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 author’s 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” (p. 1206). In their 23-year longitudinal study investigating earned-secure attachment, the study’s authors described it as having “a history of insecure attachments that change over time and endure consistently harsh or ineffective parenting in their youth.” (p. 1206) They determined that adults, fortunately, 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 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) were the first to differentiate earned-secure attachment from continuous-secure attachment, proposing that “earned security” applies to those with early insecure attachment styles that became secure by later relationships. Unlike those with continuous-secure attachments, who describe positive childhood experiences, those with earned security describe negative childhood experiences. However, unlike those with insecure attachments who incoherently describe their negative childhood experiences, those with earned security 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 those with earned security as speaking coherently and collaboratively about their histories (Wallin, 2007).

Collaboration is an important characteristic of secure attachment, including the ability to value relationships and the positive communications—often unconscious—among those who care for one another. Collaboration 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, P. 9). 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, individuals who are earned-secure 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 one’s 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 selfblame.

Individuals who are earned-secure had early attachment failures but developed the capacity for coherence, collaboration, reflection, and mentalization. These characteristics allow for the development of trust, selfexpression, self-compassion, self-care, self-protection, self-efficacy and healthy intimate relationships. Just as trauma can 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 often are 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 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. She reported anxiety about starting her new job, but the conversation quickly and regularly turned to focus on her childhood.

She was raised by a single mother and never had met her father. Psykhe’s 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 Psykhe’s birthday her mother recounted the story of Psykhe’s birth. She recalled how, on the day they came home from the hospital, she had left the newborn baby in the car and watched television for a good while before remembering to retrieve her. As she grew up, Psykhe felt guilty for existing: She was an afterthought for her mother and was 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 recalled she was beaten methodically if she “didn’t 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. When Psykhe decided to play softball, her mother made Psykhe practice for hours until she deemed her daughter’s technique was up to standard. Needless to say, it was not long before Psykhe quit softball and stopped participating in any activities. Her mother always said, “if you can’t do something right, you shouldn’t do it at all.” In this context, Psykhe’s avoidance of social activities and occupational risks in adulthood was understandable.

If beatings and impossible standards were not bad enough, Psykhe’s mother was also a hoarder. For years they lived without functional plumbing in unsanitary and uninhabitable conditions. One of Psykhe’s earliest memories was 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 Psykhe’s fifth-grade teacher asked if there were any problems at home, Psykhe said “no.” She attributed her lie 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 was 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. She spent weeks in the hospital, enduring multiple surgeries for lacerations and fractures 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 Psykhe to the recommended physical therapist, electing to do the therapy herself. Though a Psykhe’s mother was a nurse, the over-ambitious regimen the mother enforced was more akin to physical torture than therapy. As a result, Psykhe blamed “hopefulness” about her future for the collision, though the other driver was at fault.

Most of Psykhe’s 20s were what she called the “decade of coasting.” Despite acceptance to the university being deferred a year while he physically recovered, Psykhe decided not to go when the time came. Instead, she went to community college, attending on and off for a few years. She rarely went to classes or completed schoolwork, and she failed out. During this time she moved in with a romantic partner. While the relationship removed her from her mother’s home and was as an attempt at intimacy, the relationship was quite emotionally distant, though not abusive. “I wasn’t really happy [in the relationship], but I stayed because it wasn’t bad enough.” Psykhe worked several jobs and made little more than minimum wage, despite being quite intelligent and reliable. She summarized this decade by saying, “nothing really good or really bad happened. I wasn’t happy or sad, just on autopilot.”

The last few years of that decade included Psykhe’s progressively increased access to feelings and risk-taking 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 the mother), but creative writing required “silencing my inner editor.” Sometimes in her mother’s voice and sometimes in her own, her “inner editor” criticized what she wrote and discouraged perseverance through “writer’s block” because, after all, “if you can’t do something right, you shouldn’t 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 associate freely on the page more often. Villains were difficult. Whenever they appeared in her writing, her inclination was to give then a backstory explaining how all their seemingly evil actions were not 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 about which she was passionate. 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, the roommate was abusing Psykhe: yelling and punching her, once, 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 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 anew, she feared not making the “right” decision and, most of all; Psykhe feared hoping for a better life because experience had taught her that disappointment and pain followed hope. Psykhe found a job and 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; however, 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 Psykhe’s 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 mother’s going to find out and I’m going to get in trouble when I don’t do something the right way.” Much of her ego function was expended defending against her unacceptable aggressive drives. For example, 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 regulate better 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 such as denial, e.g., “I don’t need friends or love,” and neurotic defenses like reaction formation, e.g., being passive to defend against aggression towards her mother, became a way of life. The result was the persistent use of defense mechanisms, which, while once adaptive to survive childhood, became 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.

Psykhe’s 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 to Psykhe’s needs and to provide reflections of empathy to protect 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. Psykhe tried vigilantly to protect others from her bad/aggressive parts. She felt wrong to have the anger, and did not defend herself from abuse and punishment, believing it was deserved. She had significant ego splitting: her hopeful, assertive true self was buried for the avoidant, passive false self. Splitting allowed Psykhe to protect the good from being destroyed by the bad, which explained her difficulty in 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, and left her paranoid about relationships and schizoid as to defense against this paranoia.

A self-psychology framework would suggest that the empathic failures of the mother prevented a cohesion of Psykhe’s 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 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 the 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 mother’s car. She learned to cope by rarely seeking comfort when distressed and avoiding expression of her emotions. Without security, trust and empathy, she developed an insecure attachment to her mother. There was no haven or attachment figure for her to return to for comfort when Psykhe was taking risks. In fact, taking risks resulted in punishment, physical abuse, and impossible demands for perfection. Psykhe learned not to take risks, and she became socially withdrawn and passive. Her experiences taught her to avoid her thoughts, emotions, and 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 appeared relaxed, but for much of the therapy when discussing emotions, she became restless with poor eye contact. 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 Psykhe’s 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 reported she had gained the “power” and “control,” and claimed she did not need more therapy because “everything is better.” This “flight into health” related to her avoidance of exploring deeper trauma-related issues, difficulty trusting people, and would end in her constructing another “wall.” It was her desire to maintain an infantile fantasy that therapy would cure her instantaneously and completely, and it combined with the fear that staying in therapy would challenge that notion. Rather than make that interpretation aloud to the patient, I 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 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 knew—unconsciously—that I needed to stay . . . didn’t know how anxious and depressed I was.”

Among the most difficult hurdles for psychotherapists who treat patients with personality disorders are gaining and maintaining trust. The trust issue played a part in Psykhe’s temptation for a “flight into health,” and difficulty with trust was the major theme of the next several sessions. While she did not stop therapy, she consistently arrived five to ten minutes late for every session during 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 arrived late. 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.

In session 35, the first significant rupture in therapy occurred. After Psykhe reported that she had completely forgiven her mother (and was not even bothered by the trauma anymore due to her sympathy for her mother’s life difficulties), I challenged her claims and questioned whether she “should” be “over” maternally inflicted trauma. She missed the next session, the only time in two years t she ever missed a therapy appointment. The following week, she explained 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. I charged for her missed appointment. As she paid, she comforted me, saying, “I can tell you don’t want to charge me this, but don’t worry. It’s fine. No-show fees are common, and it’s 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. 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 covered other feelings she was avoiding (which they did). It was apparent that I did not intend to “punish” her, and, most importantly, instead of ignoring the ruptures (as her mother would have), I encouraged Psykhe to express her negative feelings about the incident and me (which her mother would never have done). This experience was a novel one 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 encouraging self-reflection about and expression of suppressed anger. Initially, Psykhe reported only neutral feelings towards her mother: “We don’t have a relationship. I don’t have any love for her.” Over time, she was able to express a need to “protect” her mother. That is 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 mother’s physical therapy). This reenactment was unavoidable and 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 her abuser and gently encouraged Psykhe 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, which was something she was unable even to consider for over a year. Paradoxically, by expressing her anger, she became less angry and more accepting of her mother’s limitations. By acknowledging her anger (her “bad” qualities) with self-compassion, and envisioning her mother as a villain (her mother’s 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. Therapy allowed her to treat herself and others as different from her mother, permitting Psykhe’s hopeful, assertive true self to emerge and allowing Psykhe to enjoy 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 to name and express her negative feelings, even about me.

An important step to earned-secure attachment was the development of 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 mother’s 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 “I’ll 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 describe eventually 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. The therapeutic alliance became stronger as did her ability 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, and integrate her feelings and thoughts from the present 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 mother’s limitations.

Confronting Psykhe’s 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 Psychke develop discrepancy. She became able to explore whether her social avoidance was an inborn, introverted temperamental trait, as she initially purported, or a defense mechanism related to her early childhood trauma. She struggled with the cause of her social avoidance for much of therapy. Even after acknowledging that social avoidance was a defense, she concluded, “the person I was supposed to be is dead. My mother killed her.” We worked to reframe this idea to a more hopeful one: she developed defenses to survive her childhood; parts of her true self were inhibited so that she could survive. They could come out of dormancy now that the true danger had passed. After months of self-reflection, therapist interpretations (including of dreams associated with social isolation), and taking small social risks with co-workers, Psykhe 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 don’t need to think like that anymore: I want to get close, and I need to keep warm, and a lot of people aren’t porcupines, they don’t even have quills . . . I’m not introverted, and I just put up these walls to deal with things in my life, but now I don’t need them.”

For Psykhe’s avoidant attachment style to become secure, passivity had to give way to collaboration and functional self-protection. Until our relationship, virtually every relationship she had was distant or abusive. Allowing herself to trust the therapist improved her reflectivity and mentalization, and she grew to understand not all people thought poorly of her or meant her harm. She came to see that when people did mean her harm, it was because of something flawed in them, not her. Using our relationship as a secure base, allowed Psykhe 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 Psykhe reluctantly described a frightening incident in which she accidentally caused a stove fire that shot a fireball, 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 was. On the contrary, I told her, my mental image of her during this incident 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 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, excelling at work, successfully confronting a malignant supervisor, and setting boundaries with a toxic co-worker.

One enduring source of guilt and shame was Psykhe’s “decade of coasting.” She blamed herself for the years she “wasted” before going back to school. We were able to reframe how she viewed that decade as a period of a “safety cocoon” after the chaos of childhood with no major events, good or bad. That cocoon eventually allowed her to emerge with spread wings, seek the job she wanted, and feel strong enough to be independent of 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.” Another time she said, “I am like a tree which had to grow a little crooked and bend and weave, but I’m 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 success, and self-sooth when she did not meet ideals. 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 instances of praise (from a supervisor and a friend), she was an “active protector,” setting appropriate boundaries with a co-worker who had bullied her and other co-workers, and she “. . . 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. She was not waiting “for the other shoe to drop.” Work went well, and she was chosen as the lead on a special project. She was able to discuss proudly the growth of her inner “space” (i.e. letting people in) and the shrinking of a “boulder” that had blocked that space (i.e. the abuse). I often reinforced these accomplishments as being the result of her hard work. Psykhe reported being “brave,” open, and direct her in 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 an avoidant personality disorder). About one party, she said, “I realized I wasn’t going before because I was afraid I wouldn’t be liked. At this party, I didn’t like some people and some people probably didn’t like me, and that’s 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 in establishing a therapeutic alliance. During the termination phase (and before), we dealt with themes of mourning, and we both were nervous and had hopeful excitement about the future. When negative feelings arose, sometimes Psykhe expressed pride in the ability to handle these things “on my own.” 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). She wondered if she “created papier-mâché 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 sense of value and importance. “I feel like I was safe here, and we could process things together and then I’d 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. He abandoned Psykhe because she sneaked a look at his face. She spent a long time searching the world for him, during which Aphrodite forced Psykhe to perform laborious acts. Finally, she was led to the Underworld and reunited with Eros, and they wed. Psykhe is depicted as a goddess adorned with butterfly wings.

I chose the name Psykhe 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 of 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 through the therapeutic relationship, resulting in a corrective attachment experience and remission of her avoidant personality disorder.