Both classical and contemporary psychoanalytic theories stress the importance of interpersonal dynamics in treating neurotic symptoms. Associations between the symptomatic and interpersonal level were formally represented in the symptom specificity hypothesis (Blatt, 1974(Blatt, , 2004, which linked obsessional symptoms to an autonomous interpersonal stance. Findings from cross-sectional group studies on symptom specificity, however, do not converge, possibly indicating that the complexity of associations is underestimated. This article presents a theory-building case study specifically aiming at refinement of the classical symptom specificity hypothesis by quantitatively and qualitatively describing the longitudinal clinical interplay between obsessional symptoms and interpersonal dynamics throughout a psychodynamic psychotherapy. Interpersonal functioning was assessed by means of the core conflictual relationship theme method (Luborsky & Crits-Cristoph, 1998). Findings affirm a close association between symptoms and interpersonal dynamics. However, obsessional symptoms proved to be determined by profound ambivalences-manifesting both within and between relationships-between dependent and autonomous interpersonal behavior. Psychodynamic interventions focusing on interpersonal conflicts were associated with symptomatic alterations. Conceptual and methodological considerations, limitations and future research indications are discussed.

The classical symptom specificity hypothesis (Blatt, 1974) particularly associates obsessional symptoms to interpersonal behavior directed at autonomy and separation from others. Cross-sectional group research, however, has yielded inconsistent findings on this predicted association, and a previous empirical case study (Cornelis et al., in press; see Chapter 2) documented obsessional pathology to be rooted in profound ambivalences between autonomous and dependent interpersonal dynamics. Therefore, in the present empirical case study, concrete operationalizations of the classical symptom specificity hypothesis are contrasted to alternative hypotheses based on the observed complexities in Chapter 2. Dynamic associations between obsessional symptoms and interpersonal functioning is further explored, aiming at further contribution to theory building (i.e., through suggestions for potential hypothesis-refinement; Stiles, 2009). Similar to the first empirical case study (Chapter 1), Consensual Qualitative Research for Case studies is used to quantitatively and qualitatively describe the longitudinal, clinical interplay between obsessional symptoms and interpersonal dynamics throughout the process of supportive-expressive psychodynamic therapy. In line with findings from Chapter 1, findings reveal close associations between obsessions and interpersonal dynamics, and therapist interventions focusing on interpersonal conflicts are documented as related to interpersonal and symptomatic alterations. Observations predominantly accord to the ambivalence-hypothesis rather than to the classical symptom specificity hypothesis. Yet, meaningful differences are observed in concrete manifestations of interpersonal ambivalences within significant relationships. Findings are again discussed in light of conceptual and methodological considerations; and limitations and future research indications are addressed.

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In psychotherapy research, “validity” is canonically understood as the capacity of a test to measure what is purported to measure. However, we argue that this psychometric understanding of validity prohibits working researchers from considering the validity of their research. Psychotherapy researchers often use measures with a different epistemic goal than test developers intended, for example when a depression symptom measure is used to indicate “treatment success” (cf. outcome measurement for evidence-based treatment). However, the validity of a measure does not cover the validity of its use as operationalization of another target concept within a research procedure, nor the validity of its function toward an epistemic goal. In this paper, we discuss the importance of considering validity of the epistemic process beyond the validity of measures per se, based on an empirical case example from our psychotherapy study (“SCS”, Cornelis et al., 2017). We discuss why the psychometric understanding of validity is insufficient in covering epistemic validity, and we evaluate to what extent the available terminology regarding validity of research is sufficient for working researchers to accurately consider the validity of their overall epistemic process. As psychotherapy research is meant to offer a sound evidence-base for clinical practice, we argue that it is vital that psychotherapy researchers are able to discuss the validity of the epistemic choices made to serve the clinical goal.

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Objective: Adult interpersonal difficulties are considered 1 of the core consequences of childhood trauma exposure. However, research concerning the nature of interpersonal patterns associated with childhood trauma is scarce. The aim of this case study of a supportive-expressive psychodynamic therapy with a woman with a traumatic background, is to provide a detailed understanding of the nature of interpersonal patterns at the beginning and throughout therapy, and to provide an in-depth investigation of the therapeutic process. Method: The Core Conflictual Relationship Theme method (Luborsky & Crits-Christoph, 1998) and the Penn Adherence/Competence Scale for Supportive Expressive Dynamic Psychotherapy (Barber & Critis-Christoph, 1996) were applied to study dominant interpersonal patterns and therapeutic interventions, respectively. Results: At the beginning of therapy, the patient was unable to safely express herself because others were perceived as critical and rejecting. This relationship pattern originated in her primary (traumatic) childhood relationships and was repeated in her adult relationships. As treatment progresses, the patient aspired more proactively to assert herself and felt more self-confident in interactions, although she consistently perceived the reactions of others in a negative way. The neutral, acknowledging and empowering attitude of the therapist created a new relational experience, through which change (on the interpersonal level) appears to be achieved. Conclusions: We conclude that to adequately address interpersonal difficulties in therapy, it is fundamental to recognize dominant interpersonal patterns and to apprehend their dynamics within the broader context of the case. Clinical Impact StatementIn this study, we aimed to examine interpersonal features in a case of childhood trauma in detail throughout a psychodynamic treatment. We found that core interpersonal patterns, such as the wish to safely express oneself and the fear that this would lead to negative reactions, transpired in the therapeutic context as well; yet an adequate alternative response of the therapist allowed change in this respect. Our findings suggest that it is of utmost importance to understand the complexity of dominant interpersonal features dynamically in order to adequately address them in therapy.

Patients with Functional Somatic Syndromes (FSS) often display troubled relationships with health care providers, psychotherapists, and significant others. Research shows that patients' history of trauma, attachment disturbances, and mentalization deficits may result in the emergence of maladaptive interpersonal patterns, which may later contribute to the onset and maintenance of FSS, "doctor-hopping," and dropout in psychotherapy. As the nature and therapeutic consequences of such maladaptive interpersonal patterns in FSS cannot be understood sufficiently by quantitative methods alone, there is a need for in-depth qualitative research. To address this issue, we conducted a metasynthesis of 23 published case studies of patients with FSS from various psychotherapeutic orientations. Results show that patients with FSS from our sample perceived others as unreliable, i.e., unavailable, overcontrolling, and overprotective. To adapt to such unreliable others, patients attempted to please and to control them. Patients also suppressed their emotional awareness and expression. Although alexithymia could also play a role, the primary reason for emotional avoidance seemed to be interpersonal in nature, i.e., patients were avoiding negative emotions in order to please and control the unreliable others. The onset and worsening of FSS were associated with both interpersonal and physical triggers. Showing signs of physical or emotional distress lead to more rejection, overcontrol, and overprotection from unreliable others, which could create a "vicious circle." Our results suggest that offering a more interpersonal perspective on emotion regulation difficulties would be beneficial for patients with FSS, counselors, psychotherapists, and other health care professionals.