1. It is often difficult to decide whether to encourage, discourage or even try to forbid contact between a patient and patients family. Dr. Edmunds support for cutting off contact between Caroline and her parents was a very useful step. There is evidence that Caroline would have an increase in symptoms after contact with parents. Partially this might have been due to the parents continuing negative attitude towards Caroline which is the opposite of the affirming mirroring she needed. More important was the history of the fathers highly inappropriate interest in Carolines sexuality as manifested by his talk about her body, her genitals and breasts. In addition, there was mothers passivity in not protecting her from father. Inevitably the young womans own sexuality is bound to be stimulated, and, at the same time, her arousal would cause much guilt, shame and self-condemnation. It is revealing that during her Jr. or Sr. year she went out of control with drugs and sex after father turned from the older sister to Caroline as his golden girl and wanted to take her on trips with him. The erotic stimulation is obvious, and so is the ensuing suicidal ideation. Difficult as this might be, I think there is a need to tell her that, much as she might hate to experience it, some erotic arousal is unavoidable. Thus one might attempt to relieve some of her guilt/shame.
2. Even more difficult is to bring the feared sexual arousal into discussions of the relationship with the therapist. When the patient talks about fun sex etc. the therapist is in a dilemma: if the therapist lets it go by passively, the pt feels unprotected and, worse, feels that the therapist does not care; if the therapist has a negative attitude toward sexual activity because its dangerous, etc. the pt. will feel the therapist is insincere, is like the parent who acts like being interested in the child while really only being interested in the parents own agenda; if the therapist indicates some positive interest in the pt.s sexual life, the pt. will experience it like the fathers inappropriate interest. What to do? I would try to enlist the pts understanding by sharing with the pt. the therapists dilemma. Of course, that is a demand for the pt. to be empathic with the therapist and can easily be misinterpreted as the therapist wanting to be mothered by the pt. So that must then also be explained. In good therapy there is always some of this interaction where the pt.s understanding becomes therapeutic for the therapist and vice-versa. Such a merging of transference with countertransference is not only inevitable but also useful if done consciously and carefully.
3. About the question concerning the use of drugs and alcohol (and sex) as a coping strategy designed to anesthetize the pain and shame internalized from childhood: the child that has been deprived of self-strengthening selfobject experiences will emerge from childhood with a defective and fragile self. When as an adult this fragile self is exposed to more faulty selfobject experiences from the needed people in the surround then this fragile self will experience an increased need for the missing experiences. Drugs and alcohol by their chemical effect or intimate relationships with people by becoming sexualized can become substitutes for the missing experiences. It is not necessarily a search for an idealized transference though it might be. The experiences created by drugs, alcohol or sex are so plastic, fluid and variable that they can substitute for most any needed experiences. And because they are so easily available and temporarily appear so gratifying of a desperate need they are hard to turn down especially since the self is already weakened and vulnerable due to its fragile state. Add to that the physiological addiction and it becomes an almost impossible task to free oneself. Almost but fortunately not completely imposible.