Struggling for resonance: Mediopassive interaction in a long-term treatment of severe personality disorder.

Abstract

Although clinicians often report significant emotional challenges in psychotherapy for personality disorders, we still know relatively little about how these difficulties are enacted and reorganized in moment-to-moment patient-therapist interaction. We examine whether interactional resonance and mediopassive agency can help illuminate relational difficulties and change in a good-outcome long-term psychodynamic psychotherapy involving a patient with severe interpersonal pathology, chronic depressive symptoms, and somatic complaints. The patient met the diagnostic criteria for borderline and avoidant personality disorders, as well as depressive and somatic symptom disorders. For much of the treatment, the therapist described sessions as highly distressing. Over time, sessions were experienced as less distressing and more productive. We examined whether this shift could be accounted for by changes in how patient and therapist took up and developed each other's contributions in interaction. Following a preliminary screening of therapist reports, case notes, and session recordings, we selected 10 sessions for multimodal conversation analysis. Using exploratory conversation analysis, we specified analytic indicators for interactional resonance and then compared five high-distress sessions with five lower distress sessions. High-distress sessions showed lower interactional resonance, whereas lower distress sessions showed higher resonance. In lower distress sessions, patient and therapist more often engaged in mediopassive interactions-that is, they jointly participated in the stepwise construction of meaning across turns. Psychotherapy for severe interpersonal pathology may involve working with persistently low levels of interactional resonance that constrain spontaneous, collaborative meaning-making. The findings further suggest that a dyad's capacity for interactional resonance may increase over the course of long-term treatment. (PsycInfo Database Record (c) 2026 APA, all rights reserved).