When people begin psychotherapy, they are not simply choosing a treatment. They are also entering a new and potentially important human relationship.

The patient may initially be looking for help with anxiety, depression, trauma, relationship difficulties, emotional distress, or other problems affecting everyday life. However, before meaningful therapeutic work can develop, the patient must also decide whether the psychotherapist feels like the right person with whom to undertake that work.

This is what is often meant by finding a good fit.

A good fit does not mean finding someone who agrees with everything the patient says or behaves exactly as the patient expects. It means finding a psychotherapist who provides a safe, reliable, contained, professional, and strictly confidential framework. It also involves a personality factor. The patient needs to feel that the psychotherapist is somebody with whom they can gradually speak openly, take emotional risks, and discuss parts of themselves that may never have been disclosed elsewhere.

This relationship develops over time.

As it does, the patient rarely relates to the psychotherapist as though the therapist were entirely separate from every previous relationship. Earlier experiences inevitably enter the room.

The psychotherapist can become something like a screen or a mirror upon which important relationships from the patient’s life are replayed. Feelings originally connected to parents, grandparents, siblings, partners, carers, teachers, or other significant people may gradually become directed towards the therapist.

This does not mean that the psychotherapist is identical to those earlier people. It means that the patient’s established ways of attaching to others, trusting them, depending upon them, fearing them, idealising them, resisting them, or expecting disappointment from them can become active within the therapeutic relationship.

Experiences that once occurred elsewhere are therefore brought into the here and now.

They become present between the psychotherapist and the patient during the session, whether that session takes place in a consulting room or online.

This re-enactment is one of the most important parts of long-term psychodynamic and psychoanalytic psychotherapy. It allows both parties to observe how the patient forms relationships rather than relying only on descriptions of what happens with other people outside therapy.

The patient may say that they find it difficult to trust others, but the same mistrust may gradually appear towards the psychotherapist.

They may describe becoming highly dependent upon partners, and that dependency may begin to emerge within therapy.

They may speak about repeatedly fearing abandonment, then become extremely anxious when the psychotherapist takes annual leave or needs to rearrange a session.

They may insist that they do not need anybody, while simultaneously reacting very strongly to any interruption in the therapeutic relationship.

The relationship itself therefore becomes a living source of information.

Why Attachment Develops in Psychotherapy

Attachment to the psychotherapist is not inherently unhealthy.

In fact, some degree of attachment is necessary if psychotherapy is to become meaningful.

The patient needs to experience the therapist as reliable enough to return to, trustworthy enough to confide in, and emotionally stable enough to receive difficult material without becoming overwhelmed, judgemental, dismissive, or frightened.

This confidence cannot be created immediately.

It develops gradually through repeated experience.

The psychotherapist attends at the agreed time.

The therapeutic boundaries remain consistent.

Confidentiality is respected.

The patient is listened to carefully.

Difficult feelings can be expressed without the relationship collapsing.

Misunderstandings can be discussed rather than ignored.

Over time, this consistency creates emotional safety.

For patients who previously had close and reliable relationships with important people, attachment to the psychotherapist may develop in a relatively steady way. The therapeutic relationship can begin to carry some of the emotional importance once associated with a parent, grandparent, sibling, partner, or another dependable person.

If the psychotherapist fits the patient’s internal picture of somebody who can be trusted and relied upon, the therapist may become extremely important over the course of long-term treatment.

This importance should not be dismissed.

The psychotherapist may become one of the few people with whom the patient can speak completely openly. The patient may disclose secrets, painful memories, fantasies, fears, shame, anger, dependency, intimacy difficulties, or traumatic experiences that have never been shared with anyone else.

The relationship therefore acquires emotional weight.

The patient is not merely attending an appointment. They are entering a setting in which their internal world can be expressed, examined, and understood.

Healthy attachment provides the emotional foundation upon which this work can occur.

Dependence Is Not Automatically a Problem

The word dependency often carries a negative meaning.

People may assume that any dependence upon a psychotherapist is unhealthy or that successful therapy should make the patient entirely independent from the beginning.

This is an oversimplification.

A degree of dependence is normal and necessary.

When somebody seeks professional assistance, they are depending upon the psychotherapist’s training, knowledge, experience, emotional stability, judgement, and ability to maintain the therapeutic framework.

The patient depends upon the session taking place at the agreed time.

They depend upon confidentiality.

They depend upon the psychotherapist remembering important material and maintaining continuity between sessions.

They depend upon the therapist being able to think when the patient feels unable to think clearly.

They also depend upon the psychotherapist to help contain powerful anxieties that may initially feel unmanageable.

This is healthy therapeutic dependence.

It allows the patient to use the relationship as a stable structure while gradually developing greater understanding and stronger psychological capacities of their own.

The aim is not for the patient to remain permanently reliant upon the therapist for every decision, interpretation, or emotional response.

The aim is for something from the therapeutic relationship to be gradually developed within the patient.

Building an Internal Psychotherapist

One of the most important developments in successful long-term psychotherapy is the gradual formation of what might be called an internal psychotherapist.

This does not mean that the patient literally imitates the therapist or hears the therapist’s voice giving instructions.

It means that the patient gradually develops a stronger internal capacity to observe, reflect, think, and respond rather than reacting immediately and impulsively.

Before this capacity develops, a difficult situation may produce an instant emotional reaction.

The person becomes anxious, angry, frightened, ashamed, confused, or overwhelmed and responds without having enough psychological space to understand what is happening.

Through psychotherapy, another process can gradually emerge.

The patient experiences something.

They notice the emotional reaction.

They begin to think about what has triggered it.

They consider how it connects with earlier experiences or established patterns.

They reflect upon different possible responses.

Only then do they decide what to do.

This becomes a secondary or even tertiary thinking process.

Instead of experience leading directly to action, experience is followed by reflection, emotional processing, and a more considered response.

During the early stages of therapy, the psychotherapist may perform much of this reflective function.

Over time, the patient gradually absorbs and develops it for themselves.

They become more capable of holding their own anxieties, thinking about their reactions, and making decisions without needing the psychotherapist to provide immediate answers.

Healthy therapeutic dependence therefore contains a movement towards increasing internal capacity.

The patient first relies upon the psychotherapist’s ability to think and contain.

Gradually, the patient becomes more capable of doing this independently.

When Dependence Becomes Excessive

Dependence becomes problematic when the patient increasingly relies upon the psychotherapist instead of developing their own internal psychological structure.

The relationship may then begin to move away from therapeutic support and towards an excessive emotional merger.

The patient may experience the psychotherapist as the only person capable of making them feel safe, understood, protected, or emotionally stable.

They may crave increasing amounts of contact, attention, reassurance, or advice.

Rather than using the therapist’s help to strengthen their own capacity to think, they may begin relying upon the therapist to decide what they should do.

The patient may ask repeatedly:

“What do you think I should do?”

“Do you think I made the right decision?”

“Should I remain in this relationship?”

“Should I leave my job?”

“Do you think this person is good for me?”

“Can you tell me what will happen?”

Occasional questions of this kind are understandable. The problem arises when the patient cannot tolerate making decisions without the psychotherapist’s approval.

At that point, the therapy may begin to recreate a much earlier stage of development.

The patient may relate to the psychotherapist as a very young child relates to a protective parent or carer. They may experience themselves as unable to cope alone and the therapist as the person who must provide safety, direction, protection, and emotional survival.

This type of dependence can become almost symbiotic.

The patient does not simply value the psychotherapist.

They begin to feel psychologically incomplete without them.

The therapist may become a priceless emotional possession that cannot be lost, shared, interrupted, or eventually left.

This can become disabling over time because the patient’s own capacities are not being strengthened. The therapeutic relationship becomes the main source of functioning rather than a setting in which independent functioning is gradually developed.

Re-enacting Early Dependency

Excessive dependency does not appear from nowhere.

It often reflects earlier attachment experiences.

A patient who had an intensely close relationship with a parent, grandparent, sibling, or carer may unconsciously seek to recreate the same closeness with the psychotherapist.

Another patient may have lacked dependable care and therefore experience the therapist as the first reliably attentive person in their life.

The resulting attachment may become extremely powerful because it is meeting a need that remained unfulfilled for many years.

In other cases, the patient may have experienced relationships in which love and protection were available only when they remained helpless, compliant, unwell, or emotionally dependent.

They may then unconsciously recreate the same structure in psychotherapy.

Remaining dependent becomes a way of preserving the relationship.

Becoming stronger or more independent may feel dangerous because independence is unconsciously associated with losing care.

This is one reason why some patients make progress and then appear to move backwards.

Improvement itself may threaten the attachment.

If they become fully capable of managing alone, they may fear that the psychotherapist will no longer be needed and the relationship will end.

The wish to recover can therefore exist alongside an unconscious fear of separation.

Observable Signs of Excessive Attachment

Attachment and dependency can often be observed through apparently small behaviours surrounding the therapeutic session.

In face-to-face psychotherapy, some patients arrive much earlier than necessary and remain in the waiting room for a long time before the session begins.

They may stay after the session has ended, delay leaving the building, or remain near the place where the psychotherapist practises.

They may appear reluctant to move away physically because leaving the consulting environment represents a temporary separation from the therapist.

They may attempt to extend the session by introducing important material just as the allotted time is ending.

They may continue speaking after the therapist has indicated that the session must finish.

They may create reasons to remain in the doorway, corridor, or waiting area.

Online psychotherapy can produce equivalent patterns.

The patient may enter the Microsoft Teams or Zoom waiting room far earlier than required and remain there waiting for the therapist to appear.

They may repeatedly contact the therapist outside the therapeutic hour.

They may send additional messages, ask for advice between sessions, or seek reassurance about issues that could be discussed during the next appointment.

They may want the online session to continue after the agreed finishing time or introduce emotionally intense material in the final minutes in a way that makes ending particularly difficult.

These behaviours should not automatically be interpreted as deliberate boundary violations.

They may be communications about attachment.

The patient may be expressing:

“I want more time with you.”

“I find separation difficult.”

“I do not feel secure when the session ends.”

“I need to know you still exist when I cannot see you.”

“I am frightened that I will be forgotten between sessions.”

“I want the relationship to continue beyond the limits of the therapeutic hour.”

The behaviour becomes meaningful when it is considered within the therapeutic relationship.

Attacking Dependency

Not every strongly dependent patient appears dependent.

Some people express dependency by attacking it.

They do everything possible to convince the psychotherapist that they have no need for the therapist or for psychotherapy.

They may make dismissive or sarcastic comments about the treatment.

They may repeatedly question the therapist’s knowledge, competence, background, or motives.

They may miss sessions, arrive late, delay payment, or refuse to follow agreed arrangements.

They may challenge every observation, reject anything helpful, or insist that they already understand everything the therapist is saying.

They may deliberately derail the discussion or ask investigative personal questions designed to place the psychotherapist under pressure.

On the surface, the message is:

“I do not need you.”

Underneath, the opposite may be true.

The person may fear dependency so intensely that they must attack every sign of it.

Depending upon another person can feel humiliating, dangerous, weak, or uncontrollable. The patient therefore tries to reverse the position. Instead of acknowledging that the therapist matters, they attempt to make the therapist feel unimportant, inadequate, or unnecessary.

Non-attendance can serve the same purpose.

By missing a session, the patient may feel they are proving that they control the relationship.

By withholding payment, they may feel they are refusing to recognise the professional value of what is being provided.

By arriving late, they may attempt to show that the therapist’s time and the therapeutic structure do not control them.

By criticising the therapist, they may try to reduce the therapist’s emotional importance before that importance becomes too frightening.

These behaviours can easily be misunderstood as simple hostility, unreliability, or lack of commitment.

However, they may represent a conflict between a powerful need for attachment and an equally powerful fear of dependence.

Attachment Can Become a Double-Edged Sword

Attachment is necessary for psychotherapy, but it also creates risk.

Without attachment, the patient may never feel safe enough to disclose the deepest difficulties.

With excessive attachment, the patient may become unable to function without the psychotherapist.

The task is therefore not to prevent attachment but to understand its development and direction.

A healthy attachment allows the patient to rely upon the psychotherapist while gradually building stronger internal resources.

An unhealthy attachment makes the patient increasingly reliant upon the psychotherapist while weakening or preventing independent thought.

The distinction is not always obvious.

A patient may attend regularly, value therapy deeply, and feel distressed by interruptions without being pathologically dependent.

Long-term psychotherapy naturally becomes emotionally important.

The question is whether that importance supports development or prevents it.

Is the patient becoming more capable of thinking independently?

Are they making decisions with greater confidence?

Can they tolerate time between sessions?

Can they use what has been learned in therapy outside the therapeutic hour?

Can they manage disagreement without fearing that the relationship will collapse?

Can they tolerate the therapist’s absence?

Can they imagine eventually ending therapy without feeling that psychological survival itself is threatened?

These questions help distinguish healthy reliance from disabling dependence.

The Psychotherapist Can Also Become Dependent

Dependency in psychotherapy does not operate only from the patient towards the therapist.

A psychotherapist can also become emotionally dependent upon a particular patient.

This may develop through concern, protectiveness, fascination, identification, worry, or a powerful feeling of responsibility.

Something in the patient’s personality or history may connect with something deeply personal in the therapist.

The therapist may begin thinking excessively about the patient outside sessions.

They may feel unusually responsible for the patient’s wellbeing.

They may become frightened of upsetting the patient, reluctant to challenge them, or overly available outside the agreed therapeutic framework.

They may begin extending sessions, allowing repeated boundary changes, giving excessive advice, or finding reasons to continue treatment beyond the point at which it remains therapeutically useful.

The therapist may also become dependent upon being needed.

A highly dependent patient can make the psychotherapist feel important, effective, protective, or indispensable.

If this remains unexamined, both parties can lose sight of what is happening.

The therapist may believe they are providing exceptional care while unconsciously reinforcing the patient’s helplessness.

The patient may believe they are receiving unique support while becoming increasingly unable to function without it.

The relationship then becomes a mutual re-enactment rather than a therapeutic examination of the re-enactment.

This is one reason why professional supervision is essential.

The psychotherapist needs a separate reflective space in which emotional responses to the patient can be examined honestly.

Concern for a patient is not wrong.

Emotional involvement is unavoidable.

The danger emerges when the therapist’s needs, fears, unresolved experiences, or wish to be indispensable begin directing the treatment.

Advice and the Growth of Dependency

Excessive advice-giving can strengthen unhealthy dependence.

A patient may initially find direct advice reassuring because it removes uncertainty. The therapist appears to know what should be done, and the patient temporarily feels protected from the anxiety of making a decision.

However, repeated advice can prevent the development of independent thought.

The patient may become increasingly reliant upon the therapist’s judgement rather than learning how to assess situations, tolerate uncertainty, and decide for themselves.

Psychotherapy should not turn the psychotherapist into the director of the patient’s life.

The therapist’s role is to help the patient understand the emotional processes affecting judgement, relationships, and behaviour.

Through that understanding, the patient becomes better able to make decisions that are genuinely their own.

There may be circumstances in which practical information or direct guidance is appropriate. However, this must not replace the patient’s psychological development.

The central task is not to create obedience.

It is to strengthen the patient’s ability to think.

Attachment Must Be Discussed in the Here and Now

Attachment and dependency should not remain unspoken.

When these processes begin to emerge, they need to be brought into the therapeutic relationship with sensitivity and clarity.

The psychotherapist may notice that the patient becomes distressed whenever a session ends.

The patient may repeatedly request additional contact.

They may become angry before a planned break.

They may arrive unusually early or struggle to leave.

They may attack the therapist immediately after a particularly close or helpful session.

They may insist that the therapist means nothing to them while behaving as though the relationship carries enormous emotional importance.

These situations are most useful when discussed in the here and now.

Rather than speaking only about dependency upon partners, parents, or other people outside therapy, the psychotherapist can explore what is happening between the two people in the session.

The patient may then begin to recognise that the same pattern described elsewhere is active with the therapist.

This provides a direct opportunity for understanding.

The aim is not to embarrass the patient by saying that they are dependent.

It is to help them understand what closeness, reliance, separation, need, and independence mean to them.

For some people, dependence feels safe.

For others, it feels dangerous.

For some, attachment creates confidence.

For others, it immediately produces fear of abandonment.

For some, the therapist becomes idealised as completely good, knowledgeable, and protective.

For others, the therapist must be criticised and devalued before they become emotionally important.

All of these reactions provide information about how the patient’s attachment system is organised.

The Importance of Beginnings, Middles, and Endings

Every important relationship has a beginning, a middle period, and an ending.

Psychotherapy is no exception.

The patient begins by entering an unfamiliar relationship.

The middle period may involve increasing trust, attachment, dependence, conflict, understanding, and psychological change.

Eventually, therapy ends.

This ending may occur because the work has reached a natural conclusion, because the patient chooses to leave, because circumstances change, or because illness, retirement, relocation, or other realities make continuation impossible.

The inevitability of ending must be part of the psychological understanding of attachment.

For some patients, the ending is manageable because therapy has strengthened their independent functioning. They value the psychotherapist, recognise the importance of the relationship, grieve its ending, and carry forward what has been developed.

For others, ending feels catastrophic.

The therapist has become so deeply merged with the patient’s internal world that separation feels like losing part of the self.

This is particularly likely when the patient has resisted developing an internal reflective structure and has continued relying upon the therapist as the main source of emotional regulation, decision-making, safety, and psychological stability.

A properly handled ending does not deny attachment.

It acknowledges it.

The patient may feel sadness, anger, fear, gratitude, abandonment, relief, or several contradictory emotions at once.

These feelings need time to be expressed and understood.

Ending therapy successfully means that the relationship can finish without everything gained from it being lost.

The external psychotherapist is no longer regularly present, but the patient retains a stronger internal capacity to think, reflect, regulate emotion, and manage relationships.

Different Patients Experience Dependency Differently

Attachment and dependency are always shaped by personality.

Some patients lead highly independent lives and use psychotherapy principally as a setting in which particular problems can be examined and resolved. They become attached to the therapist and value the work, but their wider functioning remains stable.

Others become attached not only to the therapeutic process but to the therapist’s personality, presence, attention, and emotional availability.

For these patients, therapy may become a central organising relationship.

Neither pattern should be judged automatically.

The important question is how the relationship affects development.

Does the attachment help the patient become more secure, reflective, and independent?

Or does it create increasing fear, helplessness, possessiveness, and dependence?

Some people find it relatively easy to separate once the therapeutic work has been completed.

Others experience every interruption as a major emotional threat.

Some welcome the therapist’s help.

Others need help but attack it.

Some openly express affection or gratitude.

Others become sarcastic, dismissive, late, absent, or non-compliant precisely when attachment becomes strongest.

The therapist must understand the particular language through which each patient communicates dependency.

Early and Pre-Verbal Forms of Dependency

Some forms of dependency are not primarily expressed through words.

They are connected to very early stages of development, before the person had the language or cognitive capacity to explain emotional experience.

These reactions can therefore appear through the body, sensory experience, impulsive behaviour, or intense emotional states.

The patient may feel sudden panic when the therapist is unavailable.

They may experience physical agitation, rage, emptiness, or a sense of collapse at the end of a session.

They may be unable to explain why a minor change in timing or routine feels so devastating.

The reaction may appear excessive in relation to the present event because it is connected to a much earlier form of experience.

At this level, the patient is not simply thinking:

“My therapist has changed the appointment.”

They may be experiencing something closer to:

“The person who keeps me safe has disappeared.”

These reactions require careful containment.

The psychotherapist must recognise the intensity without either dismissing it or responding in a way that reinforces total dependency.

The patient needs help putting words and meaning around an experience that may initially be largely sensory, bodily, or impulsive.

Healthy Attachment as a Foundation for Change

A healthy therapeutic relationship allows the patient to depend without becoming permanently dependent.

The patient can rely upon the psychotherapist’s consistency, knowledge, and emotional stability while gradually strengthening their own psychological structure.

They can experience closeness without losing themselves.

They can disagree without assuming the relationship will end.

They can receive help without feeling humiliated.

They can tolerate temporary separation without feeling abandoned.

They can use the therapist’s capacity to think while gradually developing their own.

They can eventually leave therapy while retaining what the relationship helped them build.

This is the central balance.

Attachment must be strong enough to support difficult therapeutic work but flexible enough to allow independence.

Dependency must provide safety without becoming disabling.

The therapeutic relationship must matter deeply without becoming the patient’s only means of psychological survival.

In clinical practice, attachment and dependency are among the most important processes within long-term psychotherapy. The patient’s earlier relationships are often re-enacted with the psychotherapist, allowing patterns of closeness, fear, reliance, resistance, idealisation, anger, and separation to become visible in the here and now. These patterns may appear through requests for additional contact, difficulty ending sessions, early arrival, prolonged waiting, missed appointments, delayed payments, attacks on the therapist, or an insistence that the therapist is not needed. The psychotherapist must understand both the wish to depend and the fear of dependency, while also monitoring their own emotional involvement.

When the relationship remains contained, professionally boundaried, and open to reflection, healthy attachment becomes a means of psychological growth. The patient gradually develops an internal capacity to think, regulate emotion, and manage life with greater independence, eventually carrying the benefits of the therapeutic relationship forward without needing the psychotherapist to remain permanently present.

DISCUSSION POINTS:

1. Why is some degree of attachment and dependency necessary for psychotherapy to become meaningful and effective?
2. How can healthy reliance on a psychotherapist gradually support greater independence rather than weaken it?
3. What are the signs that therapeutic dependency may be becoming excessive or emotionally disabling?
4. Why do some patients openly seek closeness with their psychotherapist while others attack, dismiss, or deny the importance of the relationship?
5. How can earlier relationships with parents, carers, partners, or other important people become re-enacted within the therapeutic relationship?
6. Why is it important for both the patient and the psychotherapist to understand attachment, dependency, separation, and eventual endings as part of the therapeutic process?

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