Let me add a few comments to the discussion of the case of Carolyne. First of all I am impressed that experienced therapists with different theoretical backgrounds have more in common than they differ when it comes to the clinical approach to their patients. Sure, there are important differences but they may not be of decisive significance in helping patients get better.
My comments represent my background in Self Psychology plus some personal modifications.
Carolyne presents herself with a large number of severe symptoms: alcoholism, cocaine addiction, depression, sexual promiscuity, poor social relationships, etc. On the other hand she appears to be intelligent, serious, motivated to loose her symptoms and change herself. Especially interesting is the contradiction between her low opinion of herself and the apparent successful achievements in the world with the significant exception that she cannot achieve good social relationships with the opposite sex.
Before talking about my view of these symptoms I must state some of the most fundamental observations and subsequent basic conceptualizations of self psychology.
A newborn infant arrives in this world without a sense of self. However, s/he is equipped with a brain that has the function of making order out of the chaos of innumerable sensory perceptions (all 5 senses) that impinge on the neonate. The brain detects repetitions and configurations which are ordered into patterns such pain vs pleasure, internal vs external, etc. Certain configurations of experiences become organized into a sense of self. Those experiences that become organized into a sense of self we have designated as selfobject experiences. As Spitz showed 50 years ago (Psychoan.Study of the Child) infants in an orphanage that get all the best nutrition, health care, and physiological body needs taken care of but no personal attention (no talking to, no picking up and soothing, no rocking, etc) will often develop marasmus (a type of depression) and die. Infants that experience caregivers who care will not get marasmus but develop a sense of self.
A sense of self (abbreviated as a self) requires selfobject experiences throughout life. Even a strong, cohesive, energetic self will fall apart into disorganization when the selfobject experiences are no longer forthcoming. This has been demonstrated experimentally when healthy young people were subjected to sensory deprivation (blindfolded, ears sealed, immersed into luke warm water, etc.) they developed hallucinations and delusions and lost their sense of who they were after a few hours.
There are at least 6 fundamental types of selfobject experiences (mirroring, idealizing, alter-ego, adversarial, efficacy and vitalizing) that are needed throughout life by every human being. Infants will develop a fragile self when the selfobject experiences during early development are deficient, absent or unreliable. They may develop strategies (=defenses) to protect whatever fragile self there is against further disorganization (=fragmentation). If these strategies fail the infants self will never reach cohesion or, if it does reach cohesion, it will later fall apart. A fragmented self is one where the various constituents of the self organization are no longer integrated into a cohesive whole but where these constituent parts assert themselves on their own, so to speak metaphorically: hypochondriasis evidences loss of psychological body-wholeness and the bodily parts asserting themselves by heightened awareness. Behavior becomes disorganized and is no longer under rational control but driven by the affects that also are no longer integrated. Loss of self boundaries is experienced as an irresistible yearning to merge with idealized others. Among defensive strategies denial and withdrawal are common. But the most common defense against the threatened loss of needed selfobject experiences is to engage in behaviors that can be experienced as if they were the needed selfobject experiences: alcohol, drugs, sex all can provide a temporary sense of strengthening the self by mimicking healthy selfobject experiences.
Enough self psychology for now. Carolyne has the symptoms of disorganization (falling apart=fragmentation): unpredictable, irrational behavior, recognized as such by her without her being able to stop it anymore than an asthmatic can stop wheezing. Alcohol, cocaine and sexual promiscuity provide her with blissful moments of apparent substitute selfobject experiences of being mirrored, loved etc. The momentary bliss of the self experience however is paid for by slowly destroying the individual.
Her family history is full of evidence that her parents failed to give her the affirmation, the caring concern and soothing that are needed as basic selfobject experiences. What little self and self esteem she managed to develop was jeopardized by direct expression of their disrespect and depreciation of her. Thus she entered adulthood with a damaged and fragile self that was vulnerable to the minor slights and rejections of everyones everyday life. No solid social relations can develop under such conditions.
The therapist by offering help, setting limits and demonstrating her tolerance for disagreement was experienced by her as both strong and caring. They were needed selfobject experiences that strengthened her enough to make her want to continue treatment.