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Research Article                                                                                                                                        Open Access

## Assessment and Treatment of Identity Pathology During Adolescence

Susanne Schlüter-Müller 1,2* , Kirstin Goth 2 , Emanuel Jung 2 , Klaus Schmeck 2

1 Praxis, Frankfurt am Main, Germany

2 Department of Child and Adolescent Psychiatry, University of Basel, Switzerland

*Corresponding author: schlueter-mueller@praxis-schlueter-mueller.de

## Abstract

Personality  disorders  can  be  seen  as  patterns  of  maladaptive  personality  traits  that  have  their  onset  during  childhood  or adolescence and that have an impact on the individual throughout the life span. Identity disturbance is seen as the central construct  for  detecting  severe  personality  pathology-and,  most  notably,  borderline  personality  disorder-in  adults  and adolescents. Therefore, in the revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the construct of 'identity' has been integrated as a core diagnostic criterion for personality disorders.

One  of  the  most  central  tasks  of  normal  adolescent  development  is  the  consolidation  of  identity.  Crises  in  the development of identity usually resolve into a normal and consolidated identity with flexible and adaptive functioning. By contrast, identity diffusion is viewed as a lack of integration of the concept of the self and significant others; it is also seen as the  basis  for  subsequent  personality  pathology,  including  that  of  borderline  personality  disorder,  which  leads  to  a  broad spectrum of maladaptive and dysfunctional behaviors.

To measure identity  pathology  and  its  improvement  with  treatment,  we  developed  a  self-report  questionnaire  entitled Assessment of Identity Development in Adolescence to establish a reliable, valid, and time-efficient inventory to represent a dimensional concept  of  healthy  and  impaired  personality  development.  The  reliability  of  this  self-report  questionnaire  is excellent, and the total score differentiated significantly between controls and patients with personality disorders.

Adolescent  Identity  Treatment  is  a  treatment  model  that  focuses  on  identity  pathology  as  the  core  characteristic  of personality disorders. This model integrates specific techniques for the treatment of adolescent personality pathology on the background  of  object-relation  theories  and  modified  elements  of  Transference-Focused  Psychotherapy.  Moreover, psychoeducation, behavior-oriented home plans, and family work support the therapeutic process of the adolescent.

Keywords: adolescence;  Adolescent  Identity  Treatment  (AIT);  Assessment  of  Identity  Development  in  Adolescence (AIDA), identity; identity diffusion; personality disorder

## Introduction

In  the  revised Diagnostic  and  Statistical  Manual  of Mental Disorders, Fifth Edition (DSM-5), the definition of  personality  disorder  and  its  diagnoses  have  not been  changed  from  those  presented  in  the  DSMIV-TR.  However,  an  alternative model  for the diagnosis of personality disorders has been placed in Section  III  of  the  DSM-5,  and  the  construct  of 'identity' has been integrated as a central diagnostic criterion for personality disorders (1). The focus of this article is on the relevance of identity problems to understand personality pathology during adolescence; we will also demonstrate how identity disturbance  in  adolescents  can  be  assessed  and treated.

## Identity Disturbance During Adolescent Development

The consolidation of a stable identity is one of the core developmental tasks of adolescence. According to Erikson's definition (2), identity is  a  fundamental organizing principal that develops constantly throughout life and that provides a sense of continuity  within  the  self  and  in  interaction  with others ('self-sameness'); it is also a frame through which to differentiate the self from others ('uniqueness')  and  to  function  autonomously.  A well-integrated  identity  with  flexible  and  adaptive functioning plays a role in self-esteem, in the realistic appraisal of the self and others, and in the development of insight into the effect that one has on others. Identity is a basis of self-reflective functioning that provides predictability and continuity  of  functioning  within  a  person,  across situations, and across time (3).

Erikson (2) was the first to formulate concepts of identity crises and identity diffusion as characteristics of normal and pathological personality development. An identity crisis occurs as a result  of  a  lack  of  confirmation  by  others  of  the adolescent's changing identity. During such a period,  there  is  a  lack  of  correspondence  between the view of the adolescent by his or her immediate environment  and  the  adolescent's  changing  selfexperience  (4).  Identity  crises  are  normal  elements of adolescent development  (5). During  identity crises,  the  continuity  of  the  self  remains  across situations and across time, despite experimentations with different roles. Such crises usually resolve into a normal and consolidated identity with flexible and adaptive functioning (3).

In contrast, identity diffusion is seen as the core of  personality  pathology.  It  implies  that  there  has been a lack of integration of the concepts of the self and significant others (6,7), and it leads to a broad spectrum of maladaptive and dysfunctional behaviors:

-  The  leading  symptoms  are  chronic  emptiness, superficiality,  poor  anxiety  tolerance,  and  a  lack of impulse control (8).
-  The normal capacity for self-definition is lost, so emotional breakdowns occur at times of physical intimacy, occupational choice, or competition (1).
-  The  lack  of  a  stable  self-definition  leads  to  a threatening sense of danger of fusion or of loss of identity in intimate relationships. Thus, one of the interpersonal consequences of identity diffusion is the incapacity for intimacy in relationships; this is one of the four core criteria presented  in  the  alternative  model  given  in  the DSM-5 (9).
-  Under  the  influence  of  a  peak  affective  state, there is a serious loss of the normal capacity for self-reflection and mentalization (10). The person is  not  able  to  assess  the  affective  state  from  the perspective of an integrated sense of self.

## Assessment of Identity Development

The  Self-Report  Questionnaire  Assessment  of  Identity Development in Adolescence (AIDA)

Because identity development is regarded as the key feature  in  emerging  personality  disorders  during adolescence, we developed the self-report questionnaire Assessment of Identity Development in Adolescence (AIDA) (11) to differentiate between healthy  identity  integration,  identity  crisis, and  identity  diffusion.  This  instrument  has  proved to  be  a  reliable,  valid,  and  time-efficient  inventory that  represents  a  dimensional  concept  of  healthy and  impaired  personality  development.  It  can  also be  used  as  a  screening  instrument  to  evaluate  the outcomes of specific treatments for identity disturbance, such as Adolescent Identity Treatment (AIT).  AIDA has been translated into 15 different languages, with each translation focusing on thorough cultural adaption (12).

AIDA  is  a  58-item  self-report  questionnaire  for adolescents  and  young  adults  that  assesses  identity development  in  the  two  dimensions  of  continuity and coherence.

## Continuity/Discontinuity and Coherence/Incoherence

Characteristics  that  help  us  to  differentiate  identity diffusion from normal identity are found along the continuums of continuity/discontinuity and coherence/incoherence (8).

Continuity  is  the  basic  emotional  experience  of the self  as  existing  fully  in  the  moment  and  across time, which is also known  as the 'I.' It is characterized by the experience of a subjective selfsameness within a moment and across time and that exists  in  the  past,  the  present,  and  the  future  (i.e., ego stability). This is associated with identitystabilizing goals, talents, roles,  and  relationships within an accessible emotional context.

Coherence is the narrative experience of the self that  is  articulated  in  the  awareness  of  the  social context;  this  is  also  known  as  the  'Me,'  and  it  is defined as being identical with oneself. It is characterized by the individual being consistent and genuine  rather  than  suggestible  or  superficial.  It requires good access to cognitive awareness, which is particularly evident in the presence  of wellintegrated and differentiated mental representations, which allow for the maintenance of the self in the context of others (i.e., ego strength).

For an individual with a normal identity, coherence  and  continuity  are  both  present,  so  the experiences of 'I' and 'Me' are integrated and do not  feel  distinct  or  distant.  This  state  is  associated with the capacity for in-depth interpersonal relationships, with good self-differentiation and other differentiation, with mutuality and reciprocity, and  with  the  maintenance  of  self  within  the  social context.

AIDA has shown good reliability,  with  an  alpha of  .94  for  the  total  scale  of  identity  integration versus identity diffusion as well as alphas of .86 and .92  for  the  two  primary  scales  discontinuity  and incoherence, respectively. The total score differentiated significantly between  controls and patients with personality disorders, with effect sizes of more than two standard deviations (13).

## Treatment of Identity Pathology During Adolescence

## Adolescent Identity Treatment

In 2000, Paulina Kernberg and coworkers illustrated a  model  for  understanding  identity  pathology  in children and adolescents (3). Their primary concern was  differentiating  those  adolescents  with  normal identity crises from those with identity diffusion. In 2005,  a  clinical  supervision  study  group  co-led  by Paulina  Kernberg  and  Pamela  Foelsch  began  to develop a treatment approach to facilitate the integration  of  identity  with  consideration  for  the developmental  tasks  and  capacities  of  adolescents; the  results  were  later  developed  by  our  group  into AIT (14).

AIT is a therapeutic approach to the treatment of personality  disorders  in  adolescents  that  includes both  psychodynamic  and  integrative  perspectives. AIT  specifically  focuses  on  identity;  it  integrates modified elements of Transference-Focused Psychotherapy (15) with psychoeducation, behavior-oriented home plans, and work with parents  to  support  the  therapeutic  process  of  the adolescent.  In  contrast  with  typical  psychoanalytic treatments, AIT has characteristics that include the use of a treatment contract, emphasis on affects in the here and  now,  the preferred technique of clarification (and less interpretation), the combination with behavioral and psychoeducational  elements  like  a  home  plan,  and  the inclusion of parents, school, peer-groups, and siblings.

## The Theory Behind the Model: Object Relations Theory

In  modern  object  relations  theory,  there  is  a  basic assumption  that  early  experiences  with  caregivers, particularly those within intense affect states, lead to the development of internalized mental representations of the self and a mental representation of the other (7,16). Under conditions of peak affect activation-whether they are of an extremely positive  and  pleasurable  nature  or  an  extremely negative  and  painful  one-specific  internalizations take  place  and  are  framed  by  the  dyadic  nature  of the interaction between the baby and the care-taking person.  This  leads  to  the  development  of  specific affective memory structures with powerful motivational implications. Kernberg (7,15,17) stated that dyadic structures constituted by a representation of the self, interacting with a representation  of  a significant other,  under  the dominance  of  a  peak  affect  state  explain  adult pathology  that  is  based  on  early  developmental experiences.  These  basic  dyadic  units  are  heuristic devices  that  facilitate  the  recognition  of  shifts  in affective experience of the self and others in therapeutic 'here and now' moments.

The Kernberg model (15,17) assumes that positive  and  negative  affective  memories  are  built up  separately  during  the  early  internalization  of these intense caregiving experiences. Later on, they are  actively  split  or  dissociated  from  each  other  in an effort to maintain an ideal domain of experience of the relationship between the self and others and to escape from the frightening experiences of negative affect states. Negative affect states tend to be  projected  and  to  evolve  into  the  fear  of  'bad' external objects, whereas positive affect states evolve  into  the  memory  of  a  relationship  with 'ideal'  objects.  It  is  proposed  that  this  early  split experience  protects  the  idealized  experiences  from contamination  with  the  bad  ones  until  a  higher degree of pain tolerance and a more  realistic assessment  of  external  reality,  particularly  under painful conditions, can evolve.

## Basic Principles of Adolescent Identity Treatment

The  basis  of  AIT  is  to  clear  blockages  of  normal development-specifically  of  identity-to  produce improvements  in  behavioral,  affective,  and  social functioning. The normal development of the integration  of  positive  and  negative  aspects  of  self and  others  can  become  blocked  as  a  result  of constitutional factors, environmental factors, or their  combined  interaction.  The  psychotherapeutic interventions of AIT target both constitutional and environmental contributions to help clear the developmental blockages in adolescents who suffer from identity diffusion.

## Clearing Blockages

During  normal  adolescent  development,  situations that evoke an identity crisis create temporary confusion  regarding  the  individual's  identity.  This confusion generally resolves naturally as the adolescent  integrates  the  contradictory  images  of the  self  that  were  evoked  from  the  discontinuities between the self and others' views of the self. These occur  most  noticeably  in  the  context  of  major  life choices  (e.g.,  intimacy,  career  choice,  competition, psychosocial). However, it is the everyday situations that the adolescent encounters that evoke the daily decisions that help to define the self through actions. Most of these occur with little awareness or conflict.  For  example,  adolescents  make  decisions about what they will wear, who they will spend time with,  where  they  will  go,  and  what  they  will  do. Together, these actions define who the adolescents are,  how  they  wish  to  appear  to  others,  and  how others actually see them. The  working-through process occurs relatively smoothly and as part of the normal  discourse  with  friends,  trusted  adults,  and family members. In adolescents with identity diffusion, the normal ability to resolve the contradictory self-images evoked during an identity crisis  is  blocked  by  the  maintenance  of  various defenses,  particularly  the  split  of  the  positive  and negative  representations  of  the  self  and  of  the representations of others.

AIT focuses on clearing these blockages through the  use  of  the  therapeutic  relationship  as  well  as interpretive work  (i.e., using the techniques of clarification, confrontation, and, ultimately, interpretation)  so  that  normal  development  can occur at an age-appropriate level.

## Contract Setting

The  purpose  of  setting  a  treatment  contract  is  to provide  a  clear  frame  within  which  deviations  can be  observed,  clarified,  confronted,  and  ultimately interpreted. Although most aspects of the individual contract  will  remain  between  the  therapist  and  the adolescent (e.g. regular attendance at therapy sessions, no  drugs  before sessions, report selfcutting), there are some modifications that need the inclusion of the parents to facilitate support for the treatment  and  the  individual  contract  (e.g.,  remind the child to go to therapy, help the child to control drug  abuse).  There  is  also  a  need  for  increased direct  environmental  interventions  by  those  who work with adolescents (e.g.,  pediatricians,  teachers, social workers).  Finally, it  is  very  important  to develop  and  implement  the  'Home  Plan',  which represents the family contract as it applies to rules at home.

## Home Plan

The  Home  Plan  is  based  on  the  integration  of psychodynamic  and  family  systems  theory,  and  it involves  primarily  cognitive-behavioral  techniques. The plan  incorporates  aspects  that  the  adolescents and their parents have identified as problematic, and it  is  organized  and  prioritized  by  the  therapist. Prioritization  follows  the  standard  AIT  hierarchy, with  self-harm  being  at  the  top  of  the  list.  The therapist  must  judiciously  choose  which  norms  to support  and  include  in  the  Home  Plan;  he  or  she will need to decide which of these will be targeted for  change.  Although  the  primary  emphasis  is  on controlling the adolescent's self-destructive behavior and engendering a sense of respect for the self and others, ineffective patterns of communication  by  the  parents  are  also  addressed. Parents can also include expectations for their own behavior  in  the  home  plan,  such  as  'no  nagging' (i.e., ask only once and then leave it to the adolescent to respond). The Home Plan serves the function of organizing the overt behavioral interactions  between  the  adolescent  and his or her family.  It  provides  rewards  and  consequences  for behavior; it offers an opportunity to clarify distortions  in  the  perception  of  reality  (particularly the  discrepancies  between  the  adolescent  and  the parents); and it encourages self-reflection and personal responsibility for the actions and the contributions  to  interactions  of  each  party  while remaining  flexible.  Furthermore,  the  Home  Plan provides a 'helping ego' for the family by providing structure and an explanatory model for understanding  the  adolescent's  actions  and  world view.  Finally,  the  Home  Plan  supports  motivation and  positive  behaviors  by  helping  to  establish  a sense of competence as the adolescent increases his or  her  ability  to  contain  and  manage  his  or  her affect in a more  effective way. In essence, it represents the reality principles present in the family.

## Strategies for Treatment

With AIT, there are a few key strategies that guide the general approach and specific actions; these are articulated  in  the  tactics  and  techniques  of  this strategy.  In  general,  these  aspects  are  consistent with the object relation treatment model elaborated by Clarkin and colleagues (15,17).

## Identifying the Dominant Object Relationship Dyads

The first strategy is to identify the dominant object relationship  dyads  as  they  are  observed  within  the extra-transferential relationship and within the transference.  Understanding  these  dyads  help  to elucidate  the  adolescent's  awareness  of  them  in interpersonal  relationships  and  in  the  'here  and now'  interaction  with  the  therapist.  The  therapist can do this with the use of a four-step process. The first  step  requires  the  therapist  to  experience  and tolerate the confusion and the strong affects that are activated as the adolescent's inner world unfolds in the process. These affects are observed simultaneously  within  the  adolescent's  descriptions of  his  or  her  relationships  with  others  (i.e.,  the extratransferential relationships) and his or her reactions to those relationships as well as within the transference  itself  (i.e.,  is  the  patient  suspicious, interested, paranoid?). The second step requires the therapist  to  identify  the  dominant  object  relations. For example, the adolescent may characterize himself  or  herself  as  the  'helpless  victim'  in  the relationship  with  the  'attacking  other'  which    is also experienced in the therapist, who observes the adolescent  feels  like  the  victim  attacked  by  the therapist.  Once  the  therapist  is  clear  about  the activated  dyads,  they  can  then  be  shared  with  the adolescent (step three). However, this is only done after extensive clarification within the here and now of the affect and behaviors that are activated.

During the final step of the process, the therapist attends to the patient's reactions to the presentation of  the  object  relations  that  are  present  in  the  here and  now,  and  returns  to  clarification  to  facilitate cognitive reflection, affect tolerance, and ultimately differentiation from the other (therapist) and integration (of self and other mental representations).

## Transference and Countertransference

Adolescents maintain relationships with their parents, other family members, teachers, and peers. For adolescents with identity diffusion, these relationships  are  often  distorted  by  the  projections of  their  internal  world.  These  projections  are  the transfer  of  the  internal  object  relationship  world onto  the relationship in reality with the other person. Because these projections have more to do with the internal world than they do with objective reality,  they  create  many  interpersonal  problems, which  further  contribute  to  the  maintenance  of identity diffusion.

## Techniques in Adolescent Identity Treatment Clarification

Clarification is understood as the therapist's invitation to the patient to explore and explain any information  that  is unclear, vague,  puzzling, or contradictory. Clarification is particularly important, because  the  main  affect  of  borderline  patients  is confusion.  Often  psychotherapists  think  that  they have to understand their patients 'without words' and without asking; they believe that it is a sign of understanding  when  they  do  not  ask  questions. However,  with  the  technique  of  clarification,  it  is the opposite: the therapist shows that there are still things  that  are  unclear  and  that  he  or  she  is  also curious  to  truly  understand  the  patient.  He  or  she may say things like the following: 'I didn't understand'; 'Please explain that to me again'; and 'If I understand you correctly….' The main message  conveyed  is  that  the  therapist  is truly interested in understanding what the patient means. By asking these questions, the therapist conveys the following  ideas:  'I  am  not  perfect,  and  I  need further explanation'; 'I am honest, and I'm telling you  that  I  don't  yet  understand';  and,  'It's  OK  if someone is not perfect.'

The specific  areas  to  target  with  clarification  are the  affects,  the  object  relationship  dyads,  and  the various  perspectives  (i.e.,  with  regard  to  the  self, others,  and  time).  The  main  goal  of  clarifying  the affects  is  to  facilitate  the  adolescent's  ability  to recognize  when  he  or  she  is  having  an  affective experience;  he  or  she  will  also  then  be  able  to identify  and  name  the  affects  and  ultimately  will develop the capacity to differentiate the locus of the origin of the affect (i.e., Is the locus of origin within the self or the other? Is it internal or external?).

Clarifying  the  object  relationship  dyads  is  one focus  of  treatment;  with  adolescents,  this  is  an essential aspect of the developmental phase (i.e., the context  of  the  task  of  differentiation  from  the family of origin  and  movement  into  the  adult world).  The  focus  of  the  clarification  is  on  the differentiation  of  the  self  and  other  as  well  as  the integration of the self-representation and other representations. This directly increases reflective functioning, because adolescents are encouraged to articulate  their  internal  experience  and  to  imagine the experience of the other. This facilitates increasing  differentiation  between  the  self  and  the other. Clarification allows the adolescent to develop awareness  and  a  vocabulary  of  experience  while identifying and tolerating the affects that emerge in the context of this increasing awareness and associated meanings.

## Confrontation

The  process  of  confrontation  with  an  adolescent involves bringing the contradictory thoughts, feelings, and/or actions into the adolescent's awareness; this allows for their gradual integration, which results in improvement of affect and impulse tolerance, judgment, and interpersonal functioning.

The contradictory presentation is observed in the three  channels  of  communication:  the  verbal,  the non-verbal, and the therapist's countertransference. All of these aspects are used to assist the therapist's selection of what contradictory aspects of the material (i.e., thoughts, feelings, actions of the adolescent, as well as therapist countertransference) to confront the adolescent with and when to share these  observed  discrepancies.  Confrontations  are invitations to look at the contradictions in experience that have become more conscious during the clarification process. As indicated, sometimes these contradictions are within the adolescent's  own  experience,  but  often  they  exist between the adolescent's experience and therapist's experience.  Usually  these  are  tolerated  best  when they  are  provided  tentatively,  as  hypotheses,  about the  observations  and/or  the  meanings  of  these contradictions (e.g., 'You tell me that you are not at all disappointed that your mother didn't call you on your birthday, but you struggle with tears. What do you think could this mean?') This process elucidates the areas of contradiction or inconsistency and brings them into the adolescent's awareness. It is used to mark specific aspects in the here  and  now  of  the  adolescent's  experience  while simultaneously challenging the adolescent to reflect on  his  or  her  experience.  The  contradictions  and inconsistencies,  the  defensive  functions,  and  the unconscious  motives  are  brought  into  conscious awareness  and  used  to  confront  the  adolescent's distortions of reality. This further sets the stage for interpretation.

## Interpretation

Like  confrontations,  interpretations  are  hypotheses offered to the adolescent for his or her consideration. Unlike confrontations, which aim to bring the contradictions into awareness, interpretations help adolescents organize and develop  meaning  for  their  thoughts  and  actions. Interpretations focus on the intrapsychic functioning,  which  has  been  understood  through the  earlier  clarifications  and  confrontations  around the  material  that  is  conflicted.  The  goal  is  to  help articulate the relationship between the various aspects  of  the  adolescent's  conscious  material  and to  link  this  with  the  inferred  unconscious  material that is exerting influence on the adolescent's motivation and functioning. The interpretation links the  contradictions  between  the  verbal  and  nonverbal information and the countertransference.

In  contrast  with  the  process  used  for  adults, interpretation  involves  an  attitude  of  play when working  with  adolescents.  Because  adolescents  are in  the  transition  from  childhood  to  adulthood  and because their cognitive abstract reasoning skills are continuing to develop, it is often useful to incorporate metaphors and stories into the interpretation process.

The therapist will systematically work toward the full interpretation by providing language to articulate the affective experience in the context of the  activated  object-relationship  dyads.  He  or  she will also offer alternative possibilities (i.e., explanatory  hypotheses)  in  an  effort  to  provide concrete  options  from  which  the  adolescent  may choose. For example, 'Could it be that you feel a, b, c,  or  none  of  these  feelings  in  the  situation  you described?'

## Therapeutic Stance

There are three attitudes that optimally support the therapeutic process of AIT: 1) openness and acceptance within the treatment structure; 2) optimism (holding a positive mental representation of  the  adolescent);  and  3)  curiosity  and  interest  in wanting  to  know  the  adolescent  as  a  person  (not just  within  the  context  of  his  or  her  pathology). Optimism  is  a  general attitude that allows the therapist to engage therapeutically because he or she has a vision of the adolescent's potential and is able to imagine the patient in health. It has a counterpart within  the  adolescent,  which  we  refer  to  as  the minimum  'one  square  millimeter'  of  desire  to change in treatment. Both are required for a successful treatment to occur.

The therapeutic stance is composed of the factors associated with all good therapists (e.g., genuineness,  warmth,  empathy),  but  in  this  case emphasis  is placed on  certain aspects that are particularly  relevant  to  adolescents.  A  therapist  is fully  present  when  the  body  language,  affect  tone, and language are consistent and integrated with the cognitive  curiosity  directed  toward  understanding the  adolescent's  experience  in  all  areas,  but  with particular attention to the here and now relationship.

Although  there  are  many  techniques  that  will greatly  facilitate  the  adolescent's  ability  to  move from a position of identity diffusion toward normal identity  development,  there  is  a  simple  premise upon which all the techniques are based. Adolescents,  like  children,  learn  primarily  through actions.  Therefore,  it  is  the  therapist's  actions  that the adolescents experience. A  therapist who  is genuinely interested in and curious about an adolescent's experiences is modeling a way to productively  engage  interpersonally.  On  a  deeper level, it is important to engage the adolescents in the areas of being curious and interested in themselves as  well  as  in  their  relationship  with  the  therapist. Clinically,  therapists  observe  that  adolescents  with personality  pathology  have  often  lost  the  natural curiosity toward and interest in things that is usually a  prominent  characteristic  of  children  and  normal adolescents. The therapist needs to focus on increasing  the  adolescents' curiosity  and  interest  in their own experiences.

## Working with the Families

Working with parents is one of the core aspects that differentiates work done with children and adolescents  from  that  done  with  adult  patients. There are variations among therapeutic approaches to  when  and  how  to  work  with  the  parents  of adolescents.  Typical  psychotherapeutic  work  with adolescent and young adults places the family work much more in the background. With AIT, however, the therapist  must  work  with the parents and families  to  support  the  changes  that  will  occur within the adolescents as the treatment progresses. To do this, the therapist's stance toward the family, in the absence of any egregious boundary violations (e.g.,  the  presence  of  sexual  or  physical  abuse),  is one of general acceptance that the family members have been doing the best they can; they may just not necessarily be using the most effective strategies or acknowledging the real impact of the pathology of the  adolescent.  Even  'good  enough'  parents  can appear  to  be  quite  disturbed  under  the  loading  of the severe disorder of their child.

Even  in  very  disturbed  relationships,  there  are intense bonds between children and their parents. If the  therapist  does  not  include  the  parents  in  the treatment  process,  he  or  she  underestimates  their influence on the interactions that take place in the home  and  that  maintain  the  disorder.  Therapists also overestimate themselves if they take full responsibility for the adolescent. If the parents are viewed as terrible and invalidating, then the therapist  siding  with  the  adolescent's  view  of  the terrifying  and  persecutory  parents  may  cause  the adolescent  to  fantasize  about  the  therapist  as  a better parent (i.e., a 'savior'). This risk fosters and maintains a split internal structure as opposed to the treatment goal of integration.

## Psychoeducation

With AIT, psychoeducation is provided to parents to promote an understanding of the normal developmental tasks of adolescence as well as of the areas in which their child is having difficulties. Four areas are typically addressed: 1) communication and relationship building and maintaining; 2) limit setting;  3)  safety/rescue/judgment/autonomy;  and 4) affect management.

Information  about  what  is  normative  and  usual for  adolescents  gives  parents  a  frame  of  reference within which  to understand  the  areas that are problematic  for  their  child.  Psychoeducation  also provides  an  opportunity  for  parents  to  become aware  of  what  they  may  not  have  acknowledged about the depth and breadth of their child's difficulties.  In  rare  cases,  it  may  also  help  those parents  who  are  too  eager  to  find  dysfunction  in their child to normalize their view and expectations.

## Clinical Significance

For  a  long  period  of  time,  the  assessment  and treatment of adolescents' personality pathology was completely dependent on concepts and instruments that had been developed for personality disorders in adults.  In  this  sense,  the  adaptation  of  Dialectical Behavior Therapy for the treatment of adolescents with  Borderline  Personality  Disorder  was  a  major breakthrough (18); it was followed, in recent years, by the adaptation for adolescents of other treatment approaches  for  adults,  such  as  Cognitive  Analytic Therapy (CAT), Mentalization-Based Therapy (MBT), or Emotion Regulation Training (ERT) (1921).  Using  the  psychodynamic  approach  Transference-Focused Psychotherapy (TFP) our working group  integrated  family  systems  theory,  behavioral concepts, and psychoeducation into the integrative therapeutic  approach  of  AIT,  which  is  attuned  to the  specific  needs  and  difficulties  of  adolescents with severe identity pathology. The inclusion of the family  is  seen  as  essential  to  the  success  of  this treatment.  The  results  of  an  initial  pilot  study  are promising (14). As a next step, we plan to evaluate both the treatment outcomes and basic therapeutic processes  of  AIT  as  compared  with  DBT-A.  The AIDA  questionnaire  can  also  be  used  as  both  a screening tool to detect emerging personality pathology in adolescence and an outcome measure to assess changes in identity disturbance  from diffusion toward healthy identity integration.

## References

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