The Need-Fear Dilemma and Adult Psychopathology

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Casey is a 26-year-old college graduate who has found herself in a series of relatively short-term, unstable romantic relationships. She develops feelings for men very quickly, and they become her "entire world." Yet, almost like clockwork, the moment her partner fully reciprocates her loving feelings, she is flooded with fear and anxiety that they will abandon her. She begins to act in ways that push them away, picking fights, making accusations, and provoking jealousy. When her partners understandably begin to distance themselves, she desperately attempts to pull them back in, sometimes resorting to manipulation and threats.

The "need-fear dilemma" was first described by Burnham and colleagues as an "inordinate need and fear of the influence of other persons" (Burnham et al., 1969). The American Psychological Association defines it as "a simultaneous need for and fear of closeness with others" (American Psychological Association, 2024). In the vignette above, Casey demonstrates many of the characteristics of the need-fear dilemma, which accounts for the specificity of her reactions.

Although originally conceptualized as a feature of schizophrenia (Burnham et al., 1969), the psychiatrist Gerald Adler later applied the concept to borderline personality disorder (BPD) (Adler, 1985). Patients with BPD routinely engage in a pattern of self-destructive, paradoxical, and self-contradictory behavior, and their interpersonal relationships are often marked by chaos and tumultuousness. The borderline patient is beset by twin anxieties of engulfment and abandonment: When the other person gets too close, they feel smothered and engulfed; when the other person is too distant, they feel traumatically abandoned.

The need-fear dilemma wreaks havoc on the patient's relationships by placing the partner (or other object) into a perpetual no-win double bind (Ruffalo, in press). No matter how hard the other person tries to regulate interpersonal proximity, he or she will "lose." Too far, and they trigger the patient's abandonment fears; too close, and they trigger the patient's fears of closeness and intimacy. This paradox accounts for much of the interpersonal dysfunction observed in borderline psychopathology.

Some patients attempt to "resolve" the need-fear dilemma by remaining single or involving themselves in a number of casual, superficial relationships without committing to any one of them. Adler writes,

When the borderline personality is in relatively good equilibrium, the [need-fear dilemma] is well-controlled by adjusting interpersonal closeness: not so close as to be too threatening, not so distant as to leave the patient alone. Sometimes the equilibrium is maintained by diffusing the sources among many selfobjects, not allowing prolonged intimacy with any one of them…. Finally, relating may be characterized by rather rapid oscillations between several relationships, each of which is experienced intensely for a brief time (Adler, 1985).

What accounts for the need-fear dilemma? During periods of emotional overwhelm, healthy or neurotic persons are generally able to rely on internal resources for holding-soothing comfort. If we have been raised by "good enough" parents (Winnicott, 1957), we are able to evoke a positive mental image or representation of a caregiver to help soothe us and guide us through difficult times. Borderline patients, by contrast, have grave difficulty performing this function and rely very heavily on outside persons to perform this function for them. In psychoanalytic theory, these people are termed "selfobjects"; patients with BPD often refer to them as "favorite persons." The selfobject becomes an external regulator of the patient's emotions.

Yet, because borderline patients were frequently raised by parents or caregivers who were emotionally misattuned, neglectful, or abusive, they also exhibit significant deficits in their ability to develop basic trust (Zanarini et al., 1989). The same person who is tasked with the challenge of regulating the patient's oft-dysregulated emotions—the selfobject or favorite person—is also someone who ultimately cannot be trusted. That is, the other person is simultaneously cast into the role of benevolent helper and dangerous, harmful victimizer.

Replaying the traumatic relationship with the early caregiver, the patient approaches the partner and then subsequently avoids him, engaging unconsciously in an approach-avoidance repetition compulsion, a manifestation of the need-fear dilemma.

Casey has been working in twice-weekly psychodynamic psychotherapy with an expert on BPD for three years. The same push-pull patterns that characterize her romantic relationships have played out in the treatment relationship, too, but gradually Casey began to trust the therapist as a consistent and reliable presence in her life. Now, during periods of stress, she is able to conjure up a positive internal representation of holding-soothing and relies less and less on outside persons to perform this function for her. She has also come to understand how she unconsciously undermines attempts made by others to love and care for her. While she still struggles from time to time, her latest romantic relationship has been calmer and more stable. She feels more "at peace" in life.

As the vignette reveals, the need-fear dilemma can be resolved in intensive psychotherapy that addresses it as a feature of the patient's underlying psychopathology. Many patients effectively treated for BPD go on to develop and sustain relatively healthy interpersonal relationships, and although no treatment can promise a "rose garden" (Greenberg, 1964), success with long-term psychotherapy is both common and meaningful.

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