Key moments, in order
Picture the levels as a reverse pyramid, with what you do most at the top. That is level zero: the supportive elements, including frame, boundaries, psychoeducation, safety, the alliance and technical containment. Level one is empathic mirroring.
The first level of intervention is anything that gets the patient to keep talking and continue their narrative without changing its trajectory or content.
Keep a wide variety of nonverbal acknowledgment sounds in your back pocket.
Containment is processing thoughts and metabolizing them so the person can hear them back. Mirroring is showing the person they have an individual self that is seen, important and recognized.
Name what you notice: "I can feel how sad you are touching on these memories again right now." Saying just that may keep the patient speaking.
Punctuate: emphasize a particular word or turn of phrase the patient just used. You add no new content, only highlight something they said.
Prompting people to keep going on one line of narrative often gets you a richer story and more information than asking specific questions.
Clarification is any question or move that gets the patient to go into more depth or detail about what they are talking about. It may redirect the narrative, but it does not challenge or change it; once you challenge it, it is no longer a clarification.
Think of the narrative as a river. If it is flowing evenly and the patient suddenly stops talking or changes the subject, the river has dammed up or changed direction, and that is worth clarifying.
Surface clarifications ask for concrete details: the surrounding events in sequence and context. Where were you with your friend? How did you get into that discussion?
Depth clarifications go to fantasies, wishes, imaginations and emotions. When you got into that, what were you feeling?
Just because someone went through something does not mean they can see it clearly. Help them put it into words with both surface and depth clarifications.
Paraphrase and check: let me make sure I understood that correctly. Even repeating back almost exactly what the patient said can help them notice where the words do not capture what they are experiencing.
Have the person describe events step by step, moment to moment, in a hallucinatory level of detail. There is no time for this in medication management, but there is in therapy and in the forensic interview.
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.
You need a good therapeutic alliance for the patient to receive it.
Confrontations are how we get people from ego-syntonic to ego-dystonic, which is what we are trying to do.
In formal therapy, be doing them by session three at the latest. Always gently and with adequate groundwork, but do them.
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).
In therapy: "Have you noticed that every time we start talking about your ex-best friend, you change the subject pretty soon afterwards?"
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."
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.
Use an ordinary-person standard: know population norms and ask what most people would think, do or feel in the same situation, and whether the patient differs.
Use common sense. A patient who says they had a breakup a week ago and are doing spectacularly is worth talking with about that.
Shared cultural scotoma: a therapist and patient of the same culture can both ignore a glaring part of the clinical situation because it is a cultural norm for both.
Anything that explicitly links a pattern or defense to an unconscious process: wishes, desires, conflicts, ways of relating.
Have the receipts. Do not interpret until you have numerous examples that you have already confronted with the patient.
Play-acting psychoanalyst in once-every-three-months medication management does more harm than good.
Make an interpretation only when the patient is almost on the cusp of making it themselves.
It is not a gigantic jump that clears everything out. All the legwork happens in the earlier levels, and the interpretation is just a small skip.
In a Rogerian way, if you are just doing levels zero, one and two, your work is done. The patient will heal on their own.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.