Think Like A Shrink #2: Clarification, Confrontation, Interpretation


In Think Like a Shrink #1 I warned against the temptation to psychoanalyze your family and friends. In particular, I warned against interpreting another person’s behavior with a “you…. really” statement that tells them, in essence, “you think you know what you are doing, but you don’t know what you are doing; I know what you’re doing, and this is what it is.”

I said that in exploratory psychotherapy (we’ll leave discussion of supportive therapy for another time) interpretation should account for around 1-5% of all of a good shrink’s comments. So what should happen in the other 95-99%? Just two other things: clarification and confrontation. Clarification should account for roughly 90% of what a shrink says, particularly in the early years (yes, I said years!). Confrontation should account for roughly 5-9% of what a shrink says. And, as I talked about last time, and will flesh out in more detail below, interpretation should take up 1-5%, with the number only getting up there as therapy goes on and the shrink and patient really know and trust each other.

Kept in the correct ratios, therapy tends to go well. But if they get out of whack, the therapy tends to derail, and depending on their personality the patient will start keeping secrets, fudging the truth, skipping sessions, or end up quitting. It’s important for both parties to keep tabs on these ratios, and to wonder what’s going on if they start to skew.

Clarification

Clarification is the bread and butter of good therapy – and good friendship. If you’re ever at a loss for what to say to someone, in or out of therapy, clarify! You really can’t go wrong. Thats half of why it takes up 90% of good therapy; the other half is that it sets the shrink up to confront and interpret. Without all the information elicited through clarification, a shrink who confronts or interprets is just shooting in the dark, and quite likely to make avoidable mistakes.

Here are some examples of clarifications – albeit very simple, basic, ones; we’ll get to more complex ones in a moment:

“How are you today?”

“How did that meeting go?”

“I notice you have a cough.”

“You aren’t wearing your wedding ring today.”

“You were fifteen minutes late today.”

Notice that each of these statements has no emotional words in it. Each is either a simple statement of fact (“you aren’t wearing your wedding ring today”) or a simple request for information (“how did that meeting go?”). And each one implicitly or explicitly asks the patient to provide some information without any (explicit) value judgment.  That is, the shrink may be thinking to herself “jeeze, he looks absolutely awful today – he’s so pale, his face is so drawn, his mouth is so dry, his hands are trembling; he looks panicked” but she isn’t saying that, because that would be a (very mild) confrontation (it would be confronting the patient about how he appears even when he isn’t discussing it, and force him to think about something he might rather avoid). She’s simply asking “how are you today?” and letting the patient answer as he pleases.

If you think about the people in your life who make you most comfortable, you will probably notice that they tend to ask many, many clarifying questions, and that even when you are having a very hard time they stick to this basic principle. They don’t flood you with unwanted information (“you look terrible!” or “why didn’t you return my phone call” or “you are so inconsiderate – I’ve been waiting for half an hour!”). They let you decide what to tell them, when.

One thing that can’t show up on a blog, but is crucially important to these clarifying comments is that they have to be said in a friendly, open tone of voice, an open, curious facial expression, and with calm, confident body language. There is a lot of emphasis in psychotherapy on words, but this emphasis only focuses on the part of speech produced by (in right handed people, and to be very broad in our neuroscience) the left frontal lobe. But the right frontal lobe puts the “spin” on words — whether they are said angry or sad, worried or contemptuously, snidely or with curiosity. And the seventh cranial nerve — the facial nerve — controlled by the seventh cranial nucleus, controlled by the brainstem, controlled by the cerebellum and limbic system, controlled by the prefrontal cortex (again, a very broad generalization, of course) controls facial expression – whether one’s eyes are narrowed, or mouth pursed, or eyebrows raised.

You can create all kinds of havoc with someone, patient or friend or child, by saying one thing with your words while saying another thing with your tone and saying yet another thing with your face. This is the stuff, potentially, of comedy. But it is also the stuff of assholes. When a shrink is saying neutral things, but sending out non-verbal contempt or arrogance or judgment or disgust or anxiety through his voice or face or body language, it’s no good for the patient. And it’s even crazier for the patient who asks “wait, are you judging me” to have the shrink say, “no, I just asked how you felt about your affair,” when the truth is that the shrink is sending out, perhaps unconsciously, a very different vibe in his overall behavior.

This is why it’s so important for shrinks to at least try (and ideally succeed) in getting themselves into what’s called a “therapeutically neutral stance,” which I’ll discuss another time. But the bottom line is they can’t be attached to what the patient does or says, and has to simply try to stay empathically connected to them, wherever they are, while taking note of any transference (again, a topic for another time) the patient is stirring up. For now, the main point is that these neutral clarifications have to be said with a warmish, calm, non-judgmental, patient attitude: any emotion except, overall, respect, should not be creeping in. Most shrinks fail at this at least some of the time — but overall, they should feel essentially nonjudgmental to their patients; this is what allows honesty in the room, and honesty is a key to psychological health.

A slightly more intense version of the clarification is the “possibility.” In a possibility, the shrink very gingerly raises a question that the patient has not addressed, but communicates that whatever the patient says is going to be accepted more or less at face value (albeit with some follow up clarification being of course allowed). Here are some examples:

“You keep mentioning this study-buddy of yours, Cindy. Is it possible you have a crush on her?”

“That’s the third time this session you’ve mentioned the price of something. You told me how much my phone must have cost, you said they weren’t fixing the elevator because it cost too much. And you told me how much the Knicks are paying Carmello Anthony. Is it possible you’re thinking a lot about money these days?”

“I know you were having that meeting with your kid’s third grade teacher yesterday, but you haven’t mentioned it. Is it possible you are having some strong feelings about what you heard?”

“You keep scowling at me whenever I bring up the disagreement we had last time. Is it possible you are angry at me?”

As before, tone, facial expression, and body posture are all important here. The shrink shouldn’t ask these “possibility” questions unless he or she is really feeling curious. If these questions are asked in a hostile, angry, frightened way, they won’t ring true, and will end up being (badly delivered) confrontations.

Confrontation

As you can probably imagine, clarifications can increase in complexity. At a certain point, even if emotional words or judgment don’t enter into them, they start to get an edge to them. At this point they start to slip into a second category of comment shrinks make. Here are some examples of amped-up versions of the clarifications that came earlier, and which end up feeling at least somewhat confrontational:

“I notice you keep wiping your brow. How are you today?”

“You were very excited last week about your annual review with your boss. You were confident you were going to get a raise. But we’ve been talking for twenty minutes and you haven’t mentioned it. How did that meeting go?”

“I notice you have a cough. Yet you haven’t been using the tissues next to you, or covering your mouth when you cough.”

“Last week you were telling me that the your new account partner is very attractive, and that you’re glad your marriage is in good shape or you might start getting ideas. But now I’ve noticed that you aren’t wearing your wedding ring today.”

“We had planned to spend the beginning of today’s session talking about your unpaid bill, which is now two months late. But you were fifteen minutes late today.”

Notice that although these are more intense than the previous set of statements, they are still neutral comments, and the shrink is not coming right out and confronting the patient the way they would if they were, say, a detective in a murder mystery. That is, these aren’t at the level of “you say you weren’t at the murder scene that night, but in your wallet we found an ATM receipt from half a block away, five minutes before Miss Scarlet died!” I’m emphasizing this because it’s important for shrinks to know that they can say mildly confronting things that are more or less like clarifications in their syntax.

The key idea about a confrontation is that where clarifications let the patient say whatever he or she liked, in an open ended way, and appoint the patient as the arbiter of truth, confrontations implicitly or explicitly introduce a new idea into the room – an idea the shrink, not the patient, is thinking of.

Why would a shrink do this? Because, in a nutshell, patients often want to use therapy as an echo chamber: a place to have their view of the world validated by an authority figure. If a shrink just clarified, all sessions long, session after session, the patient would end up thinking that their way of looking at the world makes perfect sense. “My shrink never challenges or doubts me – he just accepts me as I am, whatever I have to say.” But of course, if the patient knew exactly how to run her life, she wouldn’t be in therapy! She’d just be running it that way.

Over the 90% of the time that the patient is answering one clarifying question or another, the shrink has a chance to consider whether the story makes sense. He thinks things like “the patient says he is perfectly happy to have been fired, because it was a shitty dead end job, but fifteen minutes ago he was moaning that his girlfriend complained that they never go out to dinner any more. Those two things don’t go together.” The shrink may let the patient go on, but if he appears headed for leaving the session without mentioning that being fired has its downsides, it’s time for a confrontation. Otherwise the shrink won’t have done his job of making sure that the patient has a chance to be honest about all of his life – not just the parts he’s proud of.

This is a crucial point. As I hope to cover at a later date, self-esteem is far more important to most people than pleasure (pleasure lasts only as long as the meal, or sex, or money is going on; self-esteem lasts all day long, and keeps you warm when things aren’t going your way). And the biggest enemy of self-esteem, for most people, is shame. People are ashamed of any number of things: their looks, their intelligence, their job, their children, their parents, their behavior, their religion, their race. They aren’t totally ashamed of any of these things, but there are little teeny-tiny (or sometimes huge) pieces of each of these parts of them (maybe their nose, or their poor public speaking, or their bonus, or their kid’s temper tantrums, or the way they spoke rudely to a waiter). And most people (though not all) try to avoid at least some of these little shames. So they don’t tell the therapist that they got drunk, or looked at porn, or made their daughter cry, or couldn’t look their boss in the eye, or farted in the lunch line, or had their letter to the editor rejected. They figure, nah, that doesn’t matter. But all these little bits of shame accumulate and begin to do damage to self esteem, and sometimes this leads to shame spirals, and shame snowballs, in which the person is avoiding so much — dating, or applying for jobs, or talking to their mom, or showing up to class — that they are essentially depressed. That’s why the good shrink scans what the patient is saying for holes, omissions, oversights, inconsistencies, and then, maybe once or twice a session, confronts the patient about them. Not in an angry way, but in a “hey, are we missing something here” way. Here are some common confronting statements:

“You keep mentioning that you were out to dinner with Sarah and this guy Charles and it was a lot of fun. Is that the same Charles you had a crush on last semester? I know you love her, but I wonder if you still have feelings for him, and whether seeing them go home together afterwards was complicated for you, or even bittersweet.”

“This fight you had with your wife sounds very intense, and it sounds like you were both saying some pretty cruel things to each other. Did I mishear you, or were the children in the next room watching Frozen? I wonder if they could hear you.”

“What you are saying about your mother sounds very annoying, and if we have time to get back to it, but I can’t help but remember that today was the day that you were going to get your SATs back. I wonder if you are avoiding that.”

“You reminded me three times today that you aren’t gay, when you talked about Tony and about the lunch you had with Sam, but I can’t help but notice that, if I heard you right about Saturday, this is the third weekend in a row that you convinced your friends to go dancing at that gay club down in Chelsea. I wonder whether there isn’t something that’s really exciting about being there, and how you feel when you see all these men openly interested in one another, even though you tell yourself it’s just because the DJ is the best in Manhattan.”

An even more interesting and subtle form of confrontation comes when the shrink introduces his own feelings into the room, to give the patient a chance to hear how she affects other people. These are confrontations because they force the patient, without her permission, to consider something they may not be aware of. In the examples below, I have the therapist telling the patient how he feels (something I do more than most) but these interpretations can work just as well if the therapist leaves out where he’s getting the emotional information from:

“I wanted to share with you that as you’ve been talking about how freeing it is to bicycle to work without a helmet, I’ve been feeling increasingly anxious. You talk about blowing through stop signs, and the importance of not giving way to taxi cabs, as though there’s no possibility that you could get hurt. But if my own anxiety is any indication, it sounds like you may be being quite reckless with your physical safety. What do you think is going on?”

“I wanted to share with you that even though you say you are just listing off the mistakes I’ve made today because you are trying to help me become a better therapist, I can’t help but feel that I’d better be sure that my next comment is a good one. I’m feeling a kind of pressure to perform, and am reminded that your daughter broke down last week when you asked her why she only got a B+ on her history paper. Do you think I might be catching on to a part of you that’s really hard on people?”

“You know, I realize that I’ve been laughing a lot at your stories today, and they really are very funny, and I’m reminded all over again that you always wanted to be a stand-up comic. But I can’t help but notice that I’m having so much fun listening to you that I’ve almost completely stopped thinking about the fact that this is therapy, and that your college boyfriend is getting married next weekend. Do you think that you might be trying to distract both of us from how hard it’s going to be for you on Saturday knowing that you have lately started having feelings for him again?”

These are complicated maneuvers, to be sure, and the shrink’s decision to reveal his own feelings is something we can look at another time. But that shouldn’t obscure that even though the therapist is using his own emotions and thoughts and reactions as a guide, his comments are, at root, confrontations.

Interpretation

Most of what makes therapy works happens with clarification and confrontation. It’s amazing what just giving someone a chance to verbalize what’s going on in their lives, and gently nudging them to talk about things that they find shameful but which, if left unmentioned, may undermine self-esteem and happiness, can do. People hear themselves speak, and make adjustments during the week, and as the months go by you hear them evolving in the most surprising and usually hopeful ways.

However sometimes your patient gets stuck. They’ve answered the same clarifications the same way, time after time. They’ve responded to confrontations the same way, time after time. There is a huge elephant in the room, or at least a baby one, and you begin — as a shrink — to think that the patient is never going to mention it. Maybe you wait a few sessions. Maybe you wait a few weeks. But eventually, after careful deliberation, you decide that you are going to up the ante and do the most intense thing a shrink can do: you are going to interpret the patient’s behavior by using an unconscious idea.

To get a sense of what this means, realize that in clarification the shrink was 100% interested in what the patient thought. In confrontation the shrink was maybe 50% interested in what the patient thought and 50% interested in what she, herself, thought. That is, she used two things the patient said, paired them together, and showed a contradiction in their thinking, or she used one thing the patient said, and one thing that she, the therapist, thought was being left out, and questioned whether she was getting the whole story. But in interpretation the shrink is 100% interested in what she, the shrink, thinks.

In terms of style, interpretations shouldn’t really be given neutrally. The textbooks say they should (or at least some of them do), but in practice many patients get scared that the therapist is “telling them the truth” the way a Sunday preacher would. They think the therapist is leaving them no option but to believe the interpretation, and this can be scary — especially when the interpretation is wrong. And interpretations are frequently wrong!

Instead, I like to give interpretations the way I would give my political opinion if I were in a debate or conversation about an important political issue. I own that I am about to give my opinion. Not the truth, but the truth as I see it. I try to communicate to the patient that while there is room for them to disagree, and that I don’t want them to blindly accept what I am saying as gospel, I really have thought hard about this thing, and I am giving them my best shot at understanding where I am coming from.

In a certain sense, interpretations are amped-up versions of the “possibilities” I mentioned earlier in the clarifications section. The key difference is that where in a “possibility” the therapist lets the patient decide if the idea is true or not, in an interpretation the shrink leaves no doubt about it: he thinks it is true. Examples:

“You’re still in love with her.”

“You can’t stand not being in control of their relationship.”

“You are afraid that you’re unloveable.”

“You’d rather ruin your life than admit you were wrong.”

“Apologizing is agony for you.”

In  Think Like a Shrink #1 I warned that interpretations are deadly in friendships and romantic relationships, at least when the recipient doesn’t ask for them. Any time you meet a couple or family who are unhappy in their relationship, you should wonder whether there aren’t an awful lot of interpretations (or at least the same one, over and over) being thrown around at home. Removing interpretation from the home is perhaps the #1 thing a shrink can do to bring peace to a house — which is easier said than done; people who like interpretation tend to love it.

Nevertheless the power of interpretation comes from three things: its brevity and clarity, which is to say, it’s pithiness; its aptness, which is to say, the degree to which it is on-target; and its alien quality: the degree to which the patient (or unwilling family member) is blindsided by the idea. The best interpretations have a kind of shock-value to them, which makes delivering them with compassion and tact all the more important.

I’ll return to these issues sometime in the future, but for now its useful to end by saying that simply categorizing what a shrink says to a patient (or any person says to or about any other person) as either a clarification, confrontation, or interpretation, and adding up the percentages of each, can be a very useful exercise.

And if you’re ever having trouble in one of your relationships — and feeling people pull away from you in one way or another — you can’t go wrong by dispensing with the interpretations, cutting back severely on the confrontations, and dwelling in the land of clarification until the person is reassured that you are a safe, friendly, caring listener. Then you can slowly ease back into confrontation. And if someone you love is interpreting or confronting the crap out of you, and you can’t stand it any more? Clarify! “It seems like almost everything you say to me is either a confrontation or an interpretation of my secret desires and fears. I can’t remember you asked me to tell you something about myself, in my own words, and just listened with curiosity and acceptance.” Then sit back and see if they adjust.

Back to Think Like a Shrink #1

One thought on “Think Like A Shrink #2: Clarification, Confrontation, Interpretation

  1. I really enjoyed your article. I believe that what you have described here is an excellent way for me, and I’m sure others to learn how to listen much better to people that they have relationships with. Too often we get caught up in our emotions when we disagree with people that we forget to stop and listen to what they have to say.

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About Peter Freed, M.D.

I am a psychiatrist (psychopharmacology and psychotherapy) specializing in the so-called "personality disorders," particularly narcissistic and borderline personality disorders. I was a Fellow and then an Assistant Professor of Clinical Psychiatry at Columbia from 2004- 2011. I am currently in private practice in NYC.