The Dependent Patient: A Practitioner’s Guide


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Book tackles complex phenomenon
(February 2008 Issue)

“The Dependent Patient:
A Practitioner’s Guide”
By Robert F. Bornstein
American Psychological Association
Washington, D.C., 2005

By James K. Luiselli, Ed.D., ABPP, BCBA

Do some people become dependent on psychotherapy? Are there situations that foster a dependent relationship between therapist and client? What defines de-pendency and its various manifestations? These are some of the questions pursued by psychologist Robert F. Bornstein in his book, "The Dependent Patient: A Practitioner's Guide."

Bornstein begins the book with a central premise: dependency is a vital concern in clinical practice but also "a ubiquitous feature of human experience." Among many topics, his exhaustive analysis of dependency covers laboratory and clinical data, studies with non-clinical participants and research focusing on dependent personality disorder.

There are several theories to account for dependency in the context of psychotherapy, some sharing similar characteristics but more often, incongruent concepts not easily reconciled. Bornstein examines psychoanalytic, object-relations, cognitive and social-learning perspectives on the development of "dependent personality traits." Although theories abound, one message of the book is that empirical theory testing is weak and in most cases, inconclusive.

The book reviews different assessment instruments to measure dependency via self-report inventories, interviews and clinician-administered questionnaires. Bornstein considers the advantages and disadvantages of these various methodologies and how they should be used therapeutically. An important caveat voiced by the author is that assessment has been addressed largely by academic research and not "front line" practitioners.

Bornstein spends considerable time discussing context-specific influences on patient dependency. Throughout the book he advocates for an "interactionist per-spective," in effect, understanding dependency as the interplay between personality and situational variables. This perspective, he proposes, helps explain the origins and maintenance of both healthy and unhealthy dependency.

There is a thoughtful chapter on clinical diagnosis of dependent personality disorder, evolution of the disorder through DSM-IV and commentary about associated co morbidity. I thought Bornstein's proposal and explication of empirically validated diagnostic criteria was particularly impressive.

Chapters concerning the treatment of patient dependency include many modalities. The challenge however is that there has been little research evaluating the ef-fect of psychotherapy on dependency-related behavior. Bornstein does his best to construct an "integrated treatment model" but I suspect most readers will recognize how little we know about therapeutic intervention.

"The Dependent Patient: A Practitioner's Guide" is not an easy book, in part because dependency is a complex and multidimensional phenomenon. Also, calling the book "a practitioner's guide" is misleading because the voluminous material that Bornstein presents is not easily translated on a clinical level. That said, the book is a tour de force, impeccably referenced and inarguably the best of its kind at dissecting a pervasive problem faced by mental health professionals. Reading the book may produce more questions than answers but the knowledge gained makes it a worthwhile enterprise.

James K. Luiselli, Ed.D., ABPP, BCBA, is senior vice president, applied research, clinical training and peer review at the May Institute in Norwood, Mass.