Mental representation, severe psycho pathology, and the therapeutic process

Mental representation is a central construct in psychological development. A method for assessing the developmental level of representation of self and significant figures is described, and changes in the developmental level of these representations are reported in a sample of forty seriously disturbed, treatment-resistant adolescents and young adults in intensive, psychoanalytically oriented inpatient treatment lasting more than a year. Increased differentiation-relatedness of descriptions of self and significant figures (mother, father, and therapist) was significantly correlated with improved clinical functioning. Over the course of treatment, representations moved from descriptions of self and significant figures dominated by polarization and splitting to representations involving the emergence and consolidation of object constancy. Improved clinical functioning was correlated with more positive descriptions of self, mother, and therapist and, paradoxically, with more negative descriptions of father. Two prototypical case studies of these self- and significant-figure descriptions are presented, one for a borderline patient and one for a schizophrenic. Intense negative affect, predominantly anger, and a relative preservation of self-reflexivity are typical of the self- and object representations of borderline individuals, but representations in schizophrenic individuals are characterized by affective muting and marked disturbance in reflexive self-awareness. The assessment of cognitive-affective schemas of self and significant others provides a method for investigating therapeutic change and for identifying important differences among various forms of psychopathology.