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.