Personality disorders are typically some of the most challenging mental disorders to treat, since they are, by definition, an integral part of what defines an individual and their self-perceptions. Treatment most often focuses on increasing coping skills and interpersonal relationship skills through psychotherapy.
Dependent Personality Disorder
Individuals with dependent personality disorder are usually quite needy for attention, valuation, and social contact. Clients with this disorder usually don't present in a dramatic fashion, but will often make repeated requests for attention to their complaints, whether these complaints are about their lifestyle, social relationships, lack of meaning in life, medical, or education. People who suffer from this disorder are often outwardly compliant with clinicians' suggestion for treatment, and will usually be passive in their overall treatment, no matter what form it takes. However, real gains in therapy may not be made easily, because the client's compliance (due to the disorder) is often only surface-deep. While the individual may be one of the easiest to see week after week or month after month in therapy, they may also be one of the most difficult because of their strong need for constant reassurance and support. Dependency upon the clinician specifically and therapy in general should be carefully monitored and avoided. Psychiatrists and physicians should be aware that individuals with dependent personality disorder will often present with a number of physical or somatic complaints. While appropriate medications need to be prescribed for these as necessary, the clinician should carefully monitor medication intake and maintenance to ensure the patient is not abusing it. Physical complaints should not be minimized or dismissed, as is often the case with someone who suffers from this disorder, but they must not also be encouraged. A simple, matter-of-fact approach works best in this case.
Clinicians in general should be wary of the therapeutic relationship with a person suffering from dependent personality disorder. The needs of the individual can be great and overwhelming at times, and the patient will often try to test the limits of the therapeutic frame for therapy. Burnout among therapists treating this disorder is common, because of the client's demands for constant reassurance and attention, especially between therapy sessions. A clear explanation at the onset of therapy about how treatment is to be conducted, including a discussion of appropriate times and needs for contacting the clinician in-between sessions, is vitally important. While rapport and a close, therapeutic relationship must be established, the boundaries in therapy must also be constantly and clearly delineated.
As with all personality disorders, psychotherapy is the treatment of choice. Treatment is likely to be sought by individuals suffering from this disorder when stress or other complications within their life have led to decreased efficiency in life functioning. As with all other personality disorders as well, they may present with a clear Axis I diagnosis and the personality disorder may only become apparent after a few sessions of therapy.
The most effective psychotherapeutic approach is one which is focused on solutions to specific life problems the patient is presently experiencing. Long-term therapy, while ideal for many personality disorders, is contra-indicated in this instance since it reinforces a dependent relationship upon the therapist. While some form of dependency will exist no matter the length of therapy, the shorter the better in this case. Termination issues will likely be of extreme importance and will virtually be a litmus test of how effective the therapy has been. If the individual cannot end therapy successfully and move on to become more self-reliant, it should not be seen as a therapeutic failure. Rather, the individual was not likely seeking life-changing therapy in the first instance but instead solution-focused therapy.
Examining the client's faulty cognitions and related emotions (of lack of self-confidence, autonomy versus dependency, etc.) can be an important component of therapy. Assertiveness training and other behavioral approaches have been shown to be most effective in helping treat individuals with this disorder. Group therapy can also be helpful, although care should be utilized to ensure that the patient doesn't use groups to enhance existing or new dependent relationships. Challenging dependent relationships the client has with others that may be unhealthy for the client should generally be avoided at the onset of therapy. As therapy progresses, these challenges can occur but must be done carefully; restraint must be used if the individual is not ready to give up these unhealthy relationships.
Termination of therapy with a person who has this disorder is an extremely important issue to consider. While termination should always be a joint decision between the clinician and the client, people with this disorder often don't know "how much is enough" therapy. The therapist, therefore, may need to prod the patient toward ending therapy. As the end of therapy approaches, the patient is likely to re-experience feelings of insecurity, lack of self-confidence, increased anxiety and perhaps even depression. This can be typical of individuals with this disorder terminating therapy and should be treated appropriately. The clinician should not allow the patient to use these new symptoms, though, as a way of prolonging the current therapy. The goal is to end a relationship at an agreed-upon time and way. The client should be reinforced for the positive gains made in therapy and encouraged to explore their new-found autonomy or improved management of their anxious feelings.
As with all personality disorders, medications should only be prescribed for associated disorders suffered by the individual. Sedative drug abuse and overdose is common in this population and should be prescribed with additional caution. Anti-anxiety agents and antidepressants should be prescribed only when there is a clear Axis I diagnosis in conjunction with the personality disorder. Physicians should resist the temptation to over-prescribe to someone with this disorder, because they often present with multiple physical complaints or anxiety. The anxiety in this instance is clearly situationally-related and medication may actually interfere with effective psychotherapeutic treatment.
Giving any individual with a personality or mental disorder a placebo drug for its perceived value by the patient is ethically questionable. Doctors rarely have need to prescribe a vitamin or other non-psychoactive substance unless a patient's medical condition clearly indicates it. When such a prescription is made, it should be made with the clear understanding what it is being prescribed for. Any indirect suggestion that such a medication will help an individual overcome their feelings of insecurity, inadequacy, need for dependence, etc. should be avoided. A medication should not be prescribed because of its "magical" effects, and more expensive medications should not be prescribed over less-expensive medications just because they are "newer." Prescriptions should always be written for a specific medication because of the research suggesting its effectiveness with the patient's specific medical complaint or diagnosed mental disorder and avoidance of intolerable side-effects.
The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Suggesting such a support group later in treatment, to help put some of their new skill sets to use in a group setting, may be helpful. Many support groups exist within communities throughout the world that are devoted to helping individuals with this disorder share their commons experiences and feelings.
Individuals should likely avoid using a support group as the only means of treatment for this disorder, since it is likely to encourage additional dependent relationships.
Portions are from Internet Mental Health, Copyright © 1995-1996 by Phillip W. Long, M.D.