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I chose this case to present because it contains many elements specific to adolescent treatment and it lends itself quite naturally to self-psychological understandings. This presentation focuses on the first two and one half years of an ongoing treatment which will soon enter its fifth year. Treating adolescents in the throes of the developmental process, presents special problems. The goal of helping the adolescent to overcome problems forged in the family milieu is complicated at every turn by the adolescent's actual and psychological dependency on, in this case, an enmeshed, embattled, dysfunctional family. Issues of how the treatment is constructed, where the patient lives, who pays for treatment, etc., present logistical and psychological puzzles superimposed on the clinical challenge of the presenting symptoms—in this case anorexia nervosa and bulimia, suicidal thoughts and actions, and chronic depression.
From a self-psychological point of view, I think this case is illustrative of three overlapping themes. First is the struggle to gain a stronger, more cohesive sense of self, such that intense affect could be experienced without fragmentation. Second, there are issues related to the maintenance of continuity in self experience. The third theme concerns self-delineation and the problems in achieving feelings of authenticity and conviction about her own point of view. Selfobject longings to be affirmed in her own perceptions became engaged in the treatment and Rachel's experience of me in this regard aided her attainment of strength and her development of a capacity to joyfully experience her distinctiveness. However, increases in self-delineation and feelings of authenticity were associated with fears of hurting others and isolating herself from needed others.