A pathway to therapeutic change: changes in self-representation in the treatment of adolescents and young adults.

Processes that lead to normal development of the representations of self and others are also central to understanding processes of therapeutic change. In long-term, intensive, psychodynamically oriented, inpatient treatment of seriously disturbed, treatment-resistant adolescents and young adults, we found that changes in the level of differentiation-relatedness in patients' self-representation were primarily associated with changes in the level of differentiation-relatedness of their description of their therapist. A best-fit model indicated that change in the patient's description of the therapist and of a self-designated significant other outside the family added significantly to the explained variance predicting change in self-representation. Exploratory structural equation modeling also suggested that patients' growing recognition of the therapeutic relationship (measured by a more mature representation of the therapist) is associated with changes in the patients' overall level of clinical functioning. These results add further support to the importance of the therapeutic relationship in building more differentiated and integrated representations of self and of significant others.