In this study we addressed two main research questions. First, do levels of care dependency vary over time during treatment, and if so, how? Second, do patients’ care dependency levels relate to treatment effects with regard to symptom reduction, as well as patients’ wish to continue their treatment when the end of treatment comes into sight? On average, patients’ need for contact with their therapist(s), including a fear to end the treatment and the contact with their therapists, increased significantly over time during treatment. At the same time, however, significant decreases were found with regard to patients’ lack of perceived alternative options, as well as their self-perceived dependency levels during treatment, while patients’ submissive stance in treatment did not change significantly during treatment. Moreover, decreases in patients’ lack of perceived alternatives and patients’ self-perceived dependency were associated with reductions in mental symptoms, and/ or patients’ personality problems. Finally, all dimensions of patients’ care dependency were related to a stronger wish of patients’ to continue their treatment when the end of treatment came into sight, whereby the association between patients’ self-perceived dependency and their wish for treatment continuation remained significant even when controlling for patients’ levels of symptoms and personality problems at the end of treatment.
Theoretical Implications
The linear increase in patients’ need for contact with the therapist indicates that the longer patients are in treatment, the stronger their need to be in touch with their therapist(s) and the stronger their unease to end contact with their therapist(s). This finding confirms the results of a recent treatment-analogue study amongst students (Geurtzen et al.,
2019), and supports the iatrogenic, contextual approach to patients’ care dependency. Patients’ increased need for contact may be related to a growing bond between patients and therapists during treatment, consistent with previous studies that found positive associations between care dependency (including the need for contact) and the quality of the therapeutic alliance (Geurtzen et al.,
2018,
2019). Interestingly, an increasing level of need for contact does not seem to impact treatment
outcome in either a positive or negative way. However, as there was a positive association between patients’ need for contact with their therapist and their wish for treatment continuation, it does suggest that treatment termination becomes more challenging when patients’ have a strong need to stay close with their therapist.
The significant decreases in patients’ lack of perceived alternatives options and patients’ self-perceived dependency over the course of treatment correspond, again, with the results of Geurtzen et al. (
2019). But, these findings do not seem to reflect an adverse effect of care dependency. Actually, these findings could be seen quite optimistic and promising. When treatment progresses, patients’ start to see more possibilities besides their current treatment to deal with symptoms and personality problems, such as the help and support of other people in their natural environment. Also, this finding opposes the idea that patients who experience a strong therapeutic relationship start to devaluate other alternative options, resulting in a greater lack of perceived alternatives (comparable to the derogation effect in intimate relationships, see Lydon & Karremans,
2015; and see Geurtzen et al.,
2018 for the adoption of this idea in the mental health care setting). A possible explanation is that a reduction of experienced symptoms and personality problems during treatment goes hand in hand with patients becoming more remoralized (i.e., less demoralized, Vissers et al.,
2017). Another possible explanation is that in the final phase of treatment, therapists actively discuss treatment discontinuation with their patients, including topics such as support from patients’ family and friends, which may lead to an increase of perceived alternative options and thus a decrease of self-perceived dependency on the treatment.
Consistent with an optimistic interpretation of the present findings, we found that decreases in patients’ lack of perceived alternatives and patients’ self-perceived dependency were related to larger reductions in patients’ mental symptoms and personality problems during treatment. Thus, decreasing levels of care dependency may have beneficial effects on symptom reduction during treatment, although the reverse direction (i.e., greater reduction in symptoms leading to a decrease in patients’ care dependency) may also be possible. But, patients’ care dependency levels, especially the self-perceived dependency levels, were also associated with a stronger wish to continue treatment. These latter results confirm earlier findings (Geurtzen et al.,
2019), and are also consistent with the idea that higher levels of patients’ dependency may lead to prolonged treatment duration (e.g., Bornstein,
2005; Clemens,
2010). Thus, although
decreases in patients’ self-perceived dependency and their lack of perceived alternatives options, as found in the current study, appear to reflect a beneficial development during treatment, it seems that higher levels of care dependency can still lead to less effective and longer treatments.
As the results showed, patients’ need for contact takes a different and independent path as compared to patients’ the lack of perceived alternatives. This finding shows an interesting parallel with research on dependency in the science of intimate relationships (e.g., Rusbult et al.,
2005; see also Geurtzen et al.,
2018), showing that the lack of perceived alternatives predicts relationship continuation irrespective of the current level of satisfaction with the relationship (Rusbult et al.,
2005). In line with such findings, one could speculate that although patients’ increasing need for contact with their therapist may reflect an increasing satisfaction with the therapist, this tendency might be not problematic because it may not lead to prolonged treatment duration per se as long as patients’ lack of perceived alternatives decreases towards to end of treatment. For example because patients had insight into whether or not they needed their treatment or therapist.
The third dimension of patients’ care dependency, i.e. patients’ submissive stance in treatment, did not show a significant (linear) change during treatment, and appears to be unrelated to symptom reduction during treatment. These results are in contrast to earlier findings (Geurtzen et al.,
2018,
2019). More research is needed to fully understand whether this dimension of patients’ dependency should be seen as a reflection of a more or less stable personality characteristic, or as part of the care dependency construct.
Strengths
The current study had a number of strengths. It is the first study in which the CDQ, an instrument that specifically measures patients’ care dependency on the treatment or therapists, was assessed in a longitudinal design, within a fairly large sample of 113 patients with PDs. As a result, the study not only leads to new theoretical and clinical insights regarding patients’ dependency, but is also a further validation of the CDQ, suggesting that two of the three dimensions of the CDQ indeed measure patients’ care dependency and not trait dependency, meaning that care dependency levels may be influenced by treatment processes in this naturalistic treatment setting.
Limitations
However, the study also has some limitations. First, despite the longitudinal approach, the causal direction of the findings remains uncertain. For example, a decrease of patients’ lack of alternatives predicted a reduction in symptoms and personality problems during treatment, but the inverse may also be true: a decrease in symptoms may lead to a decrease in patients’ lack of perceived alternatives. Second, despite the relatively large sample, we had quite some missing values due to practical issues and organizational changes, which have resulted for example in therapists forgetting to distribute the questionnaires to the patients. This limitation shows the challenges with recruiting a patient population for scientific research. Since we were interested in the naturalistic course of dependency over time, we were hesitant in using imputation methods and chose to continue with the more conservative and straightforward analyses (e.g., repeated measures) only including those individuals with complete response sets.
Third, we only had limited information about the demographics of the patients in our sample (e.g., no information on marital status, employment, or ethnicity), which limits the interpretability of the current findings. Last, the sample of the current study consisted of patients classified with PDs, in which dependency issues may likely play a role (Lorenzini & Fonagy,
2013), whilst at the same time also receiving psychotherapy targeting these personality problems. That means that both the specific characteristics of this patients sample as well as the type of treatment (i.e., group psychotherapy according to psychodynamic or schema-focused therapy) may have influenced patients’ care dependency patterns during treatment. Although comparable results have been found in a clinical sample with depressed patients and other types of treatment (metacognitive therapy versus cognitive behavioral analysis system of psychotherapy, both delivered in an 8-week day treatment program, Glanert et al.,
2021), it is still unknown to what extent the current findings can be generalized to other patient groups and to different treatment approaches and treatment modalities.
Directions for Future Research
First, as the current treatment setting was characterized by a time-limited treatment approach, we could only measure patients’ wish for treatment continuation at the end of their treatment. Future research is needed to determine whether patients’ care dependency levels can predict actual treatment duration. Second, the current study explored whether, on average, care dependency levels seemed to change over time during treatment. However, patients’ dependency levels may actually result from an interaction between patient characteristics (e.g., trait dependency, attachment style, psychiatric diagnoses, etcetera) and context characteristics (e.g., intensity or duration of care, type of treatment, therapeutic orientation, and so on). An important avenue for future work is to examine which patients would be particularly prone to develop high levels of care dependency, by including multiple patient-characteristics in future studies, and to explore which particular characteristics or circumstances of the mental health care context may elicit or reinforce patients’ care dependency.
Conclusion and Clinical Implications
To conclude, the current findings provide compelling support for the idea that patients’ care dependency is at least in part a contextual effect, and not merely a stable personality trait of patients. Therapists should be aware that the specific mental health care context, including the contact between them and patients, may influence patients’ care dependency levels in treatment. Care dependency may be an indicator or facilitator of a good therapeutic alliance, and thus providing a firm basis for successful treatment. However, it may also cause patients wanting to stay longer in treatment than necessary, and treatment termination may become more challenging. While the current findings also raise additional questions and offer various directions for future research, at this point we would recommend therapists to carefully address potential dependency issues later on in treatment, such as dependency related cognitions and helplessness schemes of patients. Also we argue that it is important to remind patients on the finiteness of the treatment and the therapeutic relation, and increase patients’ (perceived) alternatives options for help and support and reinforce their autonomous functioning, in order to reduce patients’ care dependency when the end of treatment comes into sight.