A confrontation points out a pattern or discrepancy so the patient can see it, and it is how patterns move from ego-syntonic to ego-dystonic. Do it gently, with a good alliance and groundwork, but do it: in formal therapy by session three, and in diagnostic interviews whenever the story does not add up, because avoiding it out of kindness leaves the differential undone.
What it is
A confrontation is any intervention that points out a pattern, a discrepancy, an inconsistency or a change in the narrative, between different parts of the patient, or between the patient's values and behaviors.
“A 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”
21:22Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026 Also said in 1 more episode
“When you notice discrepancies in the narrative, or between the patient's behaviors, thoughts, feelings, or values of things that you know the patient have, it's important to confront it”
35:37Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should KnowApr 2026 Observe and confront: when you notice a pattern or a problem, it is your job to stop the narrative, at least for a moment, and make the observation out loud.
“when you notice a pattern or you notice a problem, it is your job as the clinician to stop the narrative, at least temporarily, make an observation out loud to the patient about what you're seeing”
34:41Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should KnowApr 2026
Why it matters
Confrontations are how we get people from ego-syntonic to ego-dystonic, which is what we are trying to do.
“confrontations are how we actually get people from going ego syntonic to ego dystonic, which is what we're trying to do”
23:13Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026 In a diagnostic interview the first purpose is information gathering. You are not trying to show the patient you are right and they are wrong; you are confirming or disconfirming a piece of history.
“The first is basically in a information gathering sense to get more information. You're not trying to show the patient that you're right and they're wrong. You're trying to confirm or disconfirm an element of history that's been shown to you”
29:43How to Decide When ADHD Is Actually ADHDNov 2025
How we use it
In formal therapy, be doing them by session three at the latest. Always gently and with adequate groundwork, but do them.
“So in a formal therapy, I would say you should be doing these by session three at the latest, okay? You should always do them gently and with adequate groundwork, but you should be doing them”
23:56Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026 You need a good therapeutic alliance for the patient to receive it.
“I think you need a good therapeutic alliance to be able to do it for the patient to receive it”
22:01Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026 Build over time: first simply point out the pattern, then point it out repeatedly, then link it both to how it helps the patient (adaptive) and how it hurts them (maladaptive).
“there is 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”
25:11Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026 If you cannot form a clear picture of what happened, open more doors.
“whenever my brain can't make that picture that means that i need to open more doors”
29:25How to Decide When ADHD Is Actually ADHDNov 2025
Examples
In therapy: "Have you noticed that every time we start talking about your ex-best friend, you change the subject pretty soon afterwards?"
“Have you noticed that every time we start talking about your best friend, your ex-best friend, you change the subject pretty soon afterwards”
26:44Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026 In medication management: "It seems like you want to get better. At the same time, I can't help but notice that when we discuss side effects, you seem quite anxious about it."
“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”
27:20Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026 Patterns worth confronting show up in medication visits too: one patient wanted to taper off all their medications whenever they were mad at their psychiatrist, even in sessions where they were in acute distress.
“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”
28:14Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026
Pitfalls
Many clinicians are afraid to make technical confrontations. They notice things that do not add up but, out of human kindness, do not question them.
“a lot of psychiatrists, a lot of clinicians are afraid to do what are essentially technical confrontations. They can detect certain things that don't exactly add up, but because of their human kindness, they don't want to question about it”
28:01How to Decide When ADHD Is Actually ADHDNov 2025 Do not give an interpretation until you have numerous examples that you have already confronted with the patient. Have the receipts.
“You have to have the evidence. You got to have receipts. Do not give an interpretation. until you have countless or at least numerous examples that you have already confronted with the patient”
34:27Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026
Pearls
A patient may push back or fight you in the moment, and then the next month you see the positive change. Have some faith that what you are doing is right.
“oftentimes I'll have a patient will push back or or fight with me in the moment and and then the next month i'll see the positive change happen so in some sense you have to have faith that what you're doing is the right thing”
37:07Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should KnowApr 2026
It also comes up on
- ContainmentBefore any analysis, interpretation or confrontation: contain, contain, contain. Show the patient you have actually heard and experienced something like what they went through.
- PsychotherapyContain, contain, contain before any analysis, interpretation or confrontation. Technical containment means perceiving the other person's inner emotional experience, digesting it, and communicating back that you have perceived it; you are not giving information or changing anything.
- Rupture and repairThere are two broad kinds: withdrawal, moving away, and confrontation, moving against.
From these episodes
- Psychodynamic Technique and Therapeutic Intervention: Mirroring, Clarification, Confrontation, InterpretationJun 2026 · 9 points
- Psychiatric Technique for Diagnostic Interviewing and Therapy: 6 Mantras Every Clinician Should KnowApr 2026 · 3 points
- How to Decide When ADHD Is Actually ADHDNov 2025 · 3 points
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.