HEALTHY AND UNHEALTHY

5
DEPENDENCY
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Chapter 4 focused on situational variability in dependency and the ways

in which internal processes and external factors combine to determine the
outward expression of underlying dependency needs. In this chapter I exam-
ine individual differences in dependency-related behavior. Although many
mental health professionals associate dependency with a pervasive pattern of
help- and reassurance-seeking, studies show that people actually express un-
derlying dependency needs in many different ways. Some manifestations of
dependency are reasonably adaptive; others are not. Moreover, maladaptive
expressions of dependency take a variety of forms—passive and active, obvi-
ous and subtle, consistent and variable, direct and indirect. As discussed in
chapter 3, concerns regarding dependency and relatedness affect us from in-
fancy through old age, and the mere presence of dependency strivings—even
relatively intense dependency strivings—is not, by itself, problematic.
This chapter is divided into two parts. First, I discuss differences be-
tween unhealthy dependency and healthy dependency, providing a frame-
work the clinician can use to distinguish patients whose difficulties reflect
maladaptive dependency from patients who appear overly dependent, but
whose difficulties actually lie in other areas. Second, I describe the most com-

73
http://dx.doi.org/10.1037/11085-005
The Dependent Patient: A Practitioner's Guide, by R. F. Bornstein
Copyright © 2005 American Psychological Association. All rights reserved.
 mon unhealthy dependency styles encountered in clinical settings, using two
recently developed theoretical frameworks to conceptualize and classify these
dependency styles.

DISTINGUISHING HEALTHY AND UNHEALTHY DEPENDENCY

Numerous factors—some situational, others stemming from practition-

er expectations and experience—interfere with accurate interpretation of
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patient behavior. Studies show that these distortions can bias the clinician's
perceptions of a broad range of personality and psychopathology variables,
including—but not limited to—dependency (see Cantor, Mischel, &
Schwartz, 1982; Cantor, Smith, French, & Mezzich, 1980). These informa-
tion-processing distortions have different biasing effects on different person-
ality traits, but in most cases they lead the clinician to overperceive depen-
dency in patients, especially female patients. Two factors are responsible for
this widespread "dependency overestimation bias":

• Context and role effects. Because mental health professionals as-

sociate dependency with pathology, many practitioners inter-
pret the mere act of treatment-seeking as evidence of depen-
dency (Cadbury, 1991; Games, 1984). As a result, they attribute
dependency-related characteristics to anyone who enters vol-
untarily into the patient role. This process—which occurs
automatically and unconsciously—is essentially a clinical mani-
festation of what social psychologists call the fundamental attri-
bution error: peoples' tendency to disregard contextual informa-
tion and attribute any salient behavior exhibited by another
person to dispositional (i.e., trait) factors (Gilbert & Malone,
1995). Given societal stereotypes regarding gender and gender
role, this attribution error is particularly likely to occur when a
woman enters into the patient role (Banaji, Hardin, &
Rothman, 1993; Gilbert, 1987).
• Presenting complaints. Many of the concerns that patients dis-
cuss early in treatment are associated with dependency in the
minds of clinicians. These include depression, anxiety, low self-
esteem, lack of assertiveness, jealousy and insecurity, ambiva-
lence regarding termination of a longstanding relationship, and
exploitation or victimization by a trusted other. Some of these
issues are empirically linked with dependency (e.g., depression,
exploitation), but others (e.g., termination ambivalence) are
not (Blatt & Zuroff, 1992; Nietzel & Harris, 1990). Nonethe-
less, on hearing these presenting complaints clinicians may in-
stinctively develop a working hypothesis of underlying depen-

74 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

 dency in the patient. Once in place, such a hypothesis can be
difficult to revise or reject.1
Misperceptions notwithstanding, not all dependency-related behaviors
are dysfunctional. As discussed in chapter 4, some of these behaviors are
actually quite adaptive and promote healthy functioning in social, medical,
and work settings. Thus, it is useful, both conceptually and clinically, to dis-
tinguish healthy dependency from unhealthy dependency. Two brief definitions
capture the essential features of these contrasting relationship styles:
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" Unhealthy dependency is characterized by intense, unmodulated

dependency strivings that are exhibited indiscriminately and
reflexively across a broad range of situations.
• Healthy dependency is characterized by dependency strivings
that—even when strong—are exhibited selectively (i.e., in
some contexts but not others) and flexibly (i.e., in situation-
appropriate ways).

In the following sections I place the concept of healthy dependency in

an appropriate theoretical context and explore the contrasting interpersonal
and intrapsychic dynamics of healthy dependent and unhealthy dependent
persons. I then review assessment tools the practitioner can use to supple-
ment clinical observation in determining whether a particular patient ex-
presses underlying dependency needs in a healthy or unhealthy way.

Conceptual Issues

Although unhealthy dependency has a long history in psychology and

psychiatry, the concept of healthy dependency is relatively new. Specula-
tion regarding the possibility that dependent urges could be expressed
adaptively first appeared during the 1950s, in the writings of psychoana-
lytic (e.g., Goldman-Eisler, 1951) and trait theorists (e.g., Leary, 1957).
These theorists used different terminologies and conceptual frameworks,
but they agreed that certain forms of dependency play a critical role in
early social development and ultimately form the basis of healthy adoles-
cent and adult relationships. Following the delineation of these psychody-
namic and trait models, behavioral researchers explored the value of de-
pendent behaviors in facilitating learning and skill acquisition (e.g., Hartup,

'As Mahoney (1977) noted, this tendency to cling to an initial hypothesis even in the face of
contradictory data reflects confirmatory bias on the part of the clinician—selective attention to
supporting evidence, coupled with inattention to (or discounting of) evidence that contradicts one's
favored position. Confirmatory bias is problematic in the clinical setting, but it is not limited to this
context. Studies show that confirmatory bias also distorts the processing of hypothesis-relevant
information by experienced scientists (Mahoney, 1976, 1987).

HEALTHY AND UNHEALTHY DEPENDENCY 75

 1963; Sinha & Pandey, 1972). These behavioral analyses helped refine and
reify the instrumental-emotional dependency distinction initially described
by Heathers (1955) and others.2
Despite periodic references to adaptive features of dependency during
the 1950s and 1960s, the notion that dependent urges could actually en-
hance adjustment and functioning was not taken seriously until two devel-
opments—one theoretical, one empirical—laid the groundwork for a
paradigm shift in this area. In the theoretical realm, dependency was recon-
ceptualized within the context of attachment theory by Ainsworth (1972,
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1989), Bowlby (1969, 1973), and others (e.g., Alperin, 2001; Hetherington,
1999). Using these frameworks, researchers discovered a surprising degree of
continuity in dependency-related attachment behaviors from childhood
through adolescence and beyond (Feeney &Noller, 1990; Gjerde, 2001; Main,
Kaplan, & Cassidy, 1985).
The other major development took place in the empirical arena, where
Masling and his colleagues' pioneering studies demonstrated the adaptive
features of dependent personality traits in psychotherapy patients, college
students, and community participants (see Masling, 1986, for a review). These
studies showed that when high levels of dependency are coupled with effec-
tive defenses and good coping skills, they can actually enhance functioning
in a variety of social and occupational contexts. Later investigations (e.g.,
Bornstein & Kennedy, 1994; Pincus & Wilson, 2001) confirmed and ex-
tended Masling's (1986) results.
In its contemporary usage, the term healthy dependency overlaps with
several other constructs in psychology, sociology, and medicine. These in-
clude adaptive dependency (Bornstein, 1998d), compensatory dependency (Bakes,
1996), interdependence (Cross & Madson, 1997), connectedness (Clark & Ladd,
2000), and mature dependency (Baumeister & Leary, 1995). The essential
features of these five constructs are summarized in Table 5.1. As the defini-
tions in Table 5.1 show, these constructs overlap to some degree, but they are
not isomorphic. Moreover, healthy dependency differs from each of these
constructs, both conceptually (Bornstein, 1995a) and empirically (Bornstein
&Languirand, 2003).3

2
Early humanistic theorists also made reference to the adaptive features of dependency (e.g., Maslow,
1958; Rogers, 1963), but these frameworks have had less influence than other models on
contemporary approaches to diagnosis, assessment, and treatment of the dependent patient (cf.
Florian, Mikulincer, & Hirschberger, 2002; Harrison, 1987).
3
Healthy dependency also overlaps with the construct of insecure attachment (Collins & Read, 1990;
Sundin, Armelius, & Nilsson, 1994), but there are noteworthy differences as well. Studies show that
insecure attachment is associated with substantially greater behavioral consistency than healthy
dependency, which is expressed in very different (even diametrically opposing) ways in different
relationships (Bornstein, Riggs, Hill, & Calabrese, 1996; Heiss, Herman, & Sperling, 1996). Beyond
these behavioral differences, studies confirm that healthy dependency scores are only modestly related
to scores on measures of insecure attachment, with correlations typically in the r = 30-.40 range
(Bornstein et al., 2003; Pincus & Wilson, 2001).

76 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

 TABLE 5.1
Healthy Dependency in Context: Related Theoretical Constructs
Construct Definition
Adaptive dependency Situation-specific help- and support-seeking that
facilitates task performance and strengthens
interpersonal ties
Compensatory Goal-directed dependent behavior in one domain that
dependency enhances autonomous functioning on one or more
other domains
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Interdependence Mutual (usually constructive) dependency between

two individuals, groups, or larger entities (e.g.,
corporations, nations)
Connectedness The experience of closeness/intimacy coupled with a
firm sense of autonomy/individuality ("self-in-
relation-to-others")
Mature dependency Similar to connectedness, with the additional
implication that the individual is willing to lean on
others and be influenced by external sources
Note. Detailed discussions of these constructs are provided by Tail (1997), Baumeister and Leary (1995),
Clark and Ladd (2000), Cross and Madson (1997), and Hetherington (1999).

Contrasting Self-Presentations

Although healthy dependent and unhealthy dependent patients often

present with similar problems, they differ in the manner in which they de-
scribe these problems. Four aspects of a patient's initial self-presentation (sum-
marized in the top portion of Table 5.2) can help the clinician determine
whether that patient's dependency is healthy or unhealthy:
• Insight. At the outset of therapy, patients with unhealthy de-
pendency typically show little insight regarding the role that
underlying dependency needs play in their current difficulties.
Healthy dependent patients not only show greater initial in-
sight, but as therapy progresses they also show greater capacity
to use this insight to effect positive change (Blatt & Ford, 1994;
Bomstein, 1994c, 1998a). Healthy dependent patients display
what Weissmark and Giacomo (1998) referred to as relationship
reactivity: They are able to integrate therapist feedback into their
working self-concept and use this information to modify dys-
functional behavior patterns.
• Social skills. Although research confirms that dependency is as-
sociated with sensitivity to interpersonal cues (Masling,
Johnson, & Saturansky, 1974; Masling, Schiffner, & Shenfeld,
1980), unhealthy dependent patients are unable to apply this
information effectively in real-world situations. Even when
patients with unhealthy dependency accurately decode subtle
verbal and nonverbal signals, their ability to use this knowl-

HEALTHY AND UNHEALTHY DEPENDENCY 77

 TABLE 5.2
Unhealthy and Healthy Dependency:
Constrasting Self-Presentations and Intrapsychic Dynamics

Dimension Unhealthy dependency Healthy dependency

Insight Poor at outset; modest Good at outset; potential
gains over time for greater gain over
time
Social skills Compromised by chronic Able to apply social
anxiety information effectively
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Therapeutic goals To be "fixed" (or "cured") Enhanced self-efficacy,

Relationship quality
Urgency of experienced
dependency needs
Defense effectiveness
Impulse control
Cognitive complexity
Note. The first four dimensions in this table reflect self-presentation differences; the second four
dimensions reflect contrasting intrapsychic dynamics.
by an omniscient
therapist
Few close relationships;
fixed roles and limited
range of dynamics
Compulsive ("mindless")
help- and support-
seeking
Relatively immature (e.g.,
projection, denial);
ineffective in managing
anxiety
Poor; regression under
stress
Simple, conceptually
unsophisticated self-
representation
intimacy, and
parenting-career skills
Dense social network;
role flexibility
Selective, situation-
appropriate help- and
support-seeking
Relatively mature (e.g.,
sublimation, humor);
effective in managing
anxiety
Good; can moderate
impulses through
internal means
Complex, conceptually
sophisticated self-
representation

edge is impaired by chronic anxiety that drains cognitive re-

sources and leads to "mindless" (i.e., reflexive) support- and
reassurance-seeking (Alam, 1986; Overholser, 1996). Because
healthy dependent patients have a lower baseline anxiety level,
they apply social information more effectively and display bet-
ter social skills than do patients with unhealthy dependency.4
Therapeutic goals. Even when healthy and unhealthy depen-
dent patients report similar presenting complaints, they almost
invariably have different therapeutic goals. Unhealthy depen-
dent patients typically enter treatment with the explicit or im-
plicit agenda of being "fixed" or "cured" by an omniscient, om-

4
The "mindlessness" of unhealthy dependency is a key factor in its maladaptive impact on social and
occupational functioning. As Langer (1989) pointed out, longstanding behavior patterns tend to be
exhibited automatically and reflexively whenever relevant situational cues are encountered (see also
Bargh & Chartrand, 1999). In the case of dependency, these cues typically take the form of protectors
and caregivers (and even here, the dependent person is likely to misperceive others as potential
caregivers when in fact they are not). As Bornstein and Languirand (2003) noted, by replacing
"mindless" with "mindful" responding, the dependent individual can begin to express underlying
dependency needs in more adaptive, situation-appropriate ways.

78 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

 TABLE 5.3
Unhealthy and Healthy Dependency: Contrasting Relationship Patterns
Relationship
domain Unhealthy dependency pattern Healthy dependency pattern
Friendship Possessiveness, jealousy, Openness, relationship
overidentification, identity flexibility, clear boundaries
merging
Romance Self-validating/narcissistic Mature intimacy/relatedness,
intimacy, sexual insecurity open communication
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Parenting Autonomy-squelching parenting, Authoritative parenting, flexible

variable/inconsistent limit- limit-setting
setting
Work Difficulty taking responsibility, Interdependence, cooperation,
self-promotion, territoriality collegiality, group focus
Note. Detailed discussions of these contrasting relationship patterns are found in Bornstein and
Languirand (2003).

nipotent therapist (Coen, 1992; Emery & Lesher, 1982;

Overholser, 1987). The therapeutic goals of the healthy de-
pendent patient, in contrast, tend to center on enhancing self-
efficacy, improving parenting and career skills, and developing
greater intimacy in close relationships (Bornstein & Languirand,
2003).
• Relationship quality. Unhealthy dependent patients differ from
healthy dependent patients in the quality of their interpersonal
ties (Nelson, Hammen, Daley, Burge, & Davila, 2001). The
unhealthy dependent patient's relationships invariably share a
common core dynamic, with the patient assuming the role of
care receiver, and those closest to him functioning primarily as
caregivers (Rathus & O'Leary, 1997; Whiffen & Aube, 1999).
Healthy dependent patients have a greater number of ongoing
relationships than do unhealthy dependent patients (i.e., a
denser network of social ties), and these relationships are more
diverse, characterized by a broader array of roles (Cadbury, 1991;
Miller, 1979). Table 5.3 summarizes the contrasting relation-
ship patterns of healthy dependent and unhealthy dependent
patients in four key domains—friendship, romance, parenting,
and work—and illustrates these role flexibility differences.

Divergent Intrapsychic Dynamics

Healthy dependent and unhealthy dependent patients not only differ

with respect to outward self-presentation, but private experience as well. Four
domains of intrapersonal functioning (summarized in the bottom portion of
Table 5.2) distinguish healthy from unhealthy dependency:

HEALTHY AND UNHEALTHY DEPENDENCY 79

 Urgency of experienced dependency needs. Even when their un-
derlying dependency needs are equally intense (as reflected in
comparable scores on projective measures; see Bornstein, 1999),
healthy dependent and unhealthy dependent patients expert-
ence their dependency urges differently. Unhealthy dependency
is characterized by intense cravings for support that have a com-
pulsive, pressured quality. Healthy dependency is characterized
by urges that are more intermittent and less intense. This dif-
ference is in part a product of the individual's self-concept: The
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patient with unhealthy dependency has a pervasive sense of

vulnerability that cuts across a broad range of contexts (Blatt,
1974,1991;Bomstein, 1996a). The healthy dependent patient's
self-representation is more balanced and less extreme; her un-
derlying vulnerability is attenuated by a sense of self-efficacy in
some situations and settings.
Defense effectiveness. Dependency is associated with what
Ihilevich and Gleser (1986) termed a "turning against self de-
fense configuration, wherein anger and resentment are bottled
up and channeled inward (Berman & McCann, 1995). Within
the context of this internalizing style, however, patients with
unhealthy dependency tend to rely on less mature—and less
effective—defenses (e.g., projection, denial; see Lingiardi et al.,
1999; Vaillant, 1994). Healthy dependent patients utilize more
mature defenses (e.g., sublimation, humor), which enable them
to moderate anxiety more effectively.5
Impulse control. The more mature defenses of healthy depen-
dent patients enhance their ability to manage urges through
internal means. Thus, healthy dependent patients are better
able to control dependency-related impulses (e.g., help-
seeking) that—when expressed indiscriminately—lead to prob-
lems in social and occupational functioning (Mongrain, 1998;
Nelson, Hammen, Daley, Burge, & Davila, 2001). Patients with
unhealthy dependency have greater difficulty controlling these
impulses and may regress under stress, displaying immature,
childlike behavior that alienates those close to them (e.g., physi-
cal clinging, theatrical helplessness; see Haaga, Fine, Terrill,
Stewart, & Beck, 1995; Hollender, Luborsky, & Harvey, 1970;
Overholser, 1996).
Cognitive complexity. The self-representation of the healthy
dependent patient is more complex and nuanced than that of
the unhealthy dependent patient: It has been integrated at a

'Detailed discussions of the links between dependency and defense style are provided by Cramer,
Blatt, and Ford (1988); Devens and Erickson (1998); and Levit (1991).

80 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

 higher conceptual level (Blatt, 1991) and contains a broader
array of self-relevant traits (Cross et al., 2000; Kuperminc, Blatt,
& Leadbeater, 1997; Little & Garber, 2000). As a result, the
healthy dependent patient is capable of productive introspec-
tion, flexible interpersonal responding, and effective coping with
challenge and loss (Neuberg & Fiske, 1987; Solomon & Haaga,
1993; Tjosvold & Fabrey, 1980; Yasunaga, 1985).6

Assessment Tools
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As Table 5.3 illustrates, a variety of indicators can help the clinician

distinguish healthy dependent from unhealthy dependent patients during
the initial intake and therapy sessions. Some of these indicators (e.g., thera-
peutic goals) are revealed through patients' reports of current mental states,
whereas others (e.g., insight) are reflected in patients' descriptions of past
and present relationships, and still others (e.g., defense effectiveness, im-
pulse control) are best assessed via careful observation of patient functioning
within the clinical setting.
Beyond these clinical data, two psychological tests may be useful in
distinguishing healthy from unhealthy dependency, and in refining the
clinician's initial impressions. Both instruments were introduced briefly in
chapter 2. Here I focus on practical use of these instruments in the clinical
setting.

The Depressive Experiences Questionnaire for Adolescents (DEQ-A)

Although the DEQ-A—like the original version of the DEQ—was de-

signed to assess anaclitic and introjective personality traits. Subsequent clus-
ter and facet analyses of Anaclitic scale items revealed that these items form
two subscales (Blatt, Zohar, Quinlan, Luthar, & Hart, 1996; Blatt, Zohar,
Quinlan, Zuroff, & Mongrain, 1995). Blatt and his colleagues labeled these
subscales Dependence and Relatedness, and they demonstrated that scores on
the Dependence subscale predict maladaptive behavioral tendencies akin to
those of insecure attachment, whereas scores on the Relatedness subscale
predict a higher level of functioning reminiscent of Baumeister and Leary's
(1995) mature dependency. Ten DEQ-A items (2, 19, 22, 23, 26, 28, 38, 42,
46, and 52) compose the Dependence subscale, while eight items (9, 20, 32,
34, 45, 50, 55, and 65) compose the Relatedness subscale. Norms and con-
struct validity data for these subscales are provided by Blatt, Zohar, Quinlan,
Luthar, and Hart (1996) and Blatt, Zohar, Quinlan, Zuroff, and Mongrain

'Cognitive complexity is also adaptive in the cateer domain, and several investigations have shown
that relative to those people who are less cognitively complex, cognitively complex persons (a) are
able to make vocational choices that fit well with their skills and interests and (b) show more rapid
career progress and higher levels of career satisfaction (Bodden, 1970; Feist, 1994; Stein, 1994).

HEALTHY AND UNHEALTHY DEPENDENCY 81

 (1995). The DEQ-A can help distinguish unhealthy from healthy depen-
dency in patients in their mid- to late teens.

The Relationship Profile Test (RPT)

The RPT yields three scores, two of which—dysfunctional overdependence
(DO) and healthy dependency (HD)—are useful in identifying healthy depen-
dent and unhealthy dependent patients (Bomstein & Languirand, 2003).
DO and HD scores can also serve as a baseline for tracking therapeutic progress,
because studies indicate that successful treatment of dependent patients is
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associated with increases in HD scores and decreases in DO scores. Norms

and construct validity data for the RPT are provided by Bornstein, Geiselman,
Eisenhart, and Languirand (2002); Bornstein, Languirand, et al. (2003); and
Bornstein, Geiselman, et al. (2004). These data focus on the differential re-
lationships of DO and HD scores with scores on measures of attachment
style, self-concept, self-esteem, identity, relatedness, gender role, life satis-
faction, and affect regulation. The RPT is useful in distinguishing unhealthy
from healthy dependency in patients age 18 and older.

UNHEALTHY DEPENDENCY PATTERNS

By late adolescence, people develop relatively stable ways of expressing

underlying dependency needs. Two theoretical frameworks are useful in con-
ceptualizing these contrasting expressions of dependency: Pincus and
Gurtman's (1995) Three-Vector Model and Bornstein and Languirand's (2003)
Four-Pattern Model. Although these frameworks use different categories and
classification schemes, there is considerable convergence between the two
perspectives, both conceptually and empirically. The surface differences be-
tween these models are due largely to their different levels of analysis: Pincus
and Gurtman's (1995) framework was derived from sophisticated circumplex
analyses of participants' responses to widely used self-report dependency tests,
whereas Bornstein and Languirand's (2003) framework was based on synthe-
sis of the empirical literature examining convergences and divergences in
the results obtained with different types of dependency measures (i.e., self-
report, projective, interview, behavioral).

Pincus and Gurtman's Three-Vector Model

Beginning with the assumption that dependency reflects a core under-

lying motivation to obtain and maintain nurturant, supportive relationships,
Pincus and Gurtman (1995) explored the latent structure of dependency by
analyzing links between participants' scores on widely used self-report de-
pendency measures and their scores on circumplex and five-factor model

82 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

 TABLE 5.4
Exploitable, Submissive, and Love Dependency
Core features
Exploitable Submissive Love
Dimension dependency dependency dependency
Predominant Tolerance of Difficulty resisting Strong need for
interpersonal exploitation/ external influence succorance and
pattern mistreatment close ties with
others
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Underlying traits High on High on neuroticism; High on neuroticism

(five-factor neuroticism low on openness
domain scores)
Adult attachment Secure/fearful Fearful Secure
style
Pathological Compulsive care- Compulsive care- None (marked
attachment seeking seeking angry absence of
behaviors and angry withdrawal)
withdrawal
Parental introjects High paternal High maternal and High maternal and
affiliation paternal affiliation; paternal affiliation
high maternal
control
Note. Detailed discussions of these findings are provided by Pincus and Gurtman (1995) and Pincus and
Wilson (2001).

trait measures (Gurtman, 1992; Pincus, 1994). They found that clusters of
dependency test items were distributed in meaningful ways across three sepa-
rate regions (or vectors) of the interpersonal circumplex and represented dis-
tinct, unhealthy dependency subtypes. These test item clusters ultimately
evolved into the three 3VDI subscales (see Pincus & Gurtman, 1995).
Table 5.4 summarizes some key features of the three dependency sub-
types described by Pincus and Gurtman (1995) and Pincus and Wilson (2001).
The intra- and interpersonal dynamics of these three dependency subtypes
differ as well, and dovetail with the trait patterns summarized in Table 5.4:
• Submissive dependency. Submissive dependents are anxious and
insecure, and they attempt to strengthen interpersonal ties by
exaggerating their vulnerability. They are particularly sensitive
to interpersonal disruption and go to great lengths to prevent
conflict situations from occurring. Submissive dependent people
assume a passive role in many relationships, display the self-
presentation style of supplication (see Table 1.3), and devote
considerable energy to accommodating other people's needs to
minimize the possibility that they will have to function autono-
mously.
• Exploitable dependency. Exploitable dependents—like submis-
sive dependents—tend to acquiesce to others' needs and de-
mands. However, in contrast to the submissive dependent, the

HEALTHY AND UNHEALTHY DEPENDENCY 83

 exploitable dependent experiences a powerful, compelling urge
to seek protection from a valued other. This can sometimes
lead to victimization, as the exploitable dependent person has
difficulty terminating dysfunctional relationships or setting lim-
its on others' behavior. Supplication and exemplification are
the exploitable dependent's favored self-presentation styles.
• Love dependency. Love dependents experience strong affiliative
strivings, and accompanying these strivings is an underlying
confidence that they will be successful in maintaining close
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ties and obtaining the help and support they desire. Love de-
pendents take a more active approach than other types of de-
pendent people to cultivating ties with valued others, use a
broader array of self-presentation styles, and are more socially
skilled than submissive and exploitable dependents.7

Bornstein and Languirand's Four-Pattern Model

Following an extensive review of the empirical literature on the etiol-

ogy and dynamics of dependency, Bornstein and Languirand (2003) identi-
fied four unhealthy dependency patterns that emerge by late childhood, coa-
lesce during adolescence, and evolve throughout adulthood in response to
changing circumstances. Preliminary findings support the validity of this four-
pattern model, although additional data are needed to confirm the utility of
the model in clinical settings and assess the covariation of these dependency
patterns with other personality traits and PDs.
Table 5.5 shows the prototypic social influence strategies of individuals
with different unhealthy dependency patterns, and the characteristic reac-
tions of others to these social influence strategies. As Table 5.5 shows, these
social influence strategies elicit a broad range of reactions, ranging from af-
fection and nurturance to hostility and anger. Although some persons show
features of a single unhealthy dependency pattern, many show features of
more than one pattern (Bornstein, Geiselman, Eisenhart, & Languirand,
2002). Moreover, these patterns may shift over time, as longstanding behav-
ior tendencies are challenged within and outside therapy (Steele, van der
Hart, & Nijenhuis, 2001).
The core features of Bornstein and Languirand's (2003) four unhealthy
dependency patterns are as follows:
• Helpless dependency. People with a helpless dependency pattern
maintain ties to others by exaggerating their vulnerability. They

7
As might be expected, Pincus and Wilson (2001) found small to moderate positive correlations
among scores on the three 3VDI subscales. For example, in their initial validation sample of 921
nonclinical participants, subscale intercorrelations were as follows: Love-Exploitable, r = .52; Love-
Submissive, r = .21; Exploitable-Submissive, r = .49.

84 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

 TABLE 5.5
Unhealthy and Healthy Dependency: Prototypic Social Influence
Strategies and Characteristic Reactions of Others
Dependency Protypic social Characteristic
pattern influence strategy reactions of others
Helpless Help- and support-seeking; Supportive-protective urges,
clinging; crying; theatrical alternating with periods of
helplessness frustration and distancing
Hostile Stated or implied threats; self- Fear, guilt, hidden resentment;
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destructive gestures; eventual withdrawal/

intimidation
Hidden Weakness; vulnerability
displays; illness/symptom
exaggeration
Conflicted Inconsistency; emotional lability;
rapid shifts between
dependency and autonomy
relationship termination
Desire to protect and nurture,
coupled with infantilization
(and possible exploitation)
Anxiety, confusion, anger,
ambivalence; periodic efforts
to restore relationship stability

present themselves as weak and emotionally needy, and they

often appear childlike and immature—easily frustrated and
quick to cry. It is tempting to think of helpless dependent people
as passive and "fragile," but in fact they are not. Their helpless-
ness is a tool through which they draw others in and trap people
into gratifying their dependency needs.
Hostile dependency. Hostile dependent people maintain ties to
others by intimidating them. On the surface, the hostile de-
pendent person may appear to be in turmoil, barely function-
ing, and on the verge of breaking down. When one looks closely,
however, it becomes clear that this surface appearance is de-
ceiving: In reality, the hostile dependent person is very much
in control. This control usually stems from some implied or
stated threat (e.g., a suicide gesture), which is designed to ex-
ploit people's guilt and prevent them from ending the relation-
ship.
Hidden dependency. Individuals who display hidden dependency
behave in an overdependent manner, but oftentimes their de-
pendent behavior is so subtle and indirect that its true nature is
not recognized by the person, or by those around her. Hidden
dependency can take many forms, from feigned illnesses to
imaginary allergies, but whatever form it takes, hidden depen-
dency functions much like the helpless and hostile dependency
patterns: It traps people into remaining involved in an unsatis-
fying relationship they might otherwise end.
Conflicted dependency. Conflicted dependent people show mark-
edly inconsistent behavior, wavering between periods of ex-

HEALTHYAND UNHEALTHY DEPENDENCY 85

 treme overdependence and superficial, short-lived episodes of
autonomy. Such people can be especially difficult to interact
with over extended periods because they are so unpredictable.
Oftentimes the conflicted dependent person will show features
of hostile dependence during her "overdependent" periods and
hidden overdependence during her "autonomous" periods.8

FROM LABORATORY TO CONSULTING ROOM: DIAGNOSIS,

Copyright American Psychological Association. Not for further distribution.

ASSESSMENT, AND TREATMENT OF DEPENDENT PATIENTS

The developmental antecedents, interpersonal dynamics, and clinical

correlates of healthy dependency are discussed in detail elsewhere (Baumeister
& Leary, 1995; Bornstein & Languirand, 2003; Clark & Ladd, 2000; Cross,
Bacon, &Norris, 2000; Gabriel & Gardner, 1999; Hetherington, 1999; Sato,
2001). Although these researchers approach the topic from a variety of per-
spectives, their analyses converge to confirm that healthy dependency helps
promote optimal functioning in many different areas of life. In the context of
clinical work with dependent patients, healthy dependency is important be-
cause it helps define the goal—the ideal endpoint—of treatment. Consistent
with the conclusions that emerged from an analysis of dependency across the
life span (chap. 3), research confirms that effective therapeutic work with
dependent patients must focus on replacing unhealthy dependency with
healthy dependency, being careful not to move the patient too far toward
independence/detachment.
The remainder of this book focuses primarily on unhealthy dependency,
with healthy dependency providing background and context for this discus-
sion. Research on healthy dependency becomes increasingly important as I
move from diagnosis to assessment to treatment, and it becomes central when
I delineate an integrated treatment model for therapeutic work with depen-
dent patients.
As I move from laboratory to consulting room, I continue to use re-
search evidence to guide the discussion. The studies reviewed in chapters 1
through 5 are relevant to clinical work with dependent patients and to these
studies will be added investigations of diagnosis and comorbidity, testing and
assessment, and treatment process and outcome. By combining laboratory
evidence with clinical data, the clinician gains a deeper understanding of the
interpersonal and intrapsychic dynamics of dependency in clinical settings.

'Patients with hostile and conflicted dependency also show features of borderline PD, so care must be
taken to distinguish these patterns in the clinical setting. Because there is considerable symptom
overlap in hostile dependent, conflicted dependent, and borderline patients, assessment (rather than
diagnostic) data are particularly useful in distinguishing these syndromes (see chap. 7 for a discussion
of this issue).

86 CONCEPTUAL AND EMPIRICAL FOUNDATIONS

 Our discussion of clinical applications begins with a review of diagnos-
tic issues (chap. 6) and an analysis of dependency-related assessment tech-
niques (chap. 7). I then outline the major psychotherapeutic approaches that
have been used with dependent patients (chap. 8) and combine the most
effective elements of these approaches into an integrated treatment model
(chap. 9). Finally (chap. 10), I discuss special treatment issues and adjunct
treatment modalities that enhance the effectiveness of traditional psycho-
therapeutic work with dependent patients.
Copyright American Psychological Association. Not for further distribution.

HEALTHY AND UNHEALTHY DEPENDENCY 87