Depathologizing dependency

Assessing Burdening Guilt and Its Correlates

Burdening guilt refers to the belief that one's emotions, needs, and ways of being are a burden to others, and is one type of interpersonal guilt proposed by the control-mastery theory (CMT). The aim of this article is to validate two new measures of burdening guilt. In the two studies conducted, we examined the psychometric properties of these scales and the relationship between burdening guilt and self-perceived burden (burdensomeness), self-esteem, shame, anxiety, depression, mental health, attachment insecurity, adverse childhood experiences, social desirability, empathy, and suicidal ideation. In Study 1, we presented a newly developed Burdening Guilt Rating Scale (BGRS) and its correlation with measures of the abovementioned dimensions. In Study 2 we verified, through confirmatory factor analysis and correlation techniques, the possibility of expanding the Interpersonal Guilt Rating Scale-15 with a shorter, 5-item burdening guilt scale derived from the BGRS, and showed that this shorter scale correlates similarly to the longer one. Findings allowed us to validate these new scales providing empirical measures of burdening guilt-a theoretical concept with important clinical implications.

Assessing the Impact of Relationship Profile Test Scores, Self-Identified Ethnic Group, and Gender on Adult Attachment Style

Research shows that the subscales of the Relationship Profile Test (RPT) are related to adult attachment. Gender differences have been implicated, but findings are inconsistent in terms of replication. A limited amount of research has been conducted on ethnic differences in the context of interpersonal dependency. This study aims to bridge the gap in the literature in terms of using the RPT to predict attachment styles and to assess gender and ethnic group differences in RPT scores. Four samples from various treatment settings were combined to yield a heterogeneous group of ethnically diverse men and women (N = 470) with a mean age of 31.96. No gender differences were observed; however, ethnic differences were noted, with the RPT scales predicting unique variance in secure and insecure attachment styles. This study evidences the incremental validity of the RPT scales when predicting adult attachment style with consideration of ethnic group differences, which can help inform the treatment and assessment process.

A Multimethod Investigation of Sex, Romantic Relationships, and Interpersonal Dependency

An individual's level of interpersonal dependency influences the way they engage with others, and researchers have achieved a comprehensive understanding of the interplay between dependency and interpersonal relationships across an array of social situations. This knowledge has improved the efficacy of medical and psychotherapeutic work with dependent clients and has informed approaches taken to reduce the societal costs of dependent personality disorder (e.g., increased risk for suicide and self-harm, perpetration of child abuse, perpetration of domestic violence, victimization by a partner, and physical illness). Relatively little research, however, has explored dependency's links to sexual activity and sexual functioning, the findings of which stand to offer knowledge valuable to sex counseling, couples therapy, sexual health, and our overall understanding of sexuality. The current study utilized a multimethod research design to explore dependency as it relates to sexual and romantic relationships and sexual activity. Multiple associations emerged between dependency, both interpersonal dependency and a healthy variant of dependency, and sexual activity. Based upon these findings and contemporary literature, an initial discussion of some of the therapeutic implications of this knowledge and suggestions for working with dependent clients are offered.

Psychotherapy of Dependent Personality Disorder: The Relationship of Patient-Therapist Interactions to Outcome

So far, only a few studies have focused on psychotherapy for Dependent Personality Disorder (DPD). DPD is marked by a repetitive pattern of efforts aiming at maintaining close relationships, which may present as a lack of assertiveness and as a difficulty in making routine decisions. The present study aims at exploring processes of change taking place during the working phase of a clarification-oriented psychotherapy (COP) by focusing on the in-session patient-therapist interaction, as it changes during treatment and their links with treatment outcome. Methods: N = 74 patients with DPD were recruited in a naturalistic setting; they underwent long-term COP. Sessions 15, 20 and 25 were video- or audio-recorded and analyzed using the Process-Content-Relationship Scale, an observer-rated instrument that measures the quality of the interaction processes from patient's and therapist's perspectives. Therapy outcomes were assessed with the Personality Inventory - Dependency Subscale, Beck Depression Inventory, Inventory of Interpersonal Problems and Self-efficacy Scale at intake and discharge of therapy. Three-level Hierarchical Linear Modeling was applied to test the hypotheses. Results: Improvement in interaction processes was observed in all patient's and therapist's variables over the sessions 15, 20, 25. Overall, this increase in quality of interaction process was unrelated with outcome, but decrease in dependency traits was predicted by increase in therapist's quality of relationship offer, understanding of content and directivity over the course of the working phase of COP. Conclusions: Studying interaction processes in DPD provides an initial understanding of differential roles of potential mechanisms of change in effective treatment.

Self-criticism, interpersonal conditions, and biosystemic inflammation in suicidal thoughts and behaviors within mood disorders: A bio-cognitive-interpersonal hypothesis

We review the theoretical and empirical literature on the role of self-concept in suicidal behavior in the context of mood disorders (i.e., unipolar depression and bipolar spectrum disorders). The main themes emanating from this review are then juxtaposed against (a) the Interpersonal-Psychological Theory of Suicide and (b) biological research on the role of inflammatory processes in suicidality. Such a juxtaposition paves the way for a bio-cognitive-interpersonal hypothesis. Pathologies of the self-concept-primarily self-criticism-propel mood disorder sufferers to generate interpersonal stress that culminates in two proximal causes of suicidality: thwarted belongingness and perceived burdensomeness. In turn, these two interpersonal conditions set in motion systemic biosystemic inflammation, serving as a proximal cause for suicidality in mood disorders. We conclude by describing a research project aimed at testing this hypothesis, and by outlining pertinent implications for assessment, treatment, and prevention.

Role of adolescent exposure to rockets in the links between personality vulnerability and psychopathology

The aim of this study is to examine the role of repeated exposure to rocket attacks in the links between personality vulnerability (dependency and self-criticism) and internalizing/externalizing psychopathology. A main-effect vulnerability model (personality leads to psychopathology) was compared with a main-effect scarring model (psychopathology leads to personality vulnerability). Also, a stress-diathesis pattern (personality vulnerability is activated under stress) was compared to a dual-vulnerability pattern (either personality vulnerability or stress, but not both, lead to psychopathology). Israeli adolescents (N = 362) repeatedly exposed to rocket attacks were assessed annually over 3 years. In 2008 and 2010, personality and psychopathology were assessed. Cumulative exposure was measured as the sums of exposure across the three assessment waves. Theoretical models were tested via Autoregressive Cross-Lagged Structural Equation Modeling analyses. Baseline dependency and self-criticism were associated with an increase in anxiety, whereas baseline depression was associated with an increase in dependency. Under low, not high, levels of rocket exposure, self-criticism and depression were longitudinally associated. Violence commission was associated with an increase in dependency under high, not low, cumulative exposure. Results are consistent with both scarring and vulnerability models, and with both stress-diathesis and dual-vulnerability patterns of adolescent risk and resilience.

When the "Golden Years" Turn Blue: Using the Healthy Aging Literature to Elucidate Anxious and Depressive Disorders in Older Adulthood

Current treatments for disorders of emotion, like pathological anxiety, are often less effective in older adults than in younger adults and have poorly understood mechanisms, pointing to the need for psychopathology models that better account for age-related changes in normative emotional functioning and the expression of disordered emotion. This article describes ways in which the healthy aging and emotion literature can enhance understanding and treatment of symptoms of anxiety and depression in later life. We offer recommendations for how to integrate the healthy aging literatures' theories and findings with psychopathology research and clinical practice, and highlight opportunities for future research.

Self-compassion mediates the link between dependency and depressive symptomatology in college students

Depression is highly prevalent among college students and is associated with significant morbidity and mortality. Dependency is among the known personality traits that predict an elevated risk for depression. Prior research has focused on the depressogenic role of self-critical thoughts among destructive overdependent (DO) individuals but has not considered other internal processes (such as self-compassion) that might influence mental health. The current report examined whether self-compassion had either moderating or mediating effects on the links between dependency and depression in college students. In a cross-sectional study, 85 college students completed measures of dependency, self-compassion, and depressive symptoms. Analyses suggested that self-compassion mediated both the effect of DO on depressive symptoms and the effect of healthy dependency (HD) on lower depressive symptoms; self-compassion did not moderate links between dependency and depressive symptoms. Our exploratory findings suggest that positive self-schema (in the form of self-compassion) may contribute to the downstream mental health effects of both adaptive HD and maladaptive DO.

Construct Validity of the Relationship Profile Test: Links With Measures of Psychopathology and Adult Attachment

This study assessed the construct validity of the Relationship Profile Test (RPT; Bornstein & Languirand, 2003 ) with a substance abuse sample. One hundred-eight substance abuse patients completed the RPT, Experiences in Close Relationships Scale-Short Form (Wei, Russell, Mallinckrodt, & Vogel, 2007 ), Personality Assessment Inventory (Morey, 1991 ), and Symptom Checklist-90-Revised (Derogatis, 1983 ). Results suggest that the RPT has good construct validity when compared against theoretically related broadband measures of personality, psychopathology, and adult attachment. Overall, health dependency was negatively related to measures of psychopathology and insecure attachment, and overdependence was positively related to measures of psychopathology and attachment anxiety. Many of the predictions regarding RPT detachment and the criterion measures were not supported. Implications of these findings are discussed.

Disambiguating Dependency and Attachment Among Conjugally Bereaved Adults

This study aims to investigate the effects of dependency and attachment in adjusting to the loss of a loved one by directly comparing the relative contribution of each to bereavement outcomes among midlife adults. Comparisons among attachment and dependency are made using models that control for attachment among three groups of bereaved adults (N=102): prolonged grievers (n=25), resolved grievers (n=41), and a married comparison group (n=36). Prolonged grievers displayed higher marginal means of dysfunctional detachment dependency and lower marginal means of healthy dependency compared to resolved grievers and married adults, even when controlling for attachment style. Findings suggest that attachment and dependency predict unique domains of grief outcome.

Extending the construct validity of dependency among conjugally bereaved adults

The Relationship Profile Test is a widely used measure of dependency, detachment, and healthy dependency that has been examined in both clinical and nonclinical settings, though researchers have yet to validate this measure among conjugally bereaved adults. The present study examines the construct validity of a three-facet model of dependency-detachment by comparing relationships among self-report, semistructured interview-rated, and knowledgeable informant-rated functioning among conjugally bereaved adults. Participants (N = 112) included bereaved adults (M = 51.1 years; SD = 9.7) who had experienced the loss of a spouse 1.5 to 3 years prior to taking part in this study. Findings indicate adequate psychometric properties and theoretically expected associations with various measures of wellness and health including satisfaction with life, coping flexibility, somatic complaints, and ego resiliency. Results draw attention to adaptive correlates of dependency, suggesting potentially beneficial mental health interventions.

Manifestations of interpersonal dependency and depressive subtypes in outpatient psychotherapy patients

The present study investigated the relationship between normative and pathological dependency and anaclitic and introjective depressive experiences among 71 patients participating in outpatient psychotherapy at a university-based psychology clinic. We examined the interrelationships among the Relationship Profile Test subscales, the Depressive Experiences Questionnaire subscales and the Outcome Questionnaire-45.2. Results indicated that destructive overdependence was positively correlated with anaclitic and introjective depression and negatively correlated with overall perceptions of mental health. Dysfunctional detachment was positively correlated with introjective depression and negatively correlated with generalized perceptions of one's own mental health. Healthy dependency was negatively correlated with introjective depression and positively correlated with mental health. These results not only support the construct validity of the Relationship Profile Test but also shed light on a link between depression, dependence and self-criticism.

Adaptive and Maladaptive Dependency in Bereavement: Distinguishing Prolonged and Resolved Grief Trajectories

Interpersonal dependency is typically viewed as a risk factor for prolonged grief among conjugally bereaved adults. However, emerging empirical evidence and theoretical advances suggest that one manifestation of interpersonal dependency--adaptive dependency--may serve as a protective factor in coping with loss. This study compared adaptive and maladaptive dependency across three matched groups: prolonged grievers, asymptomatically bereaved adults, and a married comparison group. Results suggest a link between adaptive dependency and asymptomatic bereavement, and between maladaptive dependency and prolonged grief.

Personality type and patient education in hand therapy

Awareness of personality differences can improve the effectiveness of treatment and patient education in hand therapy. Therapists can create treatment plans and patient education efforts that match the communication and learning styles of each individual patient.

Rethinking dependent personality disorder: comparing different human relatedness in cultural contexts

We argue that the Diagnostic and Statistical Manual of Mental Disorders dependent personality disorder is a culturally related concept reflecting deeply rooted values, beliefs, and assumptions of American individualistic convictions about self and interpersonal relationship. This article integrates social psychology concepts into the exploration of psychopathology. Beginning with the construct of individualism and collectivism, we demonstrate the limitations of this commonly used framework. The indigenous Chinese concept of Confucianism and Chinese Relationalism is introduced to highlight that a well-differentiated self is not a universal premise of human beings, healthy existence. In East Asian Confucianism the manifestation of dependence and submission may be considered individuals' proper behavior and required for their social obligation, rather than a direct display of individuals' personality. Thus, the complexity of dependent personality disorder is beyond the neo-Kraepelinian approach assumed by the Diagnostic and Statistical Manual of Mental Disorders system.

Expanding the Construct Validity of the Relationship Profile Test: Associations With Physical Health and Anaclitic and Introjective Traits

The authors examined the construct validity of the Relationship Profile Test (RPT) with respect to measures of two related constructs—physical health and well-being (functional health status), and depression-linked personality type (anaclitic vs. introjective). In Study 1, the authors administered the RPT, Depressive Experiences Questionnaire (DEQ), and Medical Outcomes Study Short Form (MOS SF-20) to 116 undergraduate students. In Study 2, the RPT, DEQ, and MOS SF-20 were administered to 110, mostly African American female, primary care outpatients. Destructive Overdependence was positively correlated with anaclitic and introjective trait scores in both samples. Dysfunctional Detachment was positively correlated with introjective scores in both samples and with anaclitic scores in the primary care sample. Healthy Dependency was negatively correlated with introjective scores in both samples and with anaclitic scores in the primary care sample. These studies support the construct validity of the RPT in ethnically diverse nonclinical and clinical samples, and extend previous findings documenting links between RPT subscale scores and scores on measures of other theoretically related constructs.

The adaptive and maladaptive faces of dependency in later life: links to physical and psychological health outcomes

OBJECTIVES

Negotiating the balance between reliance on others and desires for autonomy is a fundamental task of successful aging. The purpose of the present study was to replicate and extend a three-factor model of interpersonal dependency in a sample of older adults, and to examine the physical and psychological health correlates of this multifaceted construct.

METHODS

Data come from the third wave of a population-based study of older Americans (n = 166; mean age 80 years). We conducted an exploratory factor analysis of selected dependency items from two scales, and then conducted logistic and hierarchical linear regressions to analyze the association of dependency factors with self-reported health, use of hypertension medication, depressed affect and positive affect.

RESULTS

We found three factors closely paralleling those of Bornstein and Languirand's (Psychological Bulletin, 112(1), 3-23, 2004) measure: destructive overdependence, healthy dependency and dysfunctional detachment, as well as a fourth factor we labeled 'healthy independence'. Healthy dependency was associated with better self-reported health. Dysfunctional detachment was related to a greater likelihood and healthy independence a lesser likelihood of taking hypertension medication. Whereas both healthy independence and healthy dependency were positively related to positive affect and negatively related to depressed affect, destructive overdependence was positively related to depressed affect.

CONCLUSION

Understanding the complex nature of interpersonal dependency and autonomy in old age, as well as their implications for health and wellbeing, may enable practitioners to assist older adults in negotiating the task of balancing these needs.

Patients' self-criticism is a stronger predictor of physician's evaluation of prognosis than pain diagnosis or severity in chronic pain patients

The experience of pain is influenced by patients' personality, social and cultural background, and patient-doctor interaction. This study examines the role of self-reported pain, pain diagnosis, age, gender, depression, and the personality trait of self-criticism (defined as individuals' tendency to set unrealistically high self-standards and to adopt a punitive stance toward one's self), in determining physicians' view of expected prognosis in response to chronic pain management. Before the first visit to a tertiary chronic pain clinic, patients provided information regarding their perceived pain, depression, and self-criticism. Immediately subsequent to the visit, physicians' evaluated expected prognosis. Participating physicians were blinded to the patient's psychosocial variables collected. Sixty-four patients with chronic pain (34 women and 30 men) with various diagnoses were included. Patients' age, gender, pain diagnosis, self-reported pain, and depression did not significantly correlate with physician's estimation of expected prognosis. In contrast, patients' self-criticism emerged as an independent predictor of physicians' pessimism regarding outcome. Thus, in the chronic pain clinic setting, patients' personality, rather than self-reported pain experience, determines doctor's clinical judgment of expected prognosis.

PERSPECTIVE

Chronic pain is a multimodal negative experience that is determined by physiological, cognitive, personological, and interpersonal factors. In line with this observation, we found patients' personality, specifically, their self-criticism, determines physicians' clinical judgment of expected prognosis.

Construct validity of the relationship profile test: three-year retest reliability and links with core personality traits, object relations, and interpersonal problems

The Relationship Profile Test (RPT; Bornstein & Languirand, 2003) is a 30-item self-report measure of destructive overdependence, dysfunctional detachment, and healthy dependency. Previous research has shown that the 3 RPT subscales have adequate internal consistency, good retest reliability over 23 and 85 weeks, and good convergent and discriminant validity with respect to measures of attachment style, relatedness, gender role, self-concept, alexithymia, locus of control, need for approval, and life satisfaction. In this investigation, we assessed the 3-year retest reliability of RPT scores in a northeastern liberal arts college student sample (Study 1) and evaluated the convergent and discriminant validity of RPT scores in a southern university sample (Study 2). Results generally supported the long-term stability and convergent and discriminant validity of RPT scores but also pointed to some limitations of the measure. We discuss implications of these results and describe future research directions.

The action formulation: A proposed heuristic for clinical case formulation

The authors propose the action formulation (TAF), a heuristic for clinical case formulation. The action formulation relies on the action perspective, which depicts individuals as actively shaping their environment, and is premised upon four guidelines: (a) map the client's social environment, focusing on sources of support, chronic interpersonal difficulties, and negative and positive life events; (b) identify how the clients, in the context of their personalities, psychopathologies, and strengths, actively influence their environment; (c) differentiate between maladaptive, risk-related, interpersonal cycles, and adaptive, protective-based ones; and (d) tailor integrative techniques to short-circuit the former cycles and bolster the latter ones. Links between TAF and emerging issues in clinical assessment are discussed.

Play, pleasure, and other positive life events: "non-specific" factors in recovery from mental illness?

As part of the emerging recovery paradigm, there is an increasing need for psychiatric treatment and rehabilitation to be strengths-based and to be driven by the desires and preferences of the person with mental illness. Yet if mental illness is a brain disease, it is not at all clear how these characteristics contribute to improvement in the person's condition or influence the course and outcome of the disorder. To avoid these aspects being relegated to the role of nonspecific factors, the field must develop an understanding of the role of strengths and interests in recovery. To contribute to this effort, we review the existing empirical research on the protective and stress-buffering effects of positive life events and qualitative data on the importance of play and pleasure in the lives of people with mental illness. We conclude by considering briefly the implications of this research for clinical practice.

Construct Validity of the Relationship Profile Test: Impact of Gender, Gender Role, and Gender Role Stereotype

Research supports the construct validity of the Relationship Profile Test (RPT; Bornstein & Languirand, 2003), a 30-item, self-report measure of destructive overdependence (DO), dysfunctional detachment (DD), and healthy dependency. In this investigation, we assessed the relationships of gender, gender role, and gender role stereotype ratings to RPT subscale scores. In Study 1, we replicated earlier patterns of gender differences in RPT scores, assessed cross-sample consistency in gender difference effect sizes, and provided preliminary nonclinical norms for the RPT subscales. Study 2 showed that--as expected--DO items are perceived as stereotypically feminine, whereas DD items are perceived as stereotypically masculine. In Study 3, we examined the relationships of RPT subscale scores to masculinity, femininity, and androgyny scores. We discuss the theoretical, empirical, and clinical implications of these findings.

Construct validity of the relationship profile test: a self-report measure of dependency-detachment

This study evaluated the construct validity of the Relationship Profile Test (RPT; Bornstein & Languirand, 2003), a 30-item self-report measure of dependency-detachment that yields three subscale scores: (a) destructive overdependence, (b) dysfunctional detachment, and (c) healthy dependency. Scores on the RPT subscales generally showed the expected patterns of intercorrelations and gender differences, and comparison of RPT scores with scores on other tests supported the convergent and discriminant validity of each RPT subscale. Results of internal and retest reliability analyses were generally supportive as well, and suggested that the three RPT subscales assess aspects of the traits they purport to measure

Construct validity of the Relationship Profile Test: links with attachment, identity, relatedness, and affect

Studies suggest that overdependence and detachment have negative effects on psychological adjustment, health, and therapy process and outcome. In contrast, healthy dependency (ie., flexible, situation-appropriate help and support seeking) has beneficial effects in each of these areas. In this investigation, 90 college students (50 women and 40 men) completed a battery of personality scales including the Relationship Profile Test (RPT), a 30-item measure of destructive overdependence, dysfunctional detachment, and healthy dependency. RPT scores showed the expected patterns of subscale intercorrelations, gender differences, and links with measures of attachment style, identity, relatedness, and affect. Implications of these results for the construct validity of the RPT are discussed in the context of theoretical models of dependency-detachment.

Personality disorders

Some general recommendations can be made, collected from these subjective descriptions of personality types. Because determining an accurate psychiatric diagnosis is not the internist's aim, it is better for him or her to have a stance that generalizes to all patients, which can be refined as personality characteristics emerge. Tolerate the patient's affect (such as anger or anxiety), being firm and kind, rather than punitive or overinvested. Accept dependency and vulnerability. Accept and respect the underlying coping style. Understand that the patient's personality style is the best (and usually only) way he or she knows to have a relationship, including a relationship with the physician. Understand that personality traits additionally may have a function (e.g., to guard against anxiety or depression). Recognize that personality traits do not come in pure form. One personality trait is likely to blend into or overlap with other traits. Identify and treat any underlying symptom disorder, such as anxiety, depression, irritability, or thought disorder. Educate the patient clearly (and without patronizing) about medical illness. Document what was explained to the patient and how the patient responded, including dispassionate observations about behavior and emotional expression. Appreciate the patient's possible attachment to medical symptoms. Avoid arguments with patients who make unreasonable demands. Make timely judgments about whether or not to accede to a demand. When in doubt about a patient's honesty, give the patient the benefit of the doubt. Do not worry about being used because all patients use their physicians to some extent. Go to the limits of your tolerance for a patient's personality, but know your limits and refer to a colleague when you cannot work with the patient. Terminate an interaction and get help if there is a risk (or fear) of violence. Given the time it takes to manage the relationship and the psychiatric elements of treatment, a referral to a psychiatrist or other mental health professional often is wise if the patient will accept it. Include the mental health professional as part of the medical team. Although these various recommendations have been emphasized in connection with certain personality types, one can be flexible about their application in a variety of patients. It is important also to reiterate the limits of subjective descriptions. It is rare to find any of the aforementioned subjective descriptions in unmodified form; characteristics of more than one personality type usually appear in the same person. The descriptions are composites that provide a starting point for the physician. The physician should edit the composites based on experience with real patients. This article has described human characteristics and rough guidelines for helpful human responses and possible pharmacologic interventions. So equipped, the primary care physician may find it less troubling and more interesting to face the wide variation in human character.

Dependency in the Treatment of Complex Posttraumatic Stress Disorder and Dissociative Disorders

Dependency is a major and ubiquitous issue in the treatment of chronically traumatized patients, such as those with complex posttraumatic stress disorder (PTSD), trauma-related borderline personality disorder, and dissociative disorders. Within this context, the concept of dependency is often paired with pejorative adjectives, and is dichotomized and negatively compared to a preferred state of independence. This paper explores prevailing sociocultural and theoretical beliefs regarding dependency in the psychotherapy of trauma survivors, provides a working definition of dependency, offers an analysis of its complex nature, and describes the theory of structural dissociation, which helps illuminate the often contradictory manifestations of dependency in chronically traumatized patients. A distinction is made between secure and insecure dependency. Finally, this paper outlines the collaborative therapeutic process required to manage insecure dependency productively within a phase-oriented treatment model. Countertransference responses that interfere with a patient's conflicts regarding dependency are also discussed.