six months later she called for an appointment, and discussed whether to return to treatment for her sexual problems. She said that she was much more comfortable than before therapy, and decided against
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
Brief Psychotherapy of the Dependent Personality
Leeman/Mulvey
(352) 40
Other workers have called attention to the usefulness of one or another of the therapeutic techniques employed in the treatment of these six patients, without combining them into a form of therapy designed specifically for the dependent personality. Aldrich (1) discussed the importance of an optimistic therapeutic emphasis on the patient’s strengths in order to counter the ten dency toward dependent regression in therapy. Wolberg (9) actively invites the patient to use his understanding in changing his behavior. While both of these authors discussed brief psychotherapy only in theoretical terms, Browne (3) reported the treatment of 21 patients of ‘predominantly submissive charactertype’ who had not responded to drug therapy or brief discussion of problems. No individual descriptions were given, but the patients selected, the methods used, and the results obtained apparently were more varied than in the present study. Nevertheless, the therapy focused, as ours did, ‘on the interaction of the patient with persons in his environment, rather than on fostering and interpret ing dependency phenomena in the therapeutic relationship.... Emphasis was laid from the start on the need for change through active efforts by the patient, thus preventing the development of expectation of magical help from the therapist.’ The generally good results of the treatment of the six patients reported here are in marked contrast to the lack of success in the much longer therapy which four of them previously had experienced. Although the outcome of psycho therapy undoubtedly depends in part on idiosyncratic and almost indefinable characteristics of the relationship between a particular patient and a particular therapist, the unsatisfactory outcome of these patients’ earlier treatment can be attributed partly to technical factors. The treatment of all four patients had been relatively unstructured and essentially without limit of time. The patients had been encouraged to talk about whatever was on their mind, with the goal of understanding themselves better, but they appeared to have avoided taking re sponsibility for translating this understanding into behavioral change. There is no doubt that prolonged, relatively unstructured psychotherapy, often with exten sive use of free association by the patient, is of enormous therapeutic value to certain patients. As discussed by Bibring (2), the primary therapeutic principle of that form of therapy is interpretation. The therapeutic assumption is that the patient, once he has traced his current behavior through unconscious feelings and memories to childhood experience, will become free to change his life. Some patients have a character structure which can validate this assumption. On the other hand, the patient described here apparently had interpreted their previous therapy as offering an implicit invitation by their therapists to become
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
further treatment. In a follow-up questionnaire 2.5 years after termination. Mrs. T. said she felt ‘slightly improved’, and no longer ‘so hard on myself, but still suffered from ‘anxiety and fear’. She did not report changes in her interpersonal relationships. Apparently this woman’s severe discomfort about discussing her sexual life prevented her staying in treat ment long enough to resolve her anger and dependency toward her husband.
Brief Psychotherapy of the Dependent Personality
(353) 41
dependent on them in much the same way that they characteristically became dependent on one person after another outside of therapy. The form of therapy reported here, designed with the dependent character structure clearly in mind, appears better suited to the needs of these patients. Although clarification of material presented by these patients is important, what Bibring (2) called experi ential manipulation, using an understanding of the patient’s character structure to encourage him to undertake new forms of experience, probably is even more important. The treatment reported here also differs from various forms of brief psycho therapy described by others. It is not crisis intervention (6, 7), since these patients were suffering from chronic problems and their treatment was designed to change their habitual patterns of behavior. It also differs from ‘short-term anxiety-provoking psychotherapy’, described by Sifneos (7), in which problems of dependency are deliberately avoided, especially in our somewhat greater emphasis on deliberate behavioral change rather than understanding. Our relative de-emphasis of examination of the transference is in contrast to the work of both Sifneos (7, 8) and Malan (5), mainly with other kinds of patients, although our findings support Malan’s conclusion that long-standing neurotic behavior patterns may be altered through brief psychotherapy. The patients described here did not satisfy the selection criteria proposed by Sifneos (8) for treatment in ‘short-term anxiety-provoking psychotherapy’, since most of them did not have a specific chief complaint, and all of them began treatment with unrealistic expectations about both the nature of therapy and its results, and with minimal willingness to take an active part in treatment. The beginning of therapy in each instance was designed to shift the patient’s motivation and to reach agreement on limited therapeutic goals. The treatment of six patients with dependent personalities has been presen ted, to emphasize the importance of adapting psychotherapeutic techniques to the specific needs of particular patients. Effective psychotherapy is not a Pro crustean bed which patients can be made to fit; it is the thoughtful application of specific therapeutic techniques, based on careful diagnostic evaluation of individual patients.
1 2 3 4
Aldrich, C.K.: Brief psychotherapy. A reappraisal of some theoretical assumptions. Amer. J. Psychiat. 125: 585-592 (1968). Bibring, E.: Psychoanalysis and the dynamic psychotherapies. J. Amer. Psychoanal. Ass. 2: 745-770 (1954). Browne, S.E.: Short psychotherapy with passive patients. An experiment in general practice. Brit. J. Psychiat. 110: 233-239 (1964). Lowinger, P.; Dobie, S., and Reid, S.: What happens to the psychiatric office patient treated with drugs? A follow-up study. Psychiat. Quart. 41: 536-549 (1967).
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References
Leeman/Mulvey
7 8 9
Malan, D.H.: A study of brief psychotherapy (Tavistock, London 1963). Rapoport, L.: The state of crisis. Some theoretical considerations. Soc. Serv. Rev. 36: 211-217 (1962). Sifneos, P.E.: Two different kinds of psychotherapy of short duration. Amer. J. Psychiat. 123: 1069-1074 (1967). Sifneos, P.E.: Short-term psychotherapy and emotional crisis (Harvard University Press, Cambridge 1972). Wolberg, L.: Methodology in short-term therapy. Amer. J. Psychiat. 122: 135 140 (1965).
Request reprints from: C.P. Leeman, MD, Associate Clinical Professor of Psychiatry, Boston University School of Medicine, and Chief of Psychiatry, Framingham Union Hospi tal, 25 Evergreen Street, Framingham, MA 01701 (USA)
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5 6
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Brief Psychotherapy of the Dependent Personality. Specific Techniques Cavin P. Leeman and Catherine H. Mulvey
The life style of many patients who apply for psychiatric treatment is characterized by dependency in interpersonal relationships, by apathy and lack of initiative, and by feelings of helplessness, resentment and rage. Although these patients are not psychotic, the predominance of dependent longings in their character structure makes their treatment difficult. Traditional psychotherapy may become a prolonged stalemate in which the patient acts helpless and de pendent in still another relationship, while doing nothing to modify his depen dent way of relating outside of therapy. Indeed these patients sometimes are regarded as hopeless prospects for treatment, especially if they already have undergone one or more unsuccessful courses of psychotherapy. Perhaps greater therapeutic success with this group of patients could be obtained if the psychotherapy were tailored to fit the character structure of these patients, so as to serve their particular needs. If specific therapeutic tech niques were developed, a relatively short period of psychotherapy might prove beneficial. With this objective in mind, several innovations in the treatment of certain patients with dependent personality were decided upon, in order to minimize dependency in the therapeutic relationship and to help the patient to alter his dependent relationships to others. The following specific therapeutic techniques were employed: (1) the patient was informed early that the treat ment would be brief; (2) the therapist (a psychiatric social worker supervised by a psychiatrist) emphasized that she would not assume responsibility for manag ing the patient’s life; (3) the treatment was focused primarily on the patient’s relationships outside of therapy, rather than on the transference; (4) the thera pist actively encouraged the patient to change his behavior, not merely to under stand it; and (5) the therapist conveyed an expectation of strength on the part of the patient, both to tolerate unpleasant feelings, and to behave in more adaptive and self-satisfying ways.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
Boston University School of Medicine and Framingham Union Hospital, Framingham, Mass.
Leeman/Mulvey
(349) 37
Mr. E. was one of the four patients who changed markedly as a result of treatment. He was a 36-year-old married engineer and father of two boys, who was referred to the clinic because of recurrent anxiety attacks, obsessive ruminations and difficulties at work. He was the veteran of 10 years of psychiatric treatment, including 2 years of psychoanalysis, with four different psychiatrists. At each interruption of treatment his symptoms returned. Be cause the patient ‘used it like a crutch’, his last therapy was terminated with the understand ing that he would not call his therapist again for at least 6 months. Promptly 6 months after termination he called his therapist, who referred him to the clinic. Mr. E. was the older of two sons in a family from which the father was often absent, working at a profitable business. Mr. E’s father regarded himself as right about everything, and criticized and belittled his sons. His mother was extremely controlling of her children’s lives, conveying the attitude that her way was the only way to do anything. She criticized whatever the boys did on their own, and repeatedly appeared to rescue them from the brink of disaster. The patient’s only friend during his childhood and adolescence was his brother; when his brother was killed in an accident during late adolescence the patient became more passive and timid than before. Mr. E. had many problems. At his job, he volunteered good ideas for his colleagues to develop, while he sat unproductively with his own projects for weeks at a time. He resented the younger men who advanced beyond him into positions of authority; yet he did not feel ready to assume administrative responsibility. At home, he had trouble setting limits with his sons, and difficulty in his sexual performance. His main complaint was the failure of his treatment; although he had gained considerable insight, his panic and despair returned whenever he was not in therapy. In the initial interviews, patient and therapist discussed the patient’s strong tendency to look for other people on whom to depend, rather than assuming responsibility for himself. They agreed to limit treatment to this aspect of the patient’s problems rather than trying to solve everything. The therapist recommended that they examine the patient’s
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
Six patients who applied to the outpatient psychiatric clinic of the Beth Israel Hospital, and whose diagnostic evaluation concluded that they were suffer ing mainly from problems related to dependency, were selected for brief psycho therapy, using the specific techniques already listed. Patients were seen for 50 min once a week. The duration of treatment was decided individually, and varied from 3 to 7 months. All six patients were white middle-class Americans, between 31 and 44 years old. Three of the four women and both men were married; their educational achievement varied from high school graduation to a master’s degree. Four of six patients had prior experience with psychiatric treatment, ranging in duration from 16 months to 10 years. Their complaints included a variety of long-stand ing anxious, phobic, and depressive symptoms, and generally were not clearly circumscribed. In fact, these patients seemed almost globally dissatisfied with their lives. The results of treatment were assessed both at the time of termination and again 2.5 years later. Of the six patients, four made significant improvements in their characteristic patterns of behavior, self-esteem, and satisfaction with their lives; one improved only after an additional course of brief psychotherapy; and one reported only minimal gains.
Leeman/Mulvey
(350) 38
dependent behavior together, and that the patient begin actively to change this behavior whenever he recognized it. They agreed to limit therapy to approximately 3 months, in order to circumvent the patient’s becoming overly dependent on the therapist. Shortly after this agreement, the patient became furious at the therapist for being late for an appoint ment. He called her unprofessional, disorganized and indifferent. The therapist attributed part of the patient’s rage to her previous statement that he should learn to stand on his own rather than depending on her, which he seemed to take as a rejection. She pointed out his fantasy, threatened by her lateness, that she was perfect, and his wish that she make him perfect, too. During the next few sessions, the patient gradually recognized that his depen dent position was maintained by his angry demands, and that he might not really be incompetent. At this point Mr. E. very emotionally described how his mother had encour aged him to depend on her rather than rely on his own resources. He had depended on his previous therapists in the same way. It should be noted that the examination of this patient’s relationship with the therapist was somewhat more important than in the other five cases, perhaps because of his long experience in psychotherapy. Nevertheless, the major part of the therapy consisted of examining his past and present dependent relationships outside of treatment. Soon he began to try out new ways of relating to people, and to discuss his efforts with the therapist. He found himself more effective at work, more independent of his wife and parents, and better able to discipline his children. He was much less anxious, and was able to discontinue weekly visits as planned, without great distress. The patient returned for 12 maintenance sessions during the next 18 months, using them mainly to report on his progress. He found he could make many observations and most decisions alone, without asking his therapist, his wife, or his friends for advice. He began to speak of his maintenance appointments as a ‘security blanket’ that he would like to do without. They gradually were spaced farther apart, and then discontinued. In a follow-up interview 2.5 years after termination, and 1 year after his last mainte nance session, Mr. E. reported that his treatment was ‘very successful’. He was doing much better at work, and was feeling much happier, more self-confident, ‘more of a man’, and less dependent on his wife. Although he admitted to some residual symptoms (e.g. premature ejaculation and biting his nails) he stressed that ‘my attitude toward them has changed drastically. 1 feel that I am “cured” and can handle my symptoms myself.’
A depressed 34-year-old housewife, who deprecated herself and related in a subservient way to her husband and children, became able to set limits for her family, embark on some
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
This case illustrates not only the utilization of the specific psychothera peutic techniques already enumerated, but also the importance of limiting the goals of treatment. For the treatment to succeed, therapist and patient must strive for improvement, not for perfection. As a result of treatment, the patient’s attitudes about some of his symptoms may change more than the symptoms themselves (4, 7, 8). The most incapacitating attitudes and patterns of behavior are identified at the outset, and therapeutic effort is concentrated on these. This is another way in which the short course of successful therapy differs from the much longer unsuccessful treatment which the patient already has experienced. Three other patients made comparable gains in treatment. Only one of them was seen for a single maintenance session 6 months after termination. All three reported maintenance of improvement after 2.5 years.
(351) 39
projects of her own, and feel better about herself. A 31-year-old, single female office worker, who complained of depression, obesity, and inability to go out with men, lost weight, developed new relationships, and got a better job. She said that she could under stand herself better and that she felt more confident. A 4!-year-old married male artist, who complained of depression, inability to make decisions, an explosive temper, and sexual problems, made improvements in all these areas. A fifth patient, Mrs. G., a 44-year-old phobic housewife and mother of two adolescent children, who was afraid to be alone, seemed not to benefit from 5 months of therapy. Two prior courses of treatment elsewhere, totalling almost 3 years, allegedly had made her worse, apparently because she had become intensely dependent on each of her therapists, and then more phobic and depressed following termination. This time, the therapist repeatedly pointed out the patient’s unrealistic expectation that the therapist would intervene for her in real-life situations, especially in relation to her husband, mother-in-law, and children. The therapist explained that she could not create a beautiful life for the patient, and emphasized the necessity for the patient to take responsibility for herself. This effort got nowhere, since although the patient began to feel a little better, she continued to complain and to plead helplessness. Termination of treatment was scheduled arbitrarily at 5 months, as the thera pist was planning a 2-month absence from the clinic. As soon as the therapist returned, the patient called for an appointment, saying that she again was as fearful as ever. She had been waiting for her therapist to return to champion her cause with her family. The therapist again pointed out the patient’s unrealistic expectation, and proposed that they meet inter mittently with the specific goal of helping the patient to take responsibility for herself. As they met eight times over the next 2 years, the patient experienced no further relief, and made no changes in her relationships. At the 2.5-year follow-up interview, Mrs. G. said that in treatment she had come to understand that 'most of my fears came from anger from my childhood’. Nevertheless, she remained paralyzed. Asked about this discrepancy, she said, ‘I haven’t tried to apply my understanding’. At this point, Mrs. G. still seemed essentially unchanged. She returned a few months later, however, saying she wanted to try again, and was seen six times over a 2-month period. She took a part-time job, which she found gratifying, and began doing things that frightened her, such as driving a car alone and going out to dinner with her husband. Through tears she said, 'It might not seem like much, but nothing ever worked out for me before. I’m so happy I have to pinch myself.’ Although the initial treatment at the clinic had seemed meaningless, in retrospect it was apparent that there was value in the therapist’s persistence in reiterating what treatment could and could not accomplish, and what the patient would have to do for herself. The 2.5-year follow-up interview appeared to catalyze the reaction by which the patient finally applied her understanding to changing her behavior. One patient, Mrs. T., a 31-year-old housewife and mother of three children, made only minimal gains from treatment. She was one of only two patients in this group who had not had previous psychiatric treatment. Mrs. T’s symptoms were depression, anxiety attacks and phobias. She had an overprotective mother (typical for this group), and her childhood history included numerous fears which tied her even more closely to mother. In treatment Mrs. T. examined her idealization of her mother, and began to see how her mother had undermined her independence. As she confronted her anger toward her mother, she became more anxious in the therapy hours, and less phobic outside of treatment. She then began to explore her current conflicts with her husband, but when sexual material intruded into the sessions, Mrs. T. left treatment rather abruptly, after 4 months. Six months later she called for an appointment, and discussed whether to return to treatment for her sexual problems. She said that she was much more comfortable than before therapy, and decided against
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
Brief Psychotherapy of the Dependent Personality
Leeman/Mulvey
(352) 40
Other workers have called attention to the usefulness of one or another of the therapeutic techniques employed in the treatment of these six patients, without combining them into a form of therapy designed specifically for the dependent personality. Aldrich (1) discussed the importance of an optimistic therapeutic emphasis on the patient’s strengths in order to counter the ten dency toward dependent regression in therapy. Wolberg (9) actively invites the patient to use his understanding in changing his behavior. While both of these authors discussed brief psychotherapy only in theoretical terms, Browne (3) reported the treatment of 21 patients of ‘predominantly submissive charactertype’ who had not responded to drug therapy or brief discussion of problems. No individual descriptions were given, but the patients selected, the methods used, and the results obtained apparently were more varied than in the present study. Nevertheless, the therapy focused, as ours did, ‘on the interaction of the patient with persons in his environment, rather than on fostering and interpret ing dependency phenomena in the therapeutic relationship.... Emphasis was laid from the start on the need for change through active efforts by the patient, thus preventing the development of expectation of magical help from the therapist.’ The generally good results of the treatment of the six patients reported here are in marked contrast to the lack of success in the much longer therapy which four of them previously had experienced. Although the outcome of psycho therapy undoubtedly depends in part on idiosyncratic and almost indefinable characteristics of the relationship between a particular patient and a particular therapist, the unsatisfactory outcome of these patients’ earlier treatment can be attributed partly to technical factors. The treatment of all four patients had been relatively unstructured and essentially without limit of time. The patients had been encouraged to talk about whatever was on their mind, with the goal of understanding themselves better, but they appeared to have avoided taking re sponsibility for translating this understanding into behavioral change. There is no doubt that prolonged, relatively unstructured psychotherapy, often with exten sive use of free association by the patient, is of enormous therapeutic value to certain patients. As discussed by Bibring (2), the primary therapeutic principle of that form of therapy is interpretation. The therapeutic assumption is that the patient, once he has traced his current behavior through unconscious feelings and memories to childhood experience, will become free to change his life. Some patients have a character structure which can validate this assumption. On the other hand, the patient described here apparently had interpreted their previous therapy as offering an implicit invitation by their therapists to become
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/28/2018 3:36:12 AM
further treatment. In a follow-up questionnaire 2.5 years after termination. Mrs. T. said she felt ‘slightly improved’, and no longer ‘so hard on myself, but still suffered from ‘anxiety and fear’. She did not report changes in her interpersonal relationships. Apparently this woman’s severe discomfort about discussing her sexual life prevented her staying in treat ment long enough to resolve her anger and dependency toward her husband.
Brief Psychotherapy of the Dependent Personality
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dependent on them in much the same way that they characteristically became dependent on one person after another outside of therapy. The form of therapy reported here, designed with the dependent character structure clearly in mind, appears better suited to the needs of these patients. Although clarification of material presented by these patients is important, what Bibring (2) called experi ential manipulation, using an understanding of the patient’s character structure to encourage him to undertake new forms of experience, probably is even more important. The treatment reported here also differs from various forms of brief psycho therapy described by others. It is not crisis intervention (6, 7), since these patients were suffering from chronic problems and their treatment was designed to change their habitual patterns of behavior. It also differs from ‘short-term anxiety-provoking psychotherapy’, described by Sifneos (7), in which problems of dependency are deliberately avoided, especially in our somewhat greater emphasis on deliberate behavioral change rather than understanding. Our relative de-emphasis of examination of the transference is in contrast to the work of both Sifneos (7, 8) and Malan (5), mainly with other kinds of patients, although our findings support Malan’s conclusion that long-standing neurotic behavior patterns may be altered through brief psychotherapy. The patients described here did not satisfy the selection criteria proposed by Sifneos (8) for treatment in ‘short-term anxiety-provoking psychotherapy’, since most of them did not have a specific chief complaint, and all of them began treatment with unrealistic expectations about both the nature of therapy and its results, and with minimal willingness to take an active part in treatment. The beginning of therapy in each instance was designed to shift the patient’s motivation and to reach agreement on limited therapeutic goals. The treatment of six patients with dependent personalities has been presen ted, to emphasize the importance of adapting psychotherapeutic techniques to the specific needs of particular patients. Effective psychotherapy is not a Pro crustean bed which patients can be made to fit; it is the thoughtful application of specific therapeutic techniques, based on careful diagnostic evaluation of individual patients.
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Aldrich, C.K.: Brief psychotherapy. A reappraisal of some theoretical assumptions. Amer. J. Psychiat. 125: 585-592 (1968). Bibring, E.: Psychoanalysis and the dynamic psychotherapies. J. Amer. Psychoanal. Ass. 2: 745-770 (1954). Browne, S.E.: Short psychotherapy with passive patients. An experiment in general practice. Brit. J. Psychiat. 110: 233-239 (1964). Lowinger, P.; Dobie, S., and Reid, S.: What happens to the psychiatric office patient treated with drugs? A follow-up study. Psychiat. Quart. 41: 536-549 (1967).
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References
Leeman/Mulvey
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Malan, D.H.: A study of brief psychotherapy (Tavistock, London 1963). Rapoport, L.: The state of crisis. Some theoretical considerations. Soc. Serv. Rev. 36: 211-217 (1962). Sifneos, P.E.: Two different kinds of psychotherapy of short duration. Amer. J. Psychiat. 123: 1069-1074 (1967). Sifneos, P.E.: Short-term psychotherapy and emotional crisis (Harvard University Press, Cambridge 1972). Wolberg, L.: Methodology in short-term therapy. Amer. J. Psychiat. 122: 135 140 (1965).
Request reprints from: C.P. Leeman, MD, Associate Clinical Professor of Psychiatry, Boston University School of Medicine, and Chief of Psychiatry, Framingham Union Hospi tal, 25 Evergreen Street, Framingham, MA 01701 (USA)
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