Introduction
A major reason underlying suffering and dysfunctions in patients with
Dependent Personality Disorders (DPD) lies in their tendency to predict
that some of their core, evolutionarily selected wishes will remain
unmet (Dimaggio et al., 2015; 2020). They are driven by the need for
care, that is attachment and think they are weak and powerless.
Consequently their capacity for self-soothing and self-regulation is
diminished and they over-rely on caregivers when they feel in distress
(Bornstein, 2020; Perry, 2005). Consequently they are prone to
experience intense anxiety (Bonstein, 2005; McClintock & McCarrick,
2017), and develop a series of proximity seeking behaviours, such as
conformism and surrender, though there is much individual variability
(Bornstein, 1997, 2005; 2011; Miller & Lynam, 2008). Moreover, patients
with DPD are poorly aware of aspects of their inner world, in particular
of their own wishes and goals and their autonomy and self-efficacy are
limited (Beck et al., 1990; Dimaggio et al., 2007). Such those wishes,
also termed goals or needs, include: attachment, social rank, autonomy
and exploration, group inclusion and so on (Liotti & Gilbert, 2011).
More in general, DPD sufferers hope that others will express
appreciation when they show their deed or take care of them when they
are in need, but mostly due to their life history, they predict that the
others will neglect or humiliate them when they suffer or will despise
them when they seek for appreciation. These predictions easily trigger
feelings such as anxiety, fear, shame, guilt and so on. They are driven
by core self-ideas such as “I am inferior”, “I am powerless”, “I am
alone and fragile and deserve abandonment”, which are coupled with idea
of the others as “spiteful”, “neglectful”, “threatening” and so
on. These ideas about self and others are more than just thoughts. They
are associated with bodily sensations and behavioural automatisms. This
means that when a person with DPD is driven by the need for approval,
which is part of the social rank system (Liotti & Gilbert, 2011), not
only thinks he is inferior and that others will despise him. He also
feels weak, his posture is tense, he lowers his head and shoulders, and
his actions tend toward withdrawal, flight and avoidance.
Patients with DPD are very often unable to realize what they are
thinking and feeling and to understand that they are acting guided by
their negative predictions. In the absence of full awareness of the
reasons for their suffering and social problems, the clinician must
first allow them to become aware of their own thoughts and then try to
change them. But at another level, change is difficult because it
involves not only adopting a different and more optimistic or realistic
perspective; it also involves adopting different postures and acting
differently in order to counteract automatisms, the basic elements of
their attitude.
Recently, many therapeutic approaches for a wide array of PD include
techniques aimed at working through these embodied core elements (Matos
et al., 2023; Goldman & Goldstein, 2023; Ottavi, 2019), thinking they
can increase therapy effectiveness (Heyen, 2022). Psychotherapy does not
just work through conversation, but it includes guided imagery,
chairwork, role-playing and other forms of dramatization, which means
that clinicians ask patients to re-enact, as in a theatre, their
problematic episodes. In this way the whole body is involved in
reenacting a memory, and the change itself involves the whole body. It
is not just a matter of: “Think you can respond to your mother
differently”. “The therapist’s action is more like: “Your mother is
in the room, I will play her. I will criticize you, then try to respond
to me by standing still, try to look me in the eye, and when your voice
trembles try again, until you feel more confident and stronger”. In the
same time, the body is called into action into the therapy room.
Therapist invites patients to adopt specific postures, for example
asking patients to adopt some yoga-position in order to feel stable and
present or to regulate affect. They also asks patients to change their
posture during rewriting, for example when a patient is trying to
express a wish to her partner during a guided imagery, the therapist can
ask her to breathe deeply, to raise her chin, and expand her chest so to
feel her wish a valid and meaningful and let any doubt vanish.
People with DPD are no exception. They are driven by internal and
procedural automatisms characterized by an idea of themselves as
fragile, inadequate and weak. As a consequence, when they experience
either a desire for closeness or for autonomy, they anticipate that the
other will respond belittling or rejecting them. This triggers sadness,
anxiety, fear and emptiness. They are unable to calm themselves
resorting to an inner sense of worth or of deserving love, so in order
to regulate painful affects they adopt maladaptive behaviours such as
pleasance the other, passive-aggression, caregiving in order to make
sure the other does not abandon them and perfectionism. They experience
diminished agency, that is they are unable to recognize their own
desires, ones they know stem from within and then let them guide their
actions. Overall, they have poor awareness of their own wishes and needs
and if they recognize what they would like to achieve they often
criticize it to the point of self-invalidation. As regard somatic
states, they often feel weak, devitalised or hyperaroused and
hypervigilant to signs of possible rejection, abandonment and criticism.