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The essential feature of the dependent personality disorder is a pervasive and excessive need to be taken care of that results in submissive and clinging behavior. Individuals with DPD fear separation; they engage in dependent behavior to elicit caregiving (DSM-IV, 1994, p. 665).
The ICD-10 also has a dependent personality disorder which is characterized by a pervasive reliance on other people to make life decisions, a fear of abandonment, feelings of helplessness and incompetence, passive compliance with others, and a weak response to daily life. They are inclined to transfer responsibility to others (ICD-10, 1994, p. 233).
Individuals with DPD are often pessimistic and characterized by self-doubt; they tend to belittle their abilities and assets. They respond to the criticism and disapproval of others as proof of their worthlessness. They seek others to dominate and protect them. Occupational functioning may be impaired if independent initiative is required; they will avoid positions of responsibility (DSM-IV, 1994, p. 666).
Individuals with DPD are described as inchoate -- meaning imperfectly formed. The implication is that they are partly but not fully in existence. This personality is potential; there is a deficit in regulatory controls because of a marked tendency to expect others to take responsibility for fulfilling their needs and managing their responsibilities. This results in an undeveloped capacity to adapt adequately and difficulty in functioning independently (Dorr, Retzlaff, ed., 1995, p. 197).
Passive-dependent individuals are characterized by:
Individuals with DPD subjugate their personal needs to those of others, tolerate mistreatment, and fail to be appropriately self-assertive. They often live with someone who is controlling, domineering, overprotective and infantilizing (Frances, et.al, 1995, p. 377). In females, DPD is likely to consist of a pattern of submissiveness. In males, DPD may involve a pattern of autocratic behavior (Sperry & Carlson, 1993, p. 305).
The baseline DPD position of marked submissiveness to a dominant person is supposed to ensure unending nurturance. The connection is maintained even if the relationship is abusive because individuals with DPD believe that they cannot survive without the dominance and guidance (Benjamin, 1993, pp. 228-229). They live their lives in a manner calculated to avoid disturbing or offending others. They yield their individuality and autonomy; they are placating, self-deprecating, undemanding, and apologetic (Oldham, 1990, p. 123).
Stone (1993, pp. 340-341) believes that three of the diagnostic items for DPD may be viewed as tactics to maintain a hold on important others:
Other criteria can be seen as characterological symptoms of the failure of the first three defensive maneuvers:
Both normal and personality-disordered individuals can exhibit strong dependency-related needs; it is the way these needs are expressed that differentiates the two. Personality-disordered individuals tend to express dependency needs in a more uncontrolled, unmodulated, and maladaptive manner. The pathological manifestations of dependency needs include intense fears of abandonment, passive, helpless behaviors in intimate relationships, and phobic symptoms aimed at minimizing separation (Bornstein, Costello, ed., 1996, pp. 123-132).
Bornstein (Costello, ed., 1996, pp. 124-125) suggests that genetic factors account for a relatively small portion of the variability in dependency levels. The parent/child relationship appears to be the major causal factor in the development of dependent personality traits. He believes that two parenting styles lead to high levels of dependency: authoritarian parenting and overprotective parenting. The consequences of these two types of parenting are the development of beliefs that dependent individuals cannot function without the guidance and protection of others, and that the way to maintain relationships is to acquiesce to requests, expectations, and demands.
DPD is often co-morbid with BPD, AvPD, and HPD. A common factor for both DPD and BPD is the fear of abandonment. Individuals with BPD will respond to abandonment with feelings of emotional emptiness and rage. They will increase their demands on significant others. Individuals with DPD will react with increasing appeasement and submissiveness. People with DPD are self-effacing and docile compared to the gregarious flamboyance and active demands of those with HPD. Individuals with DPD and AvPD both feel inadequate and are hypersensitive to criticism. However, those with DPD will seek and maintain relationships while individuals with AvPD will withdraw (DSM-IV, 1994, p. 667).
On Axis I, individuals with DPD are vulnerable to anxiety disorders, phobic disorders, somatoform syndromes, and dissociative disorders (Millon & Davis, 1996, pp. 340-341). DPD is among the most frequently reported personality disorders in mental health clinics. Studies using structured assessments report similar prevalence rates for men and women (DSM-IV, 1994, p. 667).
Self-Image Individuals with DPD see themselves as inadequate and helpless; they believe they are in a cold and dangerous world and are unable to cope on their own. They define themselves as inept and abdicate self-responsibility; they turn their fate over to others . These individuals will decline to be ambitious and believe that they lack abilities, virtues and attractiveness (Beck & Freeman, 1990, p. 290) (Millon, 1981, pp. 113- 114).
The solution to being helpless in a frightening world is to find capable people who will be nurturing and supportive toward those with DPD. Within protective relationships, individuals with DPD will be self-effacing, obsequious, agreeable, docile, and ingratiating. They will deny their individuality and subordinate their desires to significant others. They internalize the beliefs and values of significant others. They imagine themselves to be one with or a part of more powerful and supporting others. By seeing themselves as protected by the power of others, they do not have to feel the anxiety attached to their own helplessness and impotence (Millon & Davis, 1996, pp. 325-334).
However, to be comfortable with themselves and their inordinate helplessness, individuals with DPD must deny the feelings they experience and the deceptive strategies they employ. They limit their awareness of both themselves and others. Their limited perceptiveness allows them to be naive and uncritical (Millon & Davis, 1996, pp. 333-334). Their limited tolerance for negative feelings, perceptions, or interaction results in the interpersonal and logistical ineptness that they already believe to be true about themselves. Their defensive structure reinforces and actually results in verification of the self-image they already hold.
View of Others
Individuals with DPD see other people as much more capable to shoulder life's responsibilities, to navigate a complex world, and to deal with the competitions of life (Millon, 1981, p. 114). Other people are powerful, competent, and capable of providing a sense of security and support to individuals with DPD. Dependent individuals avoid situations that require them to accept responsibility for themselves; they look to others to take the lead and provide continuous support (Richards, 1993, p. 243).
DPD judgement of others is distorted by their inclination to see others as they wish they were rather than as they are (Kantor, 1992, p. 172). These individuals are fixated in the past. They maintain youthful impressions; they retain unsophisticated ideas and childlike views of the people toward whom they remain totally submissive (Millon & Davis, 1996, p. 333). Individuals with DPD view strong caretakers, in particular, in an idealized manner; they believe they will be all right as long as the strong figure upon whom they depend is accessible (Beck & Freeman, 1990, p. 44).
Individuals with DPD see relationships with significant others as necessary for survival. They do not define themselves as able to function independently; they have to be in supportive relationships to be able to manage their lives. In order to establish and maintain these life-sustaining relationships, people with DPD will avoid even covert expressions of anger. They will be more than meek and docile; they will be admiring, loving, and willing to give their all. They will be loyal, unquestioning, and affectionate. They will be tender and considerate toward those upon whom they depend (Millon, 1981, p. 114).
Dependent individuals play the inferior role to the superior other very well; they communicate to the dominant people in their lives that they are useful, sympathetic, strong, and competent (Millon, 1981, p. 114). With these methods, individuals with DPD are often able to get along with unpredictable, isolated, or unpleasant people (Kantor, 1992, p. 170). To further make this possible, individuals with DPD will approach both their own and others' failures and shortcomings with a saccharine attitude and indulgent tolerance (Millon, 1981, p. 113). They will engage in a mawkish minimization, denial, or distortion of both their own and others' negative, self-defeating, or destructive behaviors to sustain an idealized, and sometimes fictional, story of the relationships upon which they depend. They will deny their individuality, their differences, and ask for little other than acceptance and support (Millon & Davis, 1996, p. 332).
Not only will individuals with DPD subordinate their needs to those of others, they will meet unreasonable demands and submit to abuse and intimidation to avoid isolation and abandonment (Millon, 1981, pp.107-108). Dependent individuals so fear being unable to function alone that they will agree with things they believe are wrong rather than risk losing the help of people upon whom they depend (DSM-IV, 1994, p. 665). They will volunteer for unpleasant tasks if that will bring them the care and support they need. They will make extraordinary self-sacrifices to maintain important bonds (DSM-IV, 1994, pp. 665-666).
It is important to note that individuals with DPD, in spite of the intensity of their need for others, do not necessarily attach strongly to specific individuals, i.e., they will become quickly and indiscriminately attached to others when they have lost a significant relationship (DSM-IV, 1990, p. 666). It is the strength of the dependency needs that is being addressed; attachment figures are basically interchangeable. Attachment to others is a self-referenced and, at times, haphazard process of securing the protection of the most readily available powerful other willing to provide nurturance and care.
Both DPD and HPD are distinguished from other personality disorders by their need for social approval and affection and by their willingness to live in accord with the desires of others. They both feel paralyzed when they are alone and need constant assurance that they will not be abandoned. Individuals with DPD are passive individuals who lean on others to guide their lives. People with HPD are active individuals who take the initiative to arrange and modify the circumstances of their lives. They have the will and ability to take charge of their lives and to make active demands on others (Millon & Davis, 1996, p. 325).
Issues With Authority
Individuals with DPD will not engage in provocative or rebellious behavior toward authority figures. They are likely to elicit protective behavior from uniformed authority because of their conciliatory, anxious eagerness to please. Because of their need for support and care, they are disinclined to question authority or dispute orders from others. If they do get into trouble with law enforcement personnel, it will likely be in the company of others who are taking the lead in illegal behavior.
Individuals with DPD can function well in families or workplaces where rewards are based on compliance with expectations and acceptance by authority figures. They will do best where interpersonal (and supportive) contact is available (Richards, 1993, p. 243).
The lack of self-confidence in individuals with DPD is apparent in their posture, voice, and mannerisms. They are cooperative, passive, and yielding. They may be viewed by others as generous and thoughtful, apologetic and obsequious. They appear humble, cordial, gracious, and gentle (Millon, 1981, p. 112). These individuals entrust themselves to others. They are overly cooperative and acquiescent. They prefer to yield and placate rather than to be assertive. They lack both initiative and competence (Millon & Davis, 1996, p. 331).
Individuals with DPD are inclined to avoid or deny harsh realities. They rely on feelings and empathic attunement with others rather than on thinking and problem-solving. DPDs are adept at sensing what others will reject and in identifying any threat to their support system (Richards, 1993, p. 243). These individuals show remarkable patience and persistence in maintaining what they have. They will use cajolery, bribery, moral censure, promises to change (rarely kept) and even threats to keep relationships upon which they depend. They rarely strive for anything more than the preservation of what they have; their efforts are put into avoiding failure (Kantor, 1992, p.169).
These individuals are marked by their need for approval and their willingness to live in accord with the desires of others. They adapt their behavior to please others; they deny thoughts and feelings that may elicit displeasure from significant others. They are so sensitive to disapproval that they can experience criticism as devastating (Millon, 1981, p.107).
Individuals with DPD minimize difficulties, are readily persuadable, uncritical, and unperceptive (Sperry, 1995, p. 78). Like individuals with the other personality disorders, dependent people have a tendency to live in fantasy with insufficient input from current reality. This produces a characteristic infantilism with mild memory disturbances due to the diminished ability to pay attention (Kantor, 1992, pp. 36-41).
Individuals with DPD have difficulty making everyday decisions without advice and reassurance. They present themselves as inept and needing constant assistance. They are likely to be able to function adequately only if they believe someone else is supervising and approving. They allow others to assume responsibility for major areas of their lives, e.g. they depend on significant others to decide where they should live, what job they should have, what they should wear, what they should do with their leisure time, etc. These individuals may rely on others so much that they fail to learn the basic skills of independent living (DSM-IV, 1994, pp. 665-666).
According to Beck & Freeman (1990, p. 45) the main affect experienced by individuals with DPD is anxiety. They are insecure; they fear abandonment and the disapproval of others; and, they experience considerable discomfort when alone (Sperry, 1995, p. 78).
However, most of DPD literature refers to the vulnerability these individuals have to depression. Because of their susceptibility to separation, people with DPD are likely to experience affective disorders. The underlying characterological pessimism of DPD lends itself to a chronic, mild depression or dysthymia. When faced with abandonment, rejection, or loss they may experience a major depression (Millon, 1996, p. 181).
Critical to the tendency toward depression in individuals with DPD is their belief that they are ineffective, inferior, and unworthy of regard. Dependent individuals depend on others for safety, help, and gratification. They are characterized by passive receiving. They require stability, predictability and reassurance in relationships. Rejection is considered worse than aloneness so no risks are taken that might lead to alienation of others. These individuals avoid making changes and stay away from novel situations. They do not feel able to cope with the unexpected. Depression for these individuals is usually brought on by interpersonal rejection or loss and is accompanied by loss of self-esteem and self-confidence (Millon, 1996, p. 183).
Individuals with DPD can be plagued by fatigue, lethargy, and diffuse anxieties (Millon, 1981, p. 130); underneath their denial of the unpleasant, these individuals are often unable to feel much joy in living. They may describe themselves as pessimistic, discouraged, and dejected. They suffer in silence; they feel they must appear satisfied and content around those upon whom they depend (Millon, 1981, p. 113). On occasion, in a desperate attempt to counter emerging feelings of hopelessness and depression, these individuals may experience a reverse in their typical passive, subdued style to that of hypomanic activity, excitement, and optimism (Millon, 1996, p. 181). They may also be able to mitigate their depression, even when experiencing abandonment, by a refusal to see what they do not want to see and a defensively sustained belief that everything will turn out all right (Kantor, 1992, p. 171).
The primary defense mechanism for individuals with DPD is introjection. These individuals go beyond identification to seek internalization of the more powerful other; they long for an inseparable interpersonal bond. Threats and conflicts in the relationship are protected against by obscuring the autonomy and identity of those with DPD. The defense of introjection is the process of devaluing the self and over-idealizing others; it may include hypochondriasis. Denial is a secondary defense to smooth over uncomfortable interpersonal events or hostile impulses (Kubacki & Smith, Retzlaff, ed., 1995, p. 170).
Millon also believes that individuals with DPD use denial as a significant defense. They soften the edges of interpersonal strain with a syrupy sweetness and a tendency to cover up or gloss over troublesome events. These individuals characteristically limit their awareness of themselves and others to a narrow sphere -- within comfortable boundaries. They are minimally introspective, naive, unperceptive, and uncritical. They are inclined to see only the good in situations -- including the pleasant side of troubling events (Millon, 1981, pp. 112-114).
The Dependent Personality Disorder Coming Into Treatment
Individuals with DPD are frequently found in outpatient mental health clinics. They often engage in fantasies of magical refueling and the provision of endless supplies by omnipotent, benevolent others (Van Denburg, Retzlaff, ed., 1995, p. 123). However, they do not usually come in for treatment saying they are too dependent nor do they identify decision making as the critical problem. In fact, passive-dependent people usually know they are dependent and do not particularly see it as a problem or they do not care if it is. They like being dependent (Kantor, 1992, p. 171). Instead, they usually complain of anxiety, tension, or depression (Turkat, 1990, p. 82). While individuals with DPD often experience a positive treatment outcome (Sperry, 1995, p. 87), it is still a serious challenge for these people to leave an abusive relationship. If they are tightly bound to a relationship in which their significant other uses drugs and alcohol, their own abstinence or recovery is unlikely.
There is little evidence to suggest that the use of medication will result in long-term benefits in the personality functioning of individuals with DPD (Perry, Gabbard & Atkinson, eds., 1996, p. 998). DPD is not amenable to pharmacological measures; treatment relies upon verbal therapies (Stone, 1993, pp. 341-343).
It is recommended that target symptoms rather than specific personality disorders be medicated. One of these target symptoms of particular importance is dysphoria -- marked by low energy, leaden fatigue, and depression. Dysphoria can also be associated with a craving for chocolate and for stimulants, e.g. cocaine. DPD is one of the most vulnerable personality disorders to dysphoria and some individuals with DPD respond well to antidepressant medications (Ellison & Adler, Adler, ed., 1990, p. 53).
People with DPD are prone to both depressive and anxiety disorders. Stone (1993, pp. 341-343) suggests that these individuals may respond well to benzodiazepines in a crisis. However, clients with DPD are likely to abuse anxiolytics and their use should be limited and monitored with caution (Sperry, 1995, pp. 93-94).
Unfortunately, individuals with DPD tend to be appealing clients. They are not inclined to be demanding and provocative. This can be precisely why they are given benzodiazepines by psychiatrists who may feel both benevolent and protective. Their inclination to use denial and escape to manage their lives makes the use of sedative-hypnotics familiar and pleasant. Iatrogenic addiction is a serious concern.
Treatment Provider Guidelines
Individuals with DPD can seem easy to treat initially; they are attentive, cooperative, and appreciative. They engage easily in the treatment process and will agree with everything their service providers say. They will be extremely compliant and openly idealize the treatment providers. Then, after a period of time, it will become apparent that these same clients are clinging to treatment and resisting any attempt to enhance autonomy (Beck & Freeman, 1990, p. 283). Clients with DPD will express their discomfort or disagreement indirectly through missing appointments or forgetting to complete assignments. They may secretly devalue the treatment providers and fail to carry out even the most undemanding suggestion given to them in the course of treatment (Kubacki & Smith, Retzlaff, ed., 1995, p. 170).
Clients with DPD must eventually become more active and self-reliant. This change is quite difficult and will trigger fantasies and fears regarding the consequences of being independent. Should they become more autonomous, most individuals with DPD fear being abandoned by those who currently care for them. They experience themselves as inept, overburdened, and inadequate to face the demands of life. They cannot conceive of their own abilities for autonomy and independent functioning.
In treatment, these individuals will develop a strong dependence on service providers while continuing to devalue their own ability to make use of the treatment. All progress will be attributed to the service providers and not to the self (McCann, Retzlaff, ed., 1995, p. 147).
Even though DPD treatment progress will be made evident through increased independent functioning, this cannot be an initial therapeutic goal. Early in the treatment process, accommodation will need to be made so that some of the dependency needs evidenced by these clients can be gratified via appropriate support and encouragement from service providers and enough security can be developed to allow change to be pursued (Van Denberg, Retzlaff, ed., p. 123). It is a delicate balance as it is equally important that service providers do not reestablish the dominance-submission pattern that characterizes other relationships for these individuals (Millon, 1981, p. 130). It needs to be determined whether or not apparent gains in treatment are merely temporary compliance with strong, demanding treatment providers (Dorr, Retzlaff, ed., 1995, p. 198). The willingness that individuals with DPD have to submit to more powerful others makes it imperative that professional boundaries and limits are established and adhered to closely. If treatment providers allow themselves to dominate DPD clients, they may eventually encounter the denied rage in these individuals for that domination (Kubacki & Smith, Retzlaff, ed., 1995, p. 171). They may then find themselves entangled in a complex web of dependency and fury with individuals who feel betrayed and damaged.
Transference and Countertransference Issues
Clients with DPD are friendly, cooperative, and compliant. These individuals are extremely pleased if their service providers are powerful and competent. However, in the course of treatment it frequently becomes apparent that changes are not happening, and eventually, someone runs out of patience (Benjamin, 1993, p. 238).
Perry (Gabbard & Atkinson, eds., 1996, pp. 995-996) suggests that there are four types of transference and countertransference problems with clients with DPD:
Zimmerman (1994, pp. 118-119) suggests the following questions when assessing individuals for DPD:
A critical element in the assessment of DPD is the relationship with dominant others. When a dominant other is available to individuals with DPD, there is often not a problem bringing them to treatment as they have the reassurance they need. The discomfort and distress occur when the dominant other is not available. When individuals with DPD do enter treatment, they will usually describe a pattern of molding their personalities to the dominant figures with whom they are involved. Treatment should, if possible, involve significant others as less dependence on the part of individuals with DPD will likely have a negative impact on the relationships (Turkat, 1990, pp. 82-83).
Perry (Gabbard & Atkinson, eds., 1996, pp. 996-997) suggests that In DPD treatment, clients should be assisted to:
Gradually, service providers should increase the level of expectations for autonomous decision making, action, and socially effective responses. This include self-management of crises and self-soothing under stress. This requires assisting clients with DPD to resolve transference wishes to be dependent and to experience a more self-reliant role in relationships. In treatment, the service provider must empathize with DPD clients' feelings of inadequacy but should point out other behaviors that demonstrate their self-efficacy, autonomy, and competence (McCann, Retzlaff, ed., 1995, p. 147).
An interpersonal approach to DPD treatment promotes healthy identification with people, e.g. service providers, group members, and peers who function at a more autonomous level (Kantor, 1992, p. 173).
An educative approach teaches clients with DPD how to be independent. Direct advice is given at the beginning of treatment. Later, advice is given indirectly by asking clients with DPD to make a decision and then assisting them with the decision once it has been made (Kantor, 1992, pp 173-174).
Cognitive-behavior therapy views the DPD client-service provider relationship as reflective of dysfunctional DPD beliefs and behaviors. Treatment is focused on fostering accurate self-appraisal and independent decision making and independent behavior. Initial dependent behavior is accepted but addressed and reflected upon in the treatment process. Treatment techniques that are used include:
When there is resistance to change, service providers help clients with DPD to think through their ambivalence about changing and to substitute constructive behavior for old dependent habits (Perry, Gabbard & Atkinson, eds., 1996, p. 997).
Adler (Adler, ed., 1990, pp. 26-28) suggests that treatment goals for all personality disorders include: preventing further deterioration, regaining an adaptive equilibrium, alleviating symptoms, restoring lost skills, and fostering improved adaptive capacity. Goals may not necessarily include characterological restructuring. The focus of treatment is adaptation, i.e., how individuals respond to the environment. Treatment interventions teach more adaptive methods of managing distress, improving interpersonal effectiveness, and building skills for affective regulation.
For individuals with DPD, the goal of treatment is not independence but autonomy. Autonomy has been defined as the capacity for independence and the ability to develop intimate relationships (Beck & Freeman, 1990, p. 291). Sperry (1995, p. 86 - 91) suggests that the basic goal for DPD treatment is self-efficacy. Individuals with DPD must recognize their dependent patterns and the high price they pay to maintain those patterns. This allows them to explore alternatives. The long-range goal is to increase DPD individuals' sense of independence and ability to function. Clients with DPD must build strength rather than foster neediness (Benjamin, 1993, p. 238).
As with other personality disorders, treatment goals should not be in contradiction to the basic personality and temperament of these individuals. They can work toward a more functional version of those characteristics that are intrinsic to their style. Oldham (1990, p. 104) suggests seven traits and behaviors of the "devoted personality style," i.e, the non-personality-disordered version of DPD:
Cluster C: Incidence of Co-Occurring Substance Abuse Disorders
Cluster C has a high incidence of co-occurring substance abuse disorders, though not as high as Cluster B (Nace, O'Connell, ed., 1990, p. 184).
Individuals with personality disorders, due to their frequent failures in self-regulation, have an increased inclination to use drugs and alcohol as alternative solutions to life problems. This failure in self-regulation and faulty adaptation to normal stressors can usually be attributed to deficiencies or disturbances in the personality (Richards, 1993, pp. 227-240). As Freud has said, intoxicating substances keep misery at a distance and provide a greatly desired degree of independence from the external world. With the help of drugs, anyone can withdraw from the pressures of reality and find refuge in a world of their own (Khantzian, Halliday, & McAuliffe, 1990, Opening page).
While Khantzian, et. al. (1990, p. 3) view the treatment of any character disorder as the road to recovery from addiction, their approach also demands a continued attention to and concern about maintaining abstinence and avoiding relapse. Addiction becomes a disorder in its own right and must be addressed directly. However, the treatment of personality disorders can lead to profound change in personality disordered individuals' experience of self and the world, which, in turn, can positively affect recovery from addiction.
Specifically, for individuals with DPD, alcoholism and other substance abuse are common presenting problems since drugs and alcohol offer an easy, passive way to either deal with or escape from problems (Beck & Freeman, 1990, p. 287). Highly dependent individuals often have a history of oral excesses, i.e., alcohol, food, and drug abuse; they also have a history of early loss or deprivation and issues of abandonment and loneliness (Millon, 1996, p. 182).
For individuals with DPD, the external search for self-comfort, security, and self-regulation makes them quite vulnerable to chemical dependency. For individuals with DPD, alcohol and other drugs can:
There may be some immunity to addiction if significant others are very disapproving of these individuals' drug use. However, the disapproval may be responded to by secretive use and greater anxiety, depression, and self-loathing. (Richards, 1993, p. 244).
Drugs of Choice for the Dependent Personality Disorder
Individuals with DPD make few choices for themselves. They are not likely to select a drug, route of administration, frequency of use, or location of use if their involvement with drugs and alcohol exists within a social or relationship context. They will use what, when, where, and how according to those with whom they are involved.
If drug or alcohol use is done in secrecy and isolation, sedative hypnotics are likely to be preferred. Few individuals with DPD, operating on their own, will have the necessary aggression and tolerance for risk to engage in acquisition of illegal drugs. They are more likely to use alcohol or seek sedative-hypnotics from physicians.
Dual Diagnosis Treatment for the Dependent Personality Disorder
Individuals with DPD often do well in inpatient treatment and in early phases of recovery since the stabilizing and supportive aspects of the treatment process meet their basic dependency needs. However, these individuals will resist movement through the recovery process; they are inclined to remain in the attached, secure, weak, and provided for position of early treatment. The greater independence involved in later recovery provokes anxiety and abandonment depression. They then become quite vulnerable to relapse as drugs and alcohol modulate feelings of abandonment. Drugs can provide escape or avoidance of the pain (Richards, 1993, p. 245). Relapse potential, particularly in relation to personality issues, needs to be addressed directly and clearly. It is important that these individuals see the impact of their dependency choices in regard to drugs and alcohol as in other areas of their lives.
Since individuals with DPD follow the lead of those around them, it is particularly important to assess their social environment to locate areas of peer pressure or the social function of their drug use. NA or AA contacts will be easy for these individuals but there is no assurance that they will seek out and attach to the healthier and more sincere members of their groups. They can often be prey for more aggressive or narcissistic people in any system. Treatment must be centered on managing dependency; specific guidance and reinforcement of preferred interpersonal attachments are often crucial to addicted individuals with DPD (Richards, 1993, p. 245).
Individuals with DPD are likely to take a depressed position in regard to their addiction. They view themselves as victims and elicit help from others. Group therapy might be quite useful in helping individuals with DPD see that other people will continue to like, accept, and assist them even if they disagree with something that is being said. This is a maturational step these individuals experience as risky (Richards, 1993, pp. 238-242). Group treatment is also effective in confronting individuals with DPD about their absolution of themselves from taking responsibility for their choices and their behavior. It is important to remember that, for individuals with DPD, self-destructive behavior in the service of relationship maintenance will look like a reasonable trade-off, no matter what it looks like to others. Group members can be effective in pointing out the impact of abusive or self-destructive relationships.
Of concern, particularly in the treatment of addicted Individuals with severe DPD is their potential for disinhibition and violence if they feel seriously threatened. These individuals usually have low activity levels and barely discernible aggression. However, they can become paranoid and even violent if their basic dependency is threatened. If they feel both endangered and are intoxicated, individuals with severe DPD have made mortal attacks on their families. Also, because of their avoidance of adult activities, immaturity, and self-identity as a child, sexual offenses against children have been made, particularly during times of intoxication and abandonment by another adult (Richards, 1993, p. 244).
Confrontation usual to substance abuse treatment should be modified to meet the severity of the dependent personality disorder. For individuals with severe DPD, confrontation will trigger fantasies of rescue from a protective other outside of the treatment process. Modulated confrontation that emphasizes self-empowerment sill also assist in addressing characterological issues.
Abstinence should be a goal of treatment. If it is a prerequisite, most individuals with DPD will remain self-destructive in the service of protecting a relationship rather than accept treatment-- unless involvement with the criminal justice system can leverage them out of the negative situation.