To answer that question, we would have to re-visit the notion of dependency, and how it is manifested.  Conventionally, dependency is associated with passivity and submissiveness.  Its current conceptualisation would comprise of four interrelated variations: cognitive, motivational, behavioural and affective dependency.  These are derived from the literature on developmental psychological dependency.  These forms can be modified by the situational demands, opportunities and constraints experienced or perceived by the individual (2), which would mean that dependency behaviour can be presented in both a negative and positive light. 

  We will start our exploration with behavioural form of dependency, as it is probably the most common variation that is observed clinically.  Other variations like cognitive and motivational dependencys are discussed more in brief.  Behavioural dependency can be described by generalised behaviours by the dependent person, which are directed towards individuals representative of potential nurturers, protectors and caretakers (2).  The common strategies one can adopt range from being passive and submissive (self-negation) to being active and assertive (self-promoting).  Clinical and social studies have also demonstrated the probable association amongst high levels of dependency, and co-operation, compliance, suggestibility, help-seeking and interpersonal yielding (2). 

It is not difficult to draw certain parallels between such manifestations with those observed in the “usual” patient-therapist relationship, whereby a person depends on another (to a variable extent) to achieve his treatment goals.  This treatment reliance can spiral into the development of a consistent, marked need for the “specialised” guidance and support (motivational dependency).  Such motivational reliance on significant others are often reciprocated and perhaps fostered, by the professed duty of care towards the patient and the helping behaviour (behavioural dependency) of the practitioner.  Medical paternalism ingrained within our health care system, whereby the judgement by healthcare individuals plays a major part in deciding the appropriate types of treatment that the person needs, can further create cognitive dependency.  An individual who exhibits some cognitive dependency would perceive himself as relatively powerless and that the presence of powerful others would determine the outcome of the problem.  It is almost affirming that certain levels of cognitive and behavioural dependency and perhaps, variably, some component of motivational dependency, are present in our daily contact with our patients.  However, is this a necessarily undesirable, unhealthy or even abnormal behaviour? 

Most would say that it is quite usual to see these variations in behaviour in the clinical setting, and probably agrees that it is desirable to a variable extent.  Patients who exhibit some of these characteristics may even be better managed, as they are compliant and seek advice for their complaints.  However, dependency can become abnormal too.  This inherent reliance can develop further into habitual reassurance and approval seeking, which may result in the patient being unwilling to take full ownership of managing his or her condition.  Subsequent discharging the patient from our care becomes problematic. 

With these different aspects of dependency, is it still bad and is it a necessary evil for the patient to get well and hopefully be discharged without hitches?  Of course, not all patients will develop such difficulties in discharge.  Perhaps the function of dependency in patient management is analogous to that of medication: beneficial in appropriate doses, potentially harmful when overdosed.  One may postulate that such fostered dependency is fine, so long as we are able to identify patients who exhibit dependent personality traits.  Theoretically, we can then prevent abnormal illness behaviour from setting in, which can affect their functional abilities (3).  However, the distinction may be grey in reality. 

Perhaps it is not exactly the type of dependency that we as therapists should really be concerned about, especially since most of us are not trained psychologists.  What is more important may be the use of behavioural modifications on the patients and on us that sets the state of self-management, knowledge and empowerment as being most desirable.  As the demand for healthcare provision rises, such issues should be addressed with appropriate research.  Dependency is probably required for effective physiotherapy provision to occur.  However, when too much has been fostered by the therapist and abnormal behaviour is exhibited, it may just be too much to expect a smooth discharge to occur.

Loy Fong Ling

Editor

References

1.   Clark MS, Smith DS.  Abnormal illness behaviour in rehabilitation from stroke.  Clinical Rehabilitation 1997; 11: 162-170.

2.   Bornstein RF.  Active dependency.  Journal of Nervous and Mental Disease 1995; 183: 64-77.

3.   Clark MS, Smith DS.  The effects of depression and abnormal illness behaviour on outcome following rehabilitation from stroke.  Clinical Rehabilitation 1998, 12:73-80.