Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, Interpretation

Summary

Podcast Summary: Psychofarm Podcast

Episode: Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, Interpretation

Release Date: June 30, 2026
Hosts: Dr. A and Dr. B

---

Episode Overview

In this episode, Dr. A and Dr. B break down the practical hierarchy of psychodynamic interventions used in psychotherapy and psychiatric practice. They explore four key levels—mirroring, clarification, confrontation, and interpretation—explaining their nuanced applications, theoretical foundations, and real-world pitfalls. The conversation highlights differences in terminology and tradition while focusing on how interventions foster insight, facilitate narrative, and catalyze real change.

---

Key Discussion Points & Insights

1. The Hierarchy of Interventions: The "Levels" Metaphor

• Levels as a Pyramid: Visualizes interventions with the base (Level 0: Support/Containment) being most frequently used, and Level 4 (Interpretation) being rarest. (00:44)
• “What is the next most common intervention you do in a therapy session? It is called empathic mirroring. Level one. Empathic mirroring.” – Dr. A [01:16]

Levels Defined

• Level 0: Technical containment and alliance (see previous episodes).
• Level 1: Mirroring (getting patients to continue their narrative).
• Level 2: Clarification (eliciting more detail or depth).
• Level 3: Confrontation (highlighting patterns, inconsistencies).
• Level 4: Interpretation (making links to unconscious process).

---

2. Level 1: Empathic Mirroring

Defining Mirroring

• Purpose: Encourage the patient to continue their narrative without redirection.
• Techniques: Simple prompts (“tell me more”), interested body language, nonverbal acknowledgments (“hmms”, “uh-huhs”).
• “You can do this nonverbally, and it prompts people and encourages them to continue speaking.” – Dr. A [02:54]

Distinguishing Mirroring from Containment

• Dr. B references Bion and Kohut: Containment is about emotional processing; mirroring is about recognition of subjective self.
• “I think of containment as more of processing and putting thoughts into a container and metabolizing thoughts… mirroring as a way to show that this person has an individual self that can be seen.” – Dr. B [03:39]
• Dr. A: Ultimately, practical effects overlap; distinctions often stem from terminology.

Practical Tips

• Punctuation: Emphasizing a patient’s words nonjudgmentally to prompt elaboration.
  • Example: Patient says, “My life is messed up.” Doctor echoes, “Messed up?”
  • “You can simply repeat back a key word… That is a form of level one empathic mirroring.” – Dr. A [07:27]
• Useful across therapy, diagnostics, and forensic psychiatry.

Memorable Moment

• Playful reference to Metal Gear Solid’s dialogue: “The main character just repeats one word… you can do the same thing as a psychiatrist.” – Dr. A [07:13]

---

3. Level 2: Clarification

What is Clarification?

• Definition: Any intervention that gets the patient to elaborate with more detail or depth, without challenging their narrative.
• Surface vs. Depth:
  • Surface: Concrete details (events, sequence, setting).
  • Depth: Emotions, wishes, imaginations, subjective experience.
• “A popular clarifying question… ‘What was that like for you?’ Very vague, but a great way to prompt people to clarify their experiences.” – Dr. A [16:19]

River Analogy

• Narrative likened to a river: asking clarifying questions explores the surface and depth of that river.
• Blockages or narrative changes may signal psychological defenses. [11:53]

Clinical Applications

• Non-assumptive: Just because an experience occurred doesn’t mean it’s understood.
• “Just because someone went through something doesn’t mean that they can see it clearly.” – Dr. A [14:56]
• Clarification is vital in therapy, diagnostics, and forensic interviews (e.g., “not guilty by reason of insanity” evaluations).

Notable Practice

• “Hallucinatory level of detail”: Eliciting rich, sensory recollections to deepen understanding.
  • E.g., Describe exactly where you were, the light in the room, the smells, etc. [17:01–19:18]

---

4. Level 3: Confrontation

Defining Confrontation

• Purpose: Pointing out patterns, inconsistencies, or contradictions in a patient’s narrative, behavior, or between values and actions.
• “It’s about holding up one thing and then comparing it to another and saying, ‘Do you notice that?’” – Dr. A [21:03]

Principles for Use

• Requires strong therapeutic alliance and clinical judgment.
• Should be gentle, non-punitive: “You should always do them gently and with adequate groundwork.” – Dr. A [22:45]
• Essential for helping patients evolve from ego-syntonic (“this is just how I am”) to ego-dystonic (“this might be a problem”) perspectives.
• “If someone sees or feels a pattern as part of them, they will never let that go… But if you can convince somebody through repetitive confrontation…that it could be changed, that’s how we get fundamental personality change.” – Dr. A [23:04]

Examples

• Linking physical symptoms to stress: “You often get sick when you’re under stress—what do you make of that?” [25:45]
• Observing avoidance patterns: “Have you noticed that any time we talk about your ex-best friend, you change the subject?”
• In medication management: Noticing anxiety around medications despite expressing a desire for improvement.

Structural Insights

• Ordinary Person Standard: Useful to compare patient reactions to population norms to avoid collusion with defenses or blind spots.
• “A big part of our job is common sense and using your common sense…” – Dr. B [31:53]

---

5. Level 4: Interpretation

What is Interpretation?

• Definition: Explicitly linking the patient’s exhibited patterns or defenses to underlying (often unconscious) drives, wishes, or conflicts.
• Prerequisites: Should only be offered when patterns have been amply confronted and patient is nearly able to make the connection themselves.
• “You have to have the evidence. You’ve got to have the receipts.” – Dr. A [34:18]

Range of Interpretations

• Surface (“You seem to love and resent your mother at the same time”) to Depth (“This ambivalence comes from childhood experiences when she was inconsistent…”).

Warnings & Misconceptions

• Use extremely sparingly, especially in medication management settings.
• “I actually think it has no place in a medication management treatment.” – Dr. A [36:29]
• All legwork for insight is at lower levels; “Interpretation is just a small skip, not a gigantic jump.” – Dr. B [38:14]

Diagnostic Parallel

• Good practice: Patients should understand their patterns before being presented with an interpretive link or diagnosis.

---

6. Integrating the Levels in Practice

• Lower-level interventions (0-2) are foundational; build alliance, narrative, and insight.
• Higher levels (3-4) should only be used once groundwork and rapport are solid.
• Not all interventions are strictly sequential; clinicians mix and match interventions according to the therapeutic moment.

---

Notable Quotes & Memorable Moments

• On Mirroring:
  “Try out Hs and Ms. Nonverbal acknowledgment sounds—very important... you’re not offering up any new content. You can do this nonverbally, and it prompts people and encourages them to continue speaking.” – Dr. A [02:53]
• On Confrontation:
  “Fundamentally, confrontations are how we actually get people from going ego syntonic to ego dystonic, which is what we’re trying to do.” – Dr. A [22:55]
• On Interpretation:
  “Interpretation should only be made when the patient is almost able to make it themselves.” – Dr. A [36:48]
• On Therapeutic Humility:
  “All the legwork is done on levels 0 through 3; the interpretation is just a small skip.” – Dr. B [38:14]

---

Key Timestamps

• [01:08] – Overview of the intervention “levels” structure
• [01:31–03:28] – Defining and applying empathic mirroring
• [06:14] – Difference between support/containment and mirroring
• [09:58] – Introduction to clarification
• [11:53] – "River" metaphor for understanding narrative flow
• [17:01–19:23] – “Hallucinatory level of detail” in clarification
• [19:53] – The “confrontation” intervention
• [23:04–25:40] – The necessity and risks of confrontation
• [33:27] – Brief on “shared cultural scotoma” and clinical blind spots
• [34:18–36:48] – When and how to use interpretation
• [38:14] – Cautions and myths about interpretation

---

Closing Thoughts

This episode gives listeners a structured, pragmatic roadmap to therapeutic interventions in psychodynamic work—emphasizing patient narrative, clinical humility, and the delicate timing necessary for true insight. Through detailed examples, playful analogies, and references to both classical and contemporary thinking, Dr. A and Dr. B provide a toolkit useful to practitioners and anyone curious about the inside workings of therapy.

For deeper dives and resources, visit psychofarm.substack.com.

Transcript

[A]

Morning, Dr. Matt.

[B]

Good morning. How's it going?

[A]

I suppose I feel a little bit more level headed today.

[B]

Level headed.

[A]

Oh, yeah.

[B]

Is this in reference to the levels?

[A]

That's right. It's the promised levels. I don't know if it's gonna really take up all that much time, but here we go.

[B]

We should have. I feel like last time I mentioned it, Kramer in Seinfeld wanted to make his house levels. So he makes a bet with Jerry on if he can do the levels, then he doesn't do the levels. And he goes, I could have done it if I wanted to. So even if we didn't actually release this episode, I don't know.

[A]

Yeah, we could have done it if we wanted to. Levels, Jerry, levels. It's a pretty good episode. So we talked about how. And then that's in the first episode. There's the level zero. It's extremely important. Remember, picture the levels in a descending pyramid, reverse pyramid, the one that you do the most. This is the top part of your food groups.

[B]

Okay?

[A]

This is level zero. That's the supportive. The supportive elements, the alliance, you know, and technical containment. Refer to the other episode for that. What is the next most common intervention you do in an interview or a therapy session? It is called empathic mirroring. Level one. Empathic mirroring.

[B]

Yeah. I'm excited to hear you talk about this because I'm curious to hear how you distinguish empathic mirroring from, say, containment. But give us, start us off.

[A]

Well, spoiler alert. They probably aren't all that different, but we can draw a distinction. So the problem with empathic mirroring is what does that mean? I don't think it's a very clear term in this context. I'm going to define it as getting the patient to talk more, to continue their narrative without changing the trajectory or content of the narrative. Okay, so it's any intervention you do that basically gets people talking more along the lines that they're already doing. In classical terms, that would be encouraging free association. Now, there's a lot of different ways you can do that. Okay? It can be very, very simple. It can be simply, tell me more, tell me more. It can simply be looking interested. You can do this nonverbally. Or it can be reacting, emoting with your face to what the patient is telling you in a way that demonstrates care, interest, and that you are feeling what the patient is feeling. Another important area that I would recommend developing, if you haven't already, is I think it's important for psychiatrists, clinicians, psychologists, therapists to Have a wide variety of HS and Ms. In their, you know, in their back pocket to try out Hs and Ms. Nonverbal acknowledgment sounds very important, right? You're not offering up any new content. You're not redirecting in a specific way. You can do this non verbally, and it prompts people and encourages them to continue speaking.

[B]

Interesting, because you're defining empathic mirroring as kind of getting the person to continue to talk. I think that in terms of I had to encapsulate in one sentence. It's reflecting the patient's subjective experience in an attuned way. I'm going to build off a little bit of theory, but it might be relevant here. Containment comes from beyond. And to me, the main focus on mayor is building the capacity to think and regulate emotions. And you do that by digesting and metabolizing what the person says and giving it back to them in a form that they can think about. Whereas mirroring comes from cohort, which has to do with the development of the self, in that essentially a child has their experiences and they need another adult to reflect it back to them so that they can see themselves and other people in some sense. And the focus when someone's doing mirroring is to say, I see your experience and the need to be recognized, and they're relatively similar. But I think of containment as more of processing and putting thoughts into a container and metabolizing thoughts in a way that they can kind of hear back. And mirroring as a way to show that this person has an individual self that can be seen and is important and recognized.

[A]

So I've actually categorized those things under the same umbrella. I think the Kahootian idea is pretty much beyond's idea. If you're doing one, you're doing the other. In my opinion, this is where we're going to some trouble. Why do I put those in level zero and this one level one? It's simply terminology. This is again an issue where, when, when different authors, different people use different. Sorry, the same terminology to refer to different things, it gets super confusing. So cast aside everything you've learned or thought about when it comes to empathic marrying. Don't even use that terminology if you don't want to. Just call it level one interventions, okay? Just anything you do that gets somebody to continue talking. And yes, it can be a level zero intervention that causes them to continue talking without redirecting them. You can simply talk about what you noticed in the patient's emotional process, like that you can Say, you know, I can feel how sad you are touching on these memories again right now. Just by saying that, you may cause the patient to continue speaking. And you have not asked some question or brought up some subject or used some new words to redirect them in some fashion, even inadvertently. So to clarify.

[B]

Oh, level Level zero is about support and containment. Level one doesn't matter what we call it, but it's about getting the person to continue talking without changing their trajectory.

[A]

That's right, yeah. Or free associating. An important tool for this, in my opinion, is called punctuation. This is via Bruce Fink of the Lacanians. You basically punctuate by basically emphasizing some particular word or turn of phrase that someone has just said to you. Okay. You're not introducing new content, but you're just sort of highlighting something that they've said. I like. I don't know if anyone listening, no audience I've spoken to has ever known this reference. But ever play Metal Gear Solid or heard of that video game series?

[B]

I remember reading it in Nintendo Power as a kid, but I never played it.

[A]

Right. So there's somebody who's made, like, some video online of the main character of that series. Because in their cutscenes, in the dialogue, the guy who writes these games, Kojima, he likes to have the main character just repeat, like, one word of what the person who's just said to them in a questioning tone. Okay. They might be talking about, like, oh, you know, well, the government has done XYZ and Solid Snake will say, the government, Right. You can do the same thing as a psychiatrist, therapist, clinician. Okay. When the patients say something, you can simply repeat back a key word that they said, and the patient will continue to discuss it. That is a form of level one empathic mirror. One example, they might just say, you know, my friendships, my life, you know, they're all just messed up right now. You know, after everything. You might just say, messed up. You might just say, after everything. Or your life and your relationships, your friendships, simply repeating back. Very powerful tool. Don't discount this. Give it a try.

[B]

Give it a try.

[A]

You're probably already doing it once in a while, but that or your hmms and hmms. Great ways to just continue getting patients to talk. Because why do we need this? Often people will think, I've already explained all there is to explain about something. But you may find that you get a richer narrative or more information that you would not have gotten if you prompt people to continue talking on one line of thought, one line of Narrative rather than asking specific questions about specific material that you, the clinician, want to learn about. Getting an encouraging narrative in this fashion. Very, very powerful for getting information. This applies to therapy. This applies to diagnostic interviewing. This applies to forensic psychiatry, like the

[B]

hmms and the ums. I feel like you could do a whole episode on your grunts and how. How they work. But yeah, I guess it's essentially like the. You're bolding what you would bold if you were to take a sentence and. And if you were to control b something, your. Your control being some aspect of what the person said. Yeah.

[A]

Maybe at the end of this episode, you can edit in some of those clips from that solid Slink video a soldier that was thrown in prison along with me. Prison. She said that she had just joined up as a new recruit. A new recruit. I was in contact contact with her by Kodak Codec. Okay, so what's level two? So again, we're going and decreasing,

[B]

you

[A]

know, amount of intervention. How much you do this in the session. You do a ton of zero all the time. You're doing zero all the time. You do one empathic marrying. Sometimes not sometimes a lot, but less so. And what's less frequent than that? Clarity, clarification level two. What is clarification? This is probably what diagnostic interviewers are the most familiar with. Okay. This is basically asking any kinds of questions or doing anything that gets the patient to go into more depth or detail about what they're talking about. But it. Even if it redirects the narrative, it doesn't challenge the narrative, and it doesn't highlight any inconsistencies or patterns just yet. You're just getting more information. And I like to think about it in two different ways. If the patient's narrative is the surface of a river, okay, imagine the surface of a river flowing. Clarifications can either increase the level of detail and attention on the surface of that river, or it can increase the level of depth information that you get. So there are subtypes of clarification.

[B]

Just a small plug to leave a review. If you can, leave a review will help other clinicians find our show and will let us keep making it. If you're on Apple podcasts, open the show page, scroll to ratings and review. If you like us, tap five stars. If you're not sure what to put for the review, just say, hi, Dr. Fu. And if you're on Reddit or YouTube, leave a comment. Dr. Foo reads absolutely. Absolutely. Every single one. Let's get back to the show. So can you Explain this river analogy a little bit more. When you say going deep and more surface, can you kind of give us a little bit more of a picture of what you're thinking?

[A]

It's basically just a way to think of what a patient is saying to you. If it's an evenly flowing river and then suddenly they stop talking or suddenly they change the subject, you might think of the river damming up or the river changing direction. When you notice that, that probably tells you that something happened inside the person. Usually what the analysts will call a defense, that changed the flow of that narrative. And sometimes it's just a matter of getting that river flowing again. That's the level one. Interventions, empathic marrying. And sometimes that part of the river is important and you want to get either more depth or more surface level details. So what do I mean by surface level details? Well, let's say they talk about, well, you know, I had a fight with my friend last week and, you know, it was terrible. Okay, well, that's important. That's some information there. But we want more details. Surface level details would be surrounding events in sequence and context.

[B]

Right.

[A]

Concrete stuff. Where were you with your friend? How did you get into that discussion? What was the discussion actually about? What happened after the discussion.

[B]

Right.

[A]

All these things are concrete, surface level, usually consciously accessible facts. That's river. Surface level clarifications. When you ask for more details. Depth, on the other hand, is another important subtype of clarifying questions. When you get clarifications with depth, I like to think of it as fantasies, wishes, imaginations, emotions. Okay, when you got into that, what were you feeling? What kind of emotions were you having there? Did you wish that it was going in a different way? What did you think about? What were you imagining your friend feeling about you when they started bringing that up? Does this remind you of anything in your life? Has this ever happened to you before? How do you usually tackle this? Still all on the same subject, not challenging the narrative, not highlighting contradictions, inconsistencies, or patterns, but just getting more information. You can get it surface or depth?

[B]

We talked about last episode that really the overarching goal of therapy is to have the patient expand on their emotional life and shine light on their emotional life. Here we're not inputting any hypotheses as to what's going on. We're not trying to, like you said, confront or point out contradictions. We're just trying to, in our mind, get a better visual per the patient of what happened and better understand the situation that they're Experiencing. Yeah.

[A]

And don't assume that that information is readily conscious for anybody. We go through a lot and we aren't fully aware of what we're going through. I like thinking about clarifications with, you know, Carl Rogers description of it in that it's just a process that's helping somebody see more clearly. Right. Figure out the meaning of things and really just what happened. So just because someone went through something doesn't mean that they can see it clearly. Try to put it into words. Get those surface and depth clarifications.

[B]

Great, awesome.

[A]

And some examples, you can simply paraphrase something. You can confirm your understanding. And you could say, hey, that sounds a lot like containment. Well, maybe, but you can just say, let me make sure I understood that correctly. So the reason why you got into this conflict with your friend was at first you were kind of having a dispute about debt.

[B]

Right.

[A]

But it spun into something a little bigger. Is that right? Or you could say, hey, just now you mentioned briefly that that was actually the end of your friendship. How exactly did that happen? How did it get from the debt to that? A popular clarifying question that I like to trot out comes from. I forget his name. I'm sorry. A trainer I had for interpersonal psychotherapy was what was that like for you? Very vague. Okay. But a great way to prompt people to clarify their experiences. What was that like for you?

[B]

Yeah, that's a great way to kind of make them go deeper and very subtle way of asking them to go a little bit deeper. I, like you said, kind of even. Even repeating things back can be clarifying. In my own individual therapy, once upon a time, a therapist would repeat back almost exactly what I would say, and then I would disagree with it, and it helped me. And then I was like. I was like, oh, no, what I'm describing isn't perfectly capturing what I'm experiencing. And when I hear someone reflect it back, then I can hear the discrepancies in terms of the things I want to add. So it can be very helpful for people.

[A]

Yeah. And then highlighting those discrepancies will be the next stage, the next level of intervention. But before that, an important concept to highlight for clarification interventions. And the process of clarification level two is the concept of exploring either imagination, fantasy, or actual memories in a hallucinatory level of detail. Okay. This is super, super important, not just for therapy, but also in forensic psychiatry and other kinds of diagnostic interviewing. Okay. This is actually what you will do. It's not the only thing you rely Your opinion on. Far from it. But this is what you do for not guilty by reason of insanity evaluations. Okay. And it's what you do in the therapy, too. Let's take that example again of the guy having a fight with a friend. Okay. Have the patient describe the events step by step, moment to moment, in a hallucinatory level of detail. Obviously, you're not going to have time for this in med management, but in the therapy, in a forensic interview, you might go into really a lot of sensory details. Do you say, where exactly were you standing in the room? Where was he standing? What time of the day was it? What was the quality of the light in that room? What was the color of the walls there? Any smells? Just a hallucinatory level of detail with all the senses. And walking moment to moment, you are essentially trying to induce the patient into a vivid memory of the event. Now, keep in mind the nature of memory means that it's going to be edited. It's not going to be fully accurate. But we don't do this stuff to take everything that someone remembers as absolutely true. We do it as a way to explore and to compare it to everything else we know. In the case, you used that expression

[B]

hallucinatory level of detail in the past, and I actually didn't quite understand what you meant. I think you put in a little more detail here. But just in case anyone else was confused, what you're just saying is that you can close your eyes and visualize exactly what happened. For some reason, I think I got caught up of hallucination. But all you're saying is you can close your eyes and feel and act. It feels like you were there. When that level of detail, it's to

[A]

a level of detail that you could even hallucinate. It basically is kind of the idea that you're getting behind it.

[B]

You can experience. Re. Experience hallucinate is just confusing because it's like. I don't know, I think of.

[A]

Look, I didn't come up with the terms. This is just how I was trained. It's the literature analysts were so flowery in the past and they. I felt like that I really feel like they had just competitions and who could be more, you know, vague or complicated intellectually in their writing? Yeah, obtuse in a sense, but we can talk about these things in an easier way. But unfortunately, I'm held prisoner by my training and the terminology.

[B]

Let's move on to level three.

[A]

Okay. So level three is, by the way, probably the. Well, traditionally you could say that this was the Intervention that set apart psychodynamic psychotherapies from other psychotherapies, especially behavioral or cognitive therapies.

[B]

Okay.

[A]

But I think that's really an artifact of when we really only had, like, maybe two different kinds of therapies that were considered bonafide therapies that academics really cared about. Today we have this vast field of different therapies, including integrative ones and eclectic ones. So probably what I would say is that the presence of the confrontation level of intervention is what sets apart a depth therapy from another type of therapy. So it's an important one to understand what is confrontation. It's not shaking your fist at the patient. It's not shaking the patient and saying, look at this. Pay attention to this. No complication.

[B]

It's about.

[A]

Yeah, it's about holding up one thing and then comparing it to another and saying, do you notice that? Do you notice that I like to hold my hands up like I'm holding up a platter? I like to say it's showing the patient their own mind or their own patterns.

[B]

Right.

[A]

That's confrontations. Confrontation is any intervention that points out a pattern, a discrepancy, an inconsistency, or some kind of a change in the narrative or between different parts of the patient or between the values of the patient and the behaviors. Anything that is odd, a pattern, or contradictory, if you point it out explicitly, bring attention to it, hold it up for the patient to notice. That's confrontation.

[B]

Yeah. And I think how this plays out is going to differ a lot. I think it's important for us not to focus on confrontation as therapists. And I think you need a good therapeutic alliance to be able to do it for the patient to receive it. We talked sometimes there will be confrontations, even on intakes. But then I think you should be a lot more gentle in terms of pointing out confrontations and in the sense of the goal isn't necessarily to have the patient learn something new and have a different experience. The goal is probably just information gathering. But when you're doing it, in a sense that you're trying to get the patient to kind of acknowledge some sort of inconsistency in their psyche or how they view things. You need a really good therapeutic rapport. And it needs to be something that you have enough understanding that the patient will be able to receive it. Yeah.

[A]

You know, depending on the level of the confrontation. Absolutely true. That's why these are in descending order of frequency of use. Right. 0, all the time, 1, extremely frequently, 2, very frequent, and 3, less frequent. But it is entirely possible for you to go 20 years with a patient and never do a confrontation, which is a problem. Because fundamentally, confrontations are how we actually get people from going ego syntonic to ego dystonic, which is what we're trying to do. Because if someone sees or feels a pattern, a set of behaviors, set of values, or any part of them as part of them, they will never let that go, no matter how much it hurts them, no matter how much it hurts other people. But if you can convince somebody through repetitive confrontation that there is something that they are doing or that's a part of them which is causing them or other people problems, and that it could be changed or should be changed, that's how we actually get fundamental personality change. Confrontation. Very important. So in a formal therapy, I would say you should be doing these by session three at the latest. You should always do them gently and with adequate groundwork, but you should be doing them in diagnostic interviewing. I don't think you should hesitate from doing these if you know how to do it gently and in a way that does not give off the impression that you're being punitive, overly critical, or anything like that. Okay, you can do confrontations. You should do confrontations, but you don't do them aggressively. You might just simply say, I noticed that. Well, I'm already picking a hot button version of this. But you've mentioned that having poor concentration is a big problem for you, and that's kind of the main reason why you're coming in. And you've also told me that you smoke six months a day of weed. What do you make of that? Is that something that's related or what do you suppose is going on there might be worth bringing up immediately in the first session. And, you know, just, you have to use your clinical judgment. And there's a difference between simply pointing it out, pointing it out repeatedly over time, and pointing out the pattern or the behavior and linking it to both. How it helps the patient, how it's adaptive, and how it hurts the patient, how it's maladaptive. That's where you're really trying to build to eventually, in terms of a long term process of confrontation. But again, these can be used in the short term in order to gather more information or to bring the patient closer to insight.

[B]

Can you give us a more specific example of a confrontation?

[A]

Yeah, because it's a level of intervention. All of them are, that covers such a broad variety of things that you can be doing. I think we can only give some very limited Examples, but it's worth talking about. One example might be simply making some kind of a connection between, let's say, somatic symptoms and stress. You know? You know, it seems like every time something that's stressful happens to you or that makes you feel like you're a bad person, you often get to get feeling very sick, have a headache, and then you lie in bed for the rest of the day and you kind of avoid people. Why do you suppose that happens? Do you agree that that happens? And why do you think it, do you think there's some connection?

[B]

Right.

[A]

A confrontation presents something to the patient as important, potentially linked, and you want to then ask if they can come up with some hypothesis about it.

[B]

Right.

[A]

That's one example. It might also just be. Have you noticed that every time we start talking about, you know, your best friend, your ex best friend, you change the subject pretty soon afterwards? These are both more therapy oriented confrontations, but they're salient nonetheless. Let's think of a more maybe medication management version of a confrontation. I gave a couple interviewing versions of it, but I suppose it can even be a confrontation about observation of affect versus statement. You're coming in here and we're talking about medications and it seems like you want to get better. At the same time, I can't help but notice that when we discuss the side effects of medications, you seem quite anxious about it. Have you noticed that? How do you really feel about taking medication? Is that something that you really feel comfortable with or do you have some doubts? Right. That was a confrontation. That was followed by a clarification. There's no problem with mixing and matching these interventions.

[B]

Right.

[A]

But it's simply finding any kind of pattern inconsistency or something that is. Doesn't make sense in a patient's narrative or presentation and highlighting it, showing it to the patient and having them reflect on it.

[B]

Yeah. I have a quick example for medication management. This patient I was actually also doing therapy with. I'll change the details, but essentially whenever they were mad at me. This is an interpretation. But whenever they were mad at me, they wanted to taper off all their medications. And there was multiple sessions that they would be in acute distress and would be essentially decompensated. And then they would say they want to taper off all their medications and I would have to hold up the conflict that put me in and saying, it's hard because I feel like whenever you're mad at me, you want to taper off the medications. But I also see that you're doing much Worse. And in terms of how in medication management, it doesn't make sense. I don't typically start thinking about tapering off medications when someone's in an acute crisis. And I would hold up that to them and try to help them to think through it.

[A]

I think that's a perfect example of confrontation. Again, it's just really holding up anything that involves the patient's own mind, behaviors or decisions, and showing it to them to look at together with you and to reflect upon it. Anything beyond that, we are probably going into a intervention outside of the psychodynamic framework, such as a directive, a skill or instruction, or we're going to interpretation. Now, before we get to level four, interpretation for confrontation, there is a important concept and I'm going to refer to a legal concept. It's the kind of ordinary reasonable person standard. Okay. When it comes to negligence, there is sort of this legal fiction of having a ordinary reasonable person standard as a finder of fact jury member. Let's say you are supposed to think, what would most reasonable people do in this situation? And if someone was sufficiently far apart from that in their actual behaviors, then they may be negligent. That's a short version of that legal concept. But you got to have an ordinary person standard when you work as a clinician. I know we are not necessarily working with people who can be held to a ordinary person standard. That wouldn't be fair. But nonetheless, it helps us understand whether or not a behavior is of clinical importance or not, or if a pattern is of clinical importance or not. So in a mental health treatment realm, I want everybody to consider and know to some extent, and this may require some research, we are not all ordinary people. We're not always just interacting with ordinary people. You have to know population norms. Gotta ask, what would most ordinary people, what do the majority of the population, what would they think, do or feel in the same situation? And is the patient different from that? Or even if the patient is not different from that, okay, are there any other things that other ordinary people would have done or felt in the same situation? This is a path to suggesting alternative behaviors or habits. Even if psychoanalytic psychotherapies are non directive, simply asking why a patient didn't do an alternative behavior or didn't think or feel something in alternative opens up that possibility. In the behavioral therapy, you would actually actively suggest it. You would go like, what about this thing? Would you like to try that? Why don't you try it and tell me how you think or feel about it? But having the ordinary person Standard allows you to notice things that are clinically important and allows you to prevent, to some extent, collusion with the patient's habits, defenses, patterns.

[B]

Yeah, it's funny, I really like the way you put it. I feel like the thing I often enforce with trainees and supervisees is a big part of our job is common sense and using your common sense for when a patient reports, oh, I had a breakup a week ago and I'm doing spectacular, like, use common sense. And this is something that, as you said, it's really helpful for not colluding with patients or not colluding with patient defenses. Common sense tells me that that's a pretty atypical reaction. And listen, maybe there is something that helps explain why that patient's having that experience, but it still needs to be talked about. Yeah.

[A]

And I think it's super important also, because when you care about a patient and you empathize with them and you want them to get better, you're going to miss stuff because you're kind of living in the world of that patient and it's going to feel emotionally correct and all makes sense, but if you don't draw back and observe it in this way, you're going to miss stuff. A similar concept is the shared cultural scotoma. Scotoma being a blind spot in the eye, in the visual field. This is something that's been written about in psychoanalysis where two people, a therapist and a patient of the same culture, may both mutually ignore some glaring aspect of the clinical situation, because for both of them, it's a cultural norm. But even if it's a cultural norm, it may be something that's of clinical interest. So just be aware of this possibility.

[B]

There's a lot here in regards to the current political climate that's relevant, but we're not going to talk about it. Let's go to level four.

[A]

Well, I think that's a different episode where we gripe about today's these American shared cultural scotomas. Perhaps people can comment if that's something that they want for another day. We're getting close to end of time, so let's just do the last level. This is the least important one, I think, unless you're object relations analyst, where they start dropping these in day one. Interpretation, interpretation. Okay, now keep in mind, again, same terminology, different concepts. I think different people in psychoanalysis, even when they talk about what an interpretation is, they're actually talking about very, very different things. Okay, so for this context, when I say interpretation as a level four rare intervention, it's basically anything that explicitly makes a link between a pattern or a defense towards some kind of a unconscious process for the patient. Wishes, desires, conflicts, ways of relating. Unconscious. Okay, how do you get to these? You have to have the evidence. You gotta have the receipts. Do not give an interpretation until you have countless or at least numerous examples that you have already confronted with the patient of the defense pattern or unconscious process happening. Okay. You know, this can be a superficial interpretation. It can be a depth interpretation. But just like confrontations, you go from surface to depth. Okay. You start out maybe just saying, you know, it kind of seems like that, you know, you love your mother and you want to be close to her, but every time you spend time with her, you spend it teasing her, criticizing her. Could this be something related to having two feelings about your mother? A part of you that wants to be close and loving and another part that resents her and feels aggressive towards her? Right. That may be a little bit more surface level. And then as you go deeper and deeper of intervention, you're going to start getting to a historical narrative. You're going to talk about why, where does this come from?

[B]

Right.

[A]

Well, you know, it seems that this tendency to feel both angry and loving towards your mother sort of comes from a little bit of the inconsistent experience you had with whether or not she was happy with you when you were younger, and that you maybe had some feelings of competition between the rest of your family for her affections because she would just be away for so many times when you were younger. That might be why it doesn't seem to be easily accessible to you, consciously, that you're not always aware of the parts of you that are angry at her alongside the parts of you that love her.

[B]

Again, again, want to reemphasize, as you said, this is the thing that should be done the least and especially in medication management. This is not something that you should be pulling out these deep emotional wounds and interpreting them for the patient. Yeah.

[A]

I actually think it has no place in a medication management treatment.

[B]

Yeah. And you do see people play acting psychoanalysts in once every three months therapy and or once every three months medication management. And I think that does more harm than good.

[A]

Yeah. Because this is my training and this is why I advocate an interpretation should only be made when the patient is almost on the cusp or able to make it themselves.

[B]

Okay.

[A]

You should have so much database of, you know, information from clarifications and repeated confrontations, showing the patient their own patterns and minds, that by bringing it up, the patient Will say, hey, you know what? That's obvious to me. You're right. This has happened so much and those things did happen to me, and I think they are related. Right. That should be the time when you do an interpretation, when the patient is almost able to explain it themselves. And in the same way I advocate for a similar thing, though it's much easier to reach for diagnosis. You should not make a diagnosis ideally until you have demonstrated to the patient that you have collected the history, made the observations, pointed them out to the patient, got in mutual agreement and say, hey, you know what? You know, so far we've been talking about multiple episodes throughout your life, starting from around the age of 20, where for three or four days in a row you've had decreased need for sleep, increased activity, and all these other things. And you spend too much and you get into fights. You know, that's basically the definition of hypomania. And I think that means that you have a bipolar 2 disorder. They should be almost ready to make the diagnosis themselves based on what you've covered in the history. It's the same principle.

[B]

Yeah. And I feel like there's almost like a, a caricature of how people think about psychoanalysis and that like you get this like mind blowing interpretation and then it's almost like a piece of advice that now that I can see the world differently and that's not how it plays out. And it's not a, a feel good, happy thing where it's like you nail the interpretation. Then it's like, oh my God, now everything's kind of cleaned out. And I understand everything. It doesn't, it doesn't look like that. As you mentioned, all the legwork is done on levels 0 through 3 and that the interpretation is just a small skip. It's not this gigantic jump of some undetected emotion that is finally elucidated by some grand therapist.

[A]

Yeah, I do believe in a Rogerian way that if you're just doing 012, your work is done, the patient will heal on their own. But, you know, if you want to do some threes and fours too, and this is a long term therapy, so much better.

[B]

Right.

[A]

But just don't neglect the first levels in order to do the rest.

[B]

Yeah. All right, I think we're wrapping up.

[A]

See you next time.

[B]

All right, have a good one. Thanks for listening. If you want to support the show, check out my very practical antidepressant course. If you want to check that out, go to Psycho Farm. If you prefer to read, you can go to Amazon.com you can just search my name. Gregory G R E G O R Y Malzberg M A L C E R G and the book is Psychopharm's Guide to Treating Depression. It's a nice, easy, readable, practical guide to medications for depression.