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The Talking Cure of Avoidant Personality

Disorder: Remission through Earned-Secure
Attachment

Article in American journal of psychotherapy September 2016

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 The Talking Cure of Avoidant Personality Disorder:

Remission through Earned-Secure Attachment

Jeffrey Guina, M.D.a,b

a
Wright-Patterson Medical Center, 4881 Sugar Maple Dr, Wright-Patterson Air Force Base, OH
b
Wright State University Department of Psychiatry, 627 S. Edwin C. Moses Blvd., Dayton, OH

Corresponding Author: Capt Jeffrey Guina, Mental Health Clinic, Wright-Patterson Medical

Center, 4881 Sugar Maple Dr, Wright-Patterson Air Force Base, US, 45433

(Email: [email protected])
 The Talking Cure of Avoidant Personality Disorder:

Remission through Earned-Secure Attachment

Abstract

The concept of earned security is important and has significant implications for psychotherapy.

Understanding how individuals with insecure attachment styles can develop secure attachment

styles through reparative relationships, such as the therapeutic relationship, can assist

psychotherapists in helping patients to overcome the effects of early negative life experiences.

Personality disorders are commonly associated with negative experiences, such as abuse, neglect

and other empathic failures. These disorders are particularly difficult to treat because of their

pervasive nature and the resultant defense mechanisms that often thwart psychotherapy.

However, an understanding of the role that attachment can play in the etiology, symptomatology

and treatment of psychopathology can greatly enhance the therapeutic process. This case report

describes the long-term psychodynamic psychotherapy of a woman with a history of childhood

trauma, avoidant attachment style and avoidant personality disorder. Through the therapeutic

relationship, she developed a secure attachment, and her symptoms remitted and her life

drastically improved.

Keywords: avoidant, personality disorder, attachment, earned security, psychodynamic

INTRODUCTION

In many ways attachment theory has preserved and rejuvenated psychotherapy in an age of

biomedical psychiatry by supporting psychodynamic theories with robust behavioral,

neurological and endocrinological research (Fonagy, 2010; Kay, 2005; Roose et al., 2008). One

important contribution to attachment theory, and mental healthcare in general, is the concept of

earned security. Based on searches of PubMed, PsycINFO, MEDLINE and the Cochrane

Library, there are no published clinical studies or case reports about earned-secure attachment in

psychotherapy. To the authors knowledge this is the first article describing a specific

psychotherapy case that resulted in earned security.

Roisman et al. (2002) defined earned security as the processes by which individuals overcome

malevolent parenting experiences. In their 23 year longitudinal study investigating earned-

secure attachment, the studys authors described earned-secures as having a history of insecure

attachments that change over time and/or endure consistently harsh or ineffective parenting in

their youth. Fortunately, they determined that adults can overcome early negative experiences

with caregivers, and the resultant psychopathology, by developing an earned-secure attachment

style. Subsequent positive relationships, including psychotherapy, can rework early attachment

relationships, changing ones attachment style from insecure to earned-secure.

A major characteristic of secure attachment is coherence: the ability to present a clear, consistent

narrative of experiences with a linear and logical flow of ideas relying upon a consistent internal

integration of thoughts, feelings, contexts and meanings. Pearson et al. (1994) was the first to

differentiate earned-secure attachment from continuous-secure attachment, proposing that

earned-secures had early insecure attachment styles that became secure by virtue of later

relationships. Unlike continuous-secures, who describe positive childhood experiences, earned-

secures describe negative childhood experiences. However, unlike insecures, who incoherently
describe their negative childhood experiences, earned-secures coherently describe their negative

childhood experiences. This high coherency suggests current secure working models despite

early negative relationships with caregivers.

Mary Main, a prominent attachment researcher, identified earned-secures as speaking coherently

and collaboratively about their histories (Wallin, 2007). Collaboration is another important

characteristic of secure attachment, including the ability to value relationships, and the positive

communications often unconscious between those who care for one another. It is, perhaps,

the most important aspect of earned-secure attachment for psychotherapists to be mindful of in

therapy. At the most fundamental level, the intersubjective work of psychotherapy is not

defined by what the therapist does for the patient, or says to the patient. Rather, the key

mechanism is how to be with the patient, especially during affectively stressful moments

(Schore & Schore, 2008). It is often the unconscious nonverbal affective factors that are more

important than the conscious verbal cognitive factors. With empathy, patience and authenticity,

the therapeutic relationship can be a corrective attachment experience.

In addition to coherence and collaboration, earned-secures are capable of trying to understand

and sometimes forgive caregivers, suggesting mentalization and self-reflection of their

experiences. Mentalization is the ability to theorize about the mental state of ones self and

others, including thoughts, feelings, intentions and explanations for behaviors (Gabbard, 2005,

pp. 60, 86). Reflection includes the ability to deconstructing experiences (e.g. childhood

traumas), including thoughts, feelings, contexts and meanings. Psychotherapists can serve as an

alternative to negative parental attachments and, through a trusting relationship, help patients
rewire their attachment style by facilitating reflection by the patient (Saunders et al., 2011).

These important aspects of secure attachment allow one to remember a negative experience with

compassion and contextual understanding, rather than shame and self-blame.

Earned-secures are those with early attachment failures that developed the capacity for

coherence, collaboration, reflection and mentalization. These characteristics allow for the

development of trust, self-expression, self-compassion, self-care, self-protection, self-efficacy

and healthy intimate relationships. Just as trauma has the ability to cause brain dysregulation,

neuroscience and interpersonal neurobiology demonstrates that trusting relationships and

communication have the ability to heal the mind (Baldini et al., 2014; Cozolino & Santos, 2014).

Attachment theory is particularly important for treating personality disorders, which are often

associated with early negative experiences and insecure attachment styles. This article focuses on

a patient with avoidant personality disorder, a disorder which has been found to have only a 31%

remission rate after 24 months of treatment (Svartberg & McCullough, 2010, p. 340).

Attachment theory has much to offer our understanding of avoidant patients. Adults with an

avoidant attachment style have generally felt rebuffed by parents or caregivers in childhood and

are thus frightened to develop love relationships in adulthood (Gabbard, 2005, p. 587). The

following case illustrates many of the important aspects of earned-secure attachment and how, by

being mindful of attachment concepts, challenging conditions like personality disorders can

improve.

CASE
Presenting History

Psykhe was a single female in her 30s when she presented with a chief complaint of difficulty

adjusting to a new job. Although she reported anxiety about starting her new job, the topics of

conversation quickly and regularly turned to focus on her childhood.

She was raised by a single mother and never met her father. Psykhes mother rarely mentioned

her father, except to say he was married to and had children with another woman, and would do

anything for anybody. Every year on her birthday, Psykhes mother recounts the story of her

birth, including how the mother returned home from the hospital and watched television for a

good while before remembering that she left the newborn baby in the car. Psykhe was left

growing up feeling guilty for existing. She was an afterthought for her mother and no thought at

all for a father who would do anything for anybody but her.

Her childhood was made absolutely terrible by a mother who physically and emotionally

abused and neglected her. Psykhe was methodically beaten if she didnt do things the right

way. Many nights were spent reading her homework aloud while her mother stood behind her,

hitting her in the back with a baseball bat in response to every mistake. Opportunities for fun

were ruined with demands for perfection, such as when she decided to play softball and her

mother made her play catch for hours on end until the mother deemed her technique up to

standard. Needless to say, it was not long before she quit softball and stopped participating in

any activities. As her mother always said, if you cant do something right, you shouldnt do it at

all. In this context, Psykhes avoidance, in adulthood, of social activities and occupational risks

is understandable.
If beatings and impossible standards were not bad enough, Psykhes mother was also a hoarder.

They lived in unsanitary and uninhabitable conditions, without functional plumbing for years.

One of her earliest memories is staring at herself in a mirror while wearing soiled clothing and

feeling dirty. She suffered severe bullying, mostly related to her personal hygiene and

malodorous clothing. When her fifth grade teacher asked her if there were any problems at home,

she said no. The lie was attributed to a combination of fear of maternal retaliation for

confessing, and the sense that her situation was normal and deserved, but she acknowledged in

hindsight that the teacher had dropped the ball.

In her senior year of high school, Psykhe was accepted to a major university to study writing,

which had been her only outlet for self-expression. She described the summer before leaving for

school as the happiest time in my life. Finally, she would escape her mother and be allowed to

pursue self-efficacy through self-expression. A car accident changed everything. Though the

other driver was at fault, she would blame her hopefulness about her future for the collision.

She spent weeks in the hospital, enduring multiple surgeries for lacerations and factures

throughout her body. Her mother stayed by the bedside, not to comfort her, but to prevent her

from pressing the button on her pain medication pump. After discharge from the hospital, her

mother refused to fill her pain medication prescription and refused to take her to the

recommended physical therapist, electing to do the therapy herself for Psykhe. Though a nurse,

the overambitious regiment the mother enforced was more akin to physical torture than therapy.
Most of her 20s were spent in what Psykhe called the decade of coasting. Despite her

acceptance to university being deferred a year, she decided not to go when the time came, despite

having physically recovered. Instead, she went to community college on and off for a few years.

She rarely did her schoolwork and rarely went to classes, most of which she failed. During this

time she lived with the only romantic partner she ever had. The relationship served to get her out

of her mothers home and as an attempt at intimacy, but, although not abusive, the relationship

was quite emotionally distant. I wasnt really happy [in the relationship], but I stayed because it

wasnt bad enough. Despite being quite intelligent and reliable, Psykhe worked several jobs and

made little more than minimum wage. She summarized this decade by saying, nothing really

good or really bad happened. I wasnt happy or sad, just on autopilot.

The last few years of that decade included progressively increased access to feelings and risk-

taking. These were not reckless, potentially harmful risks, but excursions outside her autopilot

mode. It started with writing. She used to enjoy writing stories as a child but had not written in

years. Writing was a huge emotional risk for this patient. Not only was self-expression

frightening (as it was always discouraged or punished by mother), but creative writing required

silencing my inner editor. Sometimes in her mothers voice and sometimes in her own, her

inner editor criticized what she wrote and discouraged perseverance through writers block

because, after all, if you cant do something right, you shouldnt do it at all. She often let a

whole year pass before writing again. Allowing the words to flow was often difficult, but she

gradually allowed herself to freely associate on the page more often. Villains were difficult.

Whenever they appeared in her writing, her inclination was to then give a backstory explaining

how all their seemingly evil actions were not really bad at all.
The risk of writing gave way to other social and emotional risks. It was like a light bulb went

off in my head. She left her empty relationship, she went back to college, and she got a new job.

School was difficult as she had to work extra hard to make up for the failed grades from her old

transcript. Within a matter of years, she had a degree in a field she was passionate about.

However, avoidance of school and procrastination was always a temptation. She often forced

herself to do academic work, but then displaced her avoidance on household chores. Dirty

laundry, dishes and garbage often accumulated for long periods of time. Out of financial

necessity, Psykhe put out an ad for a new roommate, a huge social risk. Soon, this woman was

abusing Psykhe: yelling at her, punching her and, once, nearly blinding her resulting in

hospitalization for a torn retina. Psykhe never fought back, saying I felt like I deserved it.

It took three years to find a job in her career field, not because of lack of opportunities but

because at the time I told myself I was taking so long because it was such an important

decision, but looking back I realize that I was afraid. She feared taking the social and

occupational risk of starting a new, she feared not making the right decision and, most of all,

Psykhe feared hoping for a better life because her experiences had taught her that hopes were

often followed by disappointment and pain. Moving for the new job afforded her an excuse to

get away from the abusive roommate.

So, with mixed feelings of excitement and fear, she moved to a one bedroom apartment and

started her new job. Psykhe found herself crying at her new job without any identifiable trigger,
procrastinating at work, and struggling with how to answer invitations to social events from co-

workers. All of this led her to take another life risk: psychotherapy.

Psychodynamic Formulation

Psykhe met the DSM-IV-TR and DSM-5 criteria for avoidant personality disorder based on a

pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative

evaluation, but the alternative model for personality disorders proposed in DSM-5 better

conceptualizes her case (APA, 2013, pp. 765-766). She had significant impairment of identity,

with low self-esteem, negative self-appraisal and excessive feelings of shame; impairment of

self-direction, with unrealistic standards for behavior associated with reluctance to pursue goals

and take personal risks; a preoccupation with and sensitivity to criticism and rejection; and a

reluctance to get involved with people and intimate relationships. Biological factors contributing

to her condition included a family history of maternal anxiety and hoarding. Psychological

factors included anxiousness, withdrawal, anhedonia, intimacy avoidance, depressivity,

submissiveness, alexithymia, low self-worth, a tendency for undeserved self-blame, turning

against the self, and the various psychodynamic factors described below. Social factors included

early paternal abandonment, maternal physical and emotional abuse and neglect throughout

childhood, controlling and overcritical parenting, peer group rejection as a child, a severe motor

vehicle collision, a physically and emotionally abusive roommate, and a new job.

A drive theory conceptualization would suggest that never knowing her father as a child and the

abuse from her mother led Psykhe to have an unresolved oedipal complex, manifested in an

overidealized notion of her father and a desire to eliminate her mother. This mother fixation led
to avoidance of self-expression of thoughts and feelings in an attempt to protect her mother from

the threats of her own aggressive drives. She had a punitive superego resulting from the

internalization of harsh parental discipline as a child, e.g., I still feel like my mothers going to

find out and Im going to get in trouble when I dont do something the right way. Much of her

ego function was expended defending against her unacceptable aggressive drives, e.g. she

described, a little monster inside me made up of aggression towards mother as well as the

internalized aggression of mother that makes me afraid that if I assert myself, it will be violent

or everyone would get hurt somehow. Writing allowed her to better regulate the conflict

between id and superego by learning how to suppress her inner editor.

Ego psychology also provides insights about Psykhe. Despite escaping her harsh childhood

experience in her 20s, she had significant difficulty adjusting her ego to adapt to environmental

changes. Poor caregiver consistency, discouraged initiative and significant anxiety about her

social status fueled by bullying made trust, initiative and industry uncomfortable, if not

unbearable at times. Primitive defenses like denial, e.g., I dont need friends or love, and

neurotic defenses like reaction formation, e.g., being passive to defend against aggression

towards mother, became a way of life. This resulted in the persistent use of defense mechanisms

that, while once adaptive to survive childhood, had become maladaptive in adulthood,

exhausting her mental energy and causing significant life dysfunction. Suppression of her self-

criticism and sublimation of her feelings through writing opened the door for the use of more

mature defenses and adaptation to a life without mother.

Interpersonal psychoanalytic principles would suggest that Psykhe protected herself from anxiety

through how she interacted, or failed to interact, with others. Her frustrated attempts to satisfy

her needs (e.g., affection, admiration, perfection) from her mother resulted in withdrawal. She

learned to feel more secure and had some sense of safety although was not truly free from

anxiety by being passive and avoidant, hence her decade of coasting. Unfortunately,

avoidance prevented her from obtaining her social and emotional needs because they came into

direct conflict with her need for security. Psykhe attempted to live her life in a way that

conformed to what she learned as a child, limiting her intimacy with others, and remaining in

relationships in which she was unhappy and even abused.

Psykhes world was filled with negative object relations. The most prominent early object was

the abusive, intrusive and unempathic mother. Without a good enough parent attuned her needs

and providing reflections of empathy to protect her childhood grandiosity (mirroring), she never

developed an internal sense of worth. Perceptions of real people later in life were unconsciously

distorted to fit this inner world of procrustean traumatic transferences. Only in late therapy was

Psykhe able to say, I guess not everyone is my mother. Psykhe internalized the bad maternal

object, requiring the use of multiple mechanisms to defend against rage against the self, towards

the internalized object. She vigilantly tried to protect others from the bad/aggressive parts of

herself, even going so far as not to defend herself from abuse, punishment she believed was

deserved (partly because she felt wrong to have the anger she felt). Subsequently, she had

significant ego splitting: her hopeful, assertive true self was buried in favor of the avoidant,

passive false self. Splitting allowed her to protect the good from being destroyed by the bad,

hence her difficulty writing villains. Her inability to reconcile the good and bad maternal objects
as the same person led to an increased sense of vulnerability to abandonment and destruction,

leaving her paranoid of relationships and schizoid to defend against this paranoia.

A self psychology framework would suggest that the empathic failures of her mother prevented a

cohesion of her bipolar self: the grandiose self, with self-assertive ambitions; and the idealized

self, driven by perfectionism. She commented that, while many abused children externalize their

anger, she internalized hers and often felt resentment towards children who were protected by

child services as a reward for being bad, while her being good (e.g. not acting out, not

reporting her mother) meant that her problems were never brought to the attention of authorities.

Psykhe avoided social risks due to unconscious fears that she would never meet expectations and

that others would inevitably harm her. Her childhood experiences of persistent abuse and neglect

left her believing that she was unworthy of happiness and success. Evidence for this

interpretation arose many times throughout therapy, including very early in the form of a joke:

after reading about psychotherapy online, she laughingly mentioned, maybe I need exposure

therapy to good stuff. Just as her perfectionist mother avoided cleaning her house, Psykhe

avoided social risks (e.g. extracurricular activities as a teenager, college in her 20s). Psykhe

reported a conflict between unconsciously resisting doing things her mother would want her to

do (e.g. keeping her house clean, going to school) and doing nothing, like her mother (e.g. letting

laundry pile up, procrastinating schoolwork). She said this struggle or catch 22 made her feel

like either way, she wins and I lose.

Early paternal abandonment and maternal neglect resulted in an avoidant attachment style.

Psykhe suffered persistent deprivation of her basic emotional needs for comfort and affection.
Even as a newborn, she was forgotten in her mothers car. She learned to cope by rarely seeking

comfort when distressed, and to avoid expression of her emotions. Without security, trust and

empathy, she developed an insecure attachment to her mother. When taking risks, there was no

safe haven or attachment figure for her to return to for comfort. In fact, taking risks generally

resulted in punishment, physical abuse and impossible demands for perfection. Psykhe learned

not to take risks, becoming socially withdrawn and passive. Her experiences taught her to avoid

her own thoughts and her own emotions, and to avoid all social and emotional risks.

Various psychodynamic theoretical frameworks applied to this case, some more than others, and

some more at certain times than others. These views helped shape the way the patient was

understood and how the therapist intervened. Always, however, the therapist maintained a

relational psychodynamic paradigm by which the therapeutic relationship was not only the

means to achieve treatment goals, but a goal of therapy in and of itself.

Themes of Treatment

Psykhe met weekly in psychodynamic psychotherapy for over two years. She was pleasant,

cooperative, and displayed appropriate humor throughout treatment. She generally appeared

relaxed, but for much of the therapy she became restless with poor eye contact when discussing

emotions. Early in treatment, she cried infrequently. Discussions of her anger were usually the

precipitant that overwhelmed her attempts to hold back tears.

Early sessions revolved mostly around Psykhes indecisiveness, harsh self-criticism and putting

up walls that inhibited relationships. Many of those early sessions started with her reporting a
revelation between sessions that greatly improved her mood. For example, she realized that her

trauma was more related to her mother than herself, and that I was a good kid who did not

deserve abuse. In session ten she reported that she was now immune to her mother, she had

gained the power and control, and no longer needed therapy because everything is better.

This was interpreted as a flight into health related to avoidance of exploring deeper trauma-

related issues, difficulty trusting people, and this was another wall she was putting up. Her

desire to maintain an infantile fantasy that therapy would cure her instantaneously and

completely was noted with the fear that staying in therapy would challenge that notion. Rather

than make that interpretation out loud to the patient, I merely recommended she continue therapy

for a few more weeks and see how it went. She did not bring up the idea of termination again for

over a year, when she said, I almost left therapy just when we were getting started. I told myself

I was only staying for you because maybe you needed more patients or something, but I really

knew unconsciously that I needed to stay. I didnt know how anxious and depressed I

really was.

One of the most difficult hurdles for psychotherapists when treating people with personality

disorders is gaining and maintaining their trust. This played a part in her temptation for a flight

into health, and her difficulty with trust was the major theme of the next several sessions. While

she did not stop therapy, she consistently came five to ten minutes late every session for the first

several months of therapy. She later described her inclination to avoid therapy entirely was

outweighed by her fear of letting me down, so she unconsciously split the difference and came

late frequently. Since people with avoidant personalities will often avoid therapy (e.g. showing

up late or not at all) due to mistrust or fears of rejection, it is important to have a healthy balance
between accepting and challenging avoidance behaviors, and between supportively bypassing

and interpreting their fears. This is why I choose not to initially interpret her wish to flee.

In session 35, the first significant rupture in therapy occurred. After reporting how she had

completely forgiven her mother and was not even bothered by the trauma any more due to her

sympathy for her mothers own life difficulties, I challenged her claims and questioned whether

she should be over her maternally inflicted trauma. She missed the next session without

warning, the only time in two years that she ever missed a therapy appointment. The following

week, she noted that she completely forgot the appointment. With some encouragement from

me, she was able to express her frustration at me for taking away her good feelings about her

changed mindset about her mother. The patient was also charged for her missed appointment. As

she paid, she comforted me, saying, I can tell you really dont want to charge me this, but dont

worry. Its fine. No-show fees are common and its my fault anyway. She later described having

felt a reenactment of experiences with mother: the therapist had taken away her good feelings

with his comment and had punished me with the fee. However, she also described that the

incident was reparative in many ways: it was apparent to her that I challenged her good feelings

because I feared they were only superficial and covering up other feelings she was avoiding

(which they did); it was apparent that I did not intend to punish her; and, most importantly,

instead of not acknowledging the ruptures (as mother would have), I encouraged Psykhe to

express her negative feelings about the incident and about me, specifically (which her mother

never would have done). This was a novel experience for the patient. Repairing this rupture

deepened her trust and the therapeutic alliance.

For those who have spent so long avoiding emotions, one of the most important tasks in therapy

is self-reflection about and expression of suppressed anger. Initially, Psykhe only reported

neutral feelings towards her mother: We dont really have a relationship. I dont really have any

love for her. Over time, she was able to express a need to protect her mother, e.g., never

telling her mother about the children who bullied her because of her hygiene, never telling her

mother about the teacher who was suspicious of problems at home, never discussing her trauma

history or how she felt about it, and forcing herself to visit her mother on holidays despite not

wanting to. Her fifth grade teacher had dropped the ball, but I would help her express what she

previously could not. When encouraging her to open up about her feelings, there was always the

risk of pushing too hard (much like her mothers physical therapy). This reenactment was

unavoidable, however, and actually necessary for the therapeutic process (i.e. a corrective

experience by reenacting a negative experience in a supportive setting). Instead of interpreting

too soon when it would likely be overwhelming for her, I normalized the idea that an abused

child would be angry at their abuser and gently encouraged her to express any feelings she might

have. Fear was easier to discuss than anger, but, with time, she was able to discuss the idea of

anger and eventually express it directly. Eventually, we connected her avoidance of anger

towards her mother to difficulty writing villains, suppressing her inner editor, and not fighting

back against her roommate. We fantasized together about unleashing her feelings on her mother,

something she was unable to even consider for over a year. Paradoxically, by expressing her

anger, she became less angry and more accepting of her mothers limitations. By acknowledging

her own anger (her bad qualities) with self-compassion, and her mother as a villain (her

mothers bad qualities), Psykhe was able to merge her split object representations. It allowed her

to achieve object constancy, in which people remain constant even when the experiences vary
between good and bad. This had allowed her to treat herself and others as different than her

mother, allowing her hopeful, assertive true self to emerge and allowing for the enjoyment of

intimacy with others without fear of destroying them or being destroyed herself. In her implicit

memory, she had no right to express her emotions, to complain, or to ask for help, but

psychotherapy challenged her to pay attention to her inner self, and name and express her

negative feelings, even about me.

An important step to earned-secure attachment was developing the ability to discuss her early life

experiences with coherence and a sense of compassion for herself. During the first year of

therapy, Psykhe tended to divide our work into several arbitrary phases, e.g. two months were

devoted to diminishing her mothers importance in her life and another month was devoted to

saying goodbye to anger, after which she tried to consider those phases and their associated

issues as closed. Gently confronting her about how these issues were all related and not so easily

fixed, she was able to admit her fear that Ill have 87 more phases and never be done. I

considered this another indication of her infantile wish for therapy to cure her quickly and easily.

Gradually, Psykhe became less focused on her phases and reframed them as cycles in which

she was working through the same issues again and again, gaining more insight and accessing

more emotions each time. This deepening of material expressed with ever greater detail about

thoughts, feelings, contexts and meanings allowed her to eventually describe her childhood in a

cohesive narrative rather than a disorganized nonlinear account vacillating between emotional

detachment and overwhelming indescribable emotion. She became more aware of her internal

states, better able to describe them, and reflect on their origins and meanings. As the therapeutic

alliance became stronger, it allowed her to filter childhood memories through our relationship. It
did not change what had happened to her, but it changed how she thought about it and how she

felt about herself. She developed the ability to deconstruct childhood experiences, integrating her

feelings and thoughts from today to better appreciate the contexts and meanings of the past, e.g.,

putting her negative thoughts about herself in the context of having been a frightened, powerless

young girl rather than a person who deserved punishment. She was better able to accept her

strengths and better able to accept her mothers limitations.

Confronting Psykhes denial and minimization of relationships was essential for growth and

collaboration. Initially, I supportively bypassed the discrepancy between her denying a need for

closeness with others and her sadness related to social isolation. Her difficulty making decisions

about whether or not she should go to social events when invited was evidence of how deeply

out of her awareness the conflict about her desire to have friends, and her fear of failing or being

harmed was. Gentle questions and reflections helped her develop discrepancy and to explore

whether her social avoidance was due to an inborn introverted temperamental trait, as she

initially purported, or a defense mechanism related to her early childhood trauma. This was

something she struggled with for much of therapy, ambivalently going back and forth. Even after

acknowledging that social avoidance was a defense, she hopelessly concluded, the person I was

supposed to be is dead. My mother killed her. We worked to reframe this idea to one that was

more hopeful: she had to develop certain defenses to survive her childhood; while parts of her

true self were suppressed in order to survive, they could come out of dormancy now that the true

danger had passed. It was only after months of self-reflection, therapist interpretations (including

of dreams associated with social isolation) and taking small social risks with co-workers, that she

was able to acknowledge her social needs. Only after proudly reporting I have three friends
now! was she able to look back on her denial and relate it to an allegory, I treated people like

we were all porcupines: keep close enough to keep each other warm, but far enough apart to

avoid poking each other. I dont need to think like that anymore: I want to get close and I need to

keep warm, and a lot of people arent really porcupines, they dont even have quills. Im not

really introverted and I just put up these walls to deal with things in my life, but now I dont need

them.

For Psykhes avoidant attachment style to become secure, passivity had to give way to

collaboration and functional self-protection. Virtually every relationship she had was distant or

abusive until ours. Allowing herself to trust the therapist improved her reflectivity and

mentalization, understanding that not all people thought poorly of her or meant her harm, and

that when they did mean her harm, it was because of something flawed in them, not her. Using

our relationship as a secure base, allowed her to leave the walls in which she had isolated

herself. Walls, forts and armor became important metaphors in therapy, and eventually she

said, When I leave the fort, I can wear armor, but sometimes I can take the armor off with

people and know it will be okay. A major breakthrough in therapy came when she reluctantly

described a frightening incident in which she accidentally caused a stove fire that shot a fireball

to the ceiling, which had to be smothered with a fire extinguisher. Her eyes filled with tears as

she expressed her shame and guilt, and how she withdrew from all social activities in the days

since. She was reluctant to tell me lest I realize how unworthy she really was. On the contrary,

my mental image of her during this incident, which I verbalized, was that of a knight defeating a

fire-breathing dragon. Something happened in that affectively stressful moment: our unconscious

minds seemed to speak to each other. The therapist was attuned to her needs, mirroring her
grandiosity, displaying empathy, and reframing an event to which she ascribed negative meaning

as one in which she performed courageously. This interaction helped move her along the path

towards a sense of mastery and personal efficacy. She became her own knight in shining armor,

not her idealized father nor the idealized therapist. She developed a cohesive self and more

adaptive defenses to more effectively assert herself. She took more risks: making friends,

exceling at work, successfully confronting a malignant supervisor, and setting boundaries with a

toxic co-worker.

One enduring source of guilt and shame was Psykhes decade of coasting. She blamed herself

for the years she wasted before going back to school and seeking relationships. Rather than

time wasted, we were able to reframe how she viewed that decade as a period of a safety

cocoon with no major events, good or bad, after the chaos of childhood. That cocoon eventually

allowed her to emerge with spread wings, seeking the job she wanted and feeling strong enough

to be independent from her internalized mother. While she struggled with viewing this time with

compassion, near the end of therapy she was able to say, after all I had been through, I guess I

deserved a rest, and another time, I am like a tree who had to grow a little crooked and bend

and weave but Im still a beautiful tree and a good tree. She was able to develop self-

forgiveness and compassion, rather than shame and self-blame. When work became

overwhelming, she said, I have to lower the bar for myself so that I can get everything done that

I need to do, instead of demanding perfection in everything I do. She reported that the choice

paradoxically gave her a sense of control and empowerment. This empowerment, allowed her to

make similar choices in the way she dealt with her mother and personal relationships. Through

therapy, she slowly developed a better sense of a cohesive self and internal reliability, which
allowed her to pursue goals, tolerate her own success and self-sooth when ideals were not met.

Psykhe no longer procrastinated in work, she no longer let the laundry pile up, and she allowed

herself to have fun with friends.

One of the hardest parts of attachment is the fear of loss and rejection. Even before coming to

therapy, there was an unconscious fantasy that the therapist would fill the role of the idealized

father who had been absent from her life. Her avoidance behaviors in therapy (e.g. her early

hesitation to trust, coming late, early thoughts of premature termination, the missed session)

were, in part, due to fears of rejection. Never did this fear become more prominent than when I

had to cancel an appointment and left a voicemail message on her phone three days in advance.

Unfortunately, Psykhe did not get the message and waited in the lobby until another therapist

told her I was out. She reported that she had not checked her phone until after that day but the

message was there. She reported sitting in the lobby wondering if something happened to you

maybe you died and I wondered if I would be all right without therapy. She acknowledged

how important therapy had become to her and how glad she was to have remained in treatment.

Facing the fear of loss and processing it with me allowed Psykhe to acknowledge her feelings of

attachment, something she had not had the opportunity to feel or had not allowed herself to feel

for most of her life.

In session 62, Psykhe reported three big things: she allowed herself to accept and internalize

two different instances of praise (from a supervisor and a friend), she had become an active

protector of herself by setting appropriate boundaries with a co-worker who had been bullying

her and other co-workers, and I asked a normal person on a date (the first time she had ever
asked anyone on a date). There had been several months of ambivalence about social needs and

working through, but her life was an upward spiral after that. She allowed herself to feel hopeful

rather than waiting for the other shoe to drop. Work was going well and she was chosen as the

lead on a special project. She was able to proudly discuss her inner space (i.e. letting people in)

getting larger and the boulder that had blocked that space (i.e. the abuse) getting smaller. I

often reinforced these accomplishments as being the result of her hard work. Psykhe reported

being brave, open and direct her in her work and personal relationships. She was able to build

new relationships with people based on their responsiveness and availability, rather than her

fears. She was taking more social risks, going to parties and even became a performer in a

theater group (an extraordinary development in the life of someone with avoidant personality

disorder). About one party, she said, I realized I wasnt going before because I was afraid I

wouldnt be liked. At this party, I didnt like some people and some people probably didnt like

me, and thats okay. A romantic relationship was going well for several months, and she was

even able to overcome her attachment-related anxiety to be the first to say, I love you. Her life

became no longer about avoidance, but about growth, acceptance, responsibility, creativity and

fun.

As with all cases, one of the most difficult and uniquely strange tasks in psychotherapy is

terminating a relationship after investing so much to establish a therapeutic alliance. During the

termination phase (and before), we dealt with themes of mourning, and both nervous and hopeful

excitement about the future. When negative feelings arose, sometimes she expressed pride in her

ability to handle these things on my own and, at other times, she expressed worry that it was a

sign that she should not leave therapy. However, with little direction from the therapist, Psykhe
realized she was being hard on herself for having normal people feelings (e.g. relationship

anxiety, stage fright) and wondered if she created papier-mch boulders to prolong therapy

(including showing up 15 minutes late for one appointment after not being late to a session for

months). Psykhe also explored the importance of the therapeutic relationship and, by extension,

the importance of the therapist and patient to each other, and how she was able to internalize her

own sense of value and importance. I feel like I was safe here and we could process things

together and then Id leave and go off into the world and try things, but then I could always come

back and check in with you. This is almost a perfect description of the attachment concepts of

the secure base, in which the attachment figure (in this case, the therapist) served as a

launching point for safe exploration of the world (e.g. taking risks), and of the safe haven, in

which one can return to the attachment figure for comfort. Through confronting the fear of loss,

the patient was able to internalize the therapist and the attachment, and leave therapy with earned

security.

DISCUSSION

In Greek mythology, Psykhe was a mortal woman who was the target of the wrath of the goddess

Aphrodite. While the god Eros fell in love with Psykhe, he hid his identity and face from her.

After sneaking a peak at his face, he abandoned her. She spent a long time searching the world

for him, during which Aphrodite forced her to perform laborious acts until she was finally led to

the Underworld. After her long journey, she was finally reunited with Eros and they wed. She is

generally depicted as a goddess adorned with butterfly wings.

The name Psykhe was chosen as a pseudonym for my patient, because, like the Greek myth, she

was abandoned by a man who should have loved her (her father) and tortured by a woman who

should have loved her (Aphrodite was the goddess of love, after all). The path to earned-secure

attachment was long and arduous, and at times she retreated beneath the earth. However, the

butterfly eventually emerged from her cocoon, finally able to receive the love she deserved yet

had so long been denied.

The Psykhe from this case had a fearful-avoidant/anxious-avoidant attachment style with high

attachment-related anxiety (e.g. fearing rejection) and high attachment-related avoidance (e.g.

claiming not to care about close relationships). Her avoidant attachment style was largely related

to the frightening mother who provided little comfort and pushed for inappropriate independence

(as early as when she was brought home as a baby). She learned not to seek comfort, to avoid

feeling and sharing emotions, and developed low self-esteem. By providing a safe, empathic

holding environment, she was provided the opportunity for trust, intimacy and freedom from the

fear of abandonment. Through the security of a genuine relationship, we could challenge and

process her mistrust, suppression of anger, denial of social needs, distorted perception of early

life experiences, passivity, guilt and shame, and fear of rejection. Through the prism of the

relationship, she developed coherence, collaboration, reflection and mentalization. These

characteristics gave way to trust, reflection, self-expression, self-compassion and self-protection

as she explored the world, took risks and sought out intimacy with others. Psykhe had an early

insecure attachment style that became secure by virtue of the therapeutic relationship, resulting

in a corrective attachment experience and remission of her avoidant personality

disorder.
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