Confrontation

as a Mode of Teaching
JAMES MANN, M.D.

e-Book 2015 International Psychotherapy Institute

From Confrontation in Psychotherapy edited by Gerald Adler and Paul G. Myerson
Copyright 1973,2013 by Gerald Adler and Paul G. Myerson

All Rights Reserved

Created in the United States of America

Confrontation as a Mode of Teaching

JAMES MANN, M.D.
It is wholly impossible to engage in psychotherapy or in psychoanalysis
without necessarily confronting the patient once, twice, or many times.
Confrontation cannot be avoided; nor should it be avoided. The issue, rather,
is to accept confrontation as an integral aspect of psychotherapy and to raise
critical questions as to the effect that confrontation is intended to produce
following on our understanding of the nature of confrontation as a process.
Some answers to these questions may then lead to a clearer appreciation of
how best to confront a patient.
As is true in all psychological issues, the subject of confrontation is
multifaceted. There are many vantage points from which one may study
confrontation. It may be worthwhile, however, to seek out among the many
avenues to confrontation some central focus or issue that may be pertinent
regardless of the particular theoretical or clinical approach one may take.
With such a central issue in hand one may then extend, think through, and
test out the various rich ideas and approaches to the meaning and clinical use
of confrontation.
I would like to consider the central issue as consisting of the statement

that, whatever else it may be, confrontation is predominantly a device for

teaching. Whatever the mode of confrontation and whether it be in individual
psychotherapy, psychoanalysis, group psychotherapy, or encountersensitivity groups, the aim of the confrontation is to teach something to the
recipient of the confrontation. At stake in this discussion is not whether the
substance of a confrontation is correct but rather whether our mode of
teaching is more or less effective.
A discussion of confrontation from this point of view illuminates the
three basic underpinnings of any kind of teaching: one, teaching by
explanation in order to enhance understanding; two, teaching by employing a
system of rewards and punishments, which presumably will reinforce desired
behaviors; and three, teaching by offering oneself as a model with the
expectation that the student (or patient) will take the best qualities of the
model and will internalize those qualities and the lessons that go with them
so that they are experienced as a syntonic part of oneself.
All these modes of teaching are present in the various meanings of
confrontation. In some a single mode is easily distinguishable and in others
one may observe a mix of two or even of all three. We must ask, therefore,
whether the purposes of confrontation are best served by explanation, by
rewards and punishments, by offering oneself as a model, or by what kind of
mix of two or of three of these. It may be equally important to determine

Confrontation in Psychotherapy

whether all confrontations include all three of these basic tenets of teaching
and whether the decisive factor is the extent to which one or another
dominates.
Generally, we tend to think of confrontation in psychotherapy as being a
means of bringing up for the patients consideration certain attitudes,
character traits, and life styles that, by virtue of the preceding work of
psychotherapy have now become conscious or preconscious. There is also a
type of confrontation that addresses itself to that which is unconscious,
distorted, and expressed primarily in the seemingly mysterious symbolic
communications of the patient. The second instance refers, of course, to the
psychotic patient in psychotherapy. I believe that this is a vastly different
situation and carries significantly different meaning as compared to the more
usual use and meaning of confrontation.
Confrontation may foster a therapeutic alliance in any case at some
given moment, but that is not the same thing as saying that confrontation and
therapeutic alliance are necessarily related one to the other. In the more
neurotic type of patient, his inner life remains unknown to him for the most
part. A variety of ego defenses and adaptive moves as well as symptoms
serves to keep out of his conscious mind the conflicting wishes and fantasies
that would make life even more unbearable were they to be undefended. A
very different state of mind exists in the psychotic patient. His inner life,

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unfortunately, is not secret, and the defenses against knowing it are few and
vulnerable. His adaptive moves and his symptoms barely serve to maintain
survival. To the psychotic patient, his inner life is a ghastly cesspool of
horrible secrets of which he is all too much aware. Confrontation that reads
through the distorted, symbolic communications of the severely disturbed
patient is not, strictly speaking, a mode of teaching. It is not explaining
anything; it is only, in an exquisitely subtle manner, rewarding or punishing;
and it is not offering oneself as a model. Rather it is a means of letting the
patient know that the therapist knows; a means of telling the patient that one
knows what the patient is suffering. It is a means of letting the patient know
that the therapist knows too that the patient did not know how to
communicate to others and could barely tolerate knowing himself. In this
sharing and in the relief for the patient in finding someone at last who also
knows and yet continues to attend, a therapeutic alliance is established that
rests on the most profound meaning of empathy. This kind of alliance
becomes the prelude to the more difficult work that will follow in
reconstructing what has happened to the patient. In a lighter vein, the
situation is not unlike that of two evil-appearing men meeting in the dark
forest and discovering that they are both psychiatrists or psychologists.
Gentle, caring concern of the therapist for the patient may well be the
most important element in a proper, effective confrontation. Such an attitude
in the therapist is important not only because all people need to know that

Confrontation in Psychotherapy

someone cares and is tender in his caring but also because such behavior in
the therapist carries with it a genuine message that the therapist is equally
devoted to the maintenance of the patients autonomyhis unique
individuality. It communicates to the patient his privilege to choose the
direction that he would like to move in rather than communicating a directive
to which the patient feels impelled to yield. Implicit in a confrontation that is
affectively shaped with gentle, caring concern is a mode of teaching that
enhances understanding and offers a model for identification rather than
teaching by suggesting reward or punishment according to whether the
patient does or does not do as we might wish him to do.
It is apropos that we be sensitive to the fact that certain styles in the
treatment of psychiatric patients are directly influenced by the historical tides
that are current. At this time in history, confrontation is the order of the day
in widespread areas of our lives. Instant demands are often made for instant
action. Encounter groups, marathon groups, and so-called sensitivity groups
are in good measure responses to demands for instant change. It is no
accident that the primary so-called therapeutic method in these groups is
confrontation, in which the reward is acceptance and the punishment
rejection by the group. In our individual work, too, we should remain aware
of the extent to which we may be responding to the demands of patients for
instant change in a profession in which instant change is impossible.

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From this point of view, the particular emphasis on gentle, caring

concern and respect for the individuality of the patient as central should not
be underestimated as a most positively weighted teaching method at a time
when all of us are tempted to exercise control wherever we can. After all, we
are very much limited in how much control we may exercise in the conduct of
our own lives.
Another aspect of confrontation arises in the comparison between the
therapeutic methods of the psychoanalyst as compared to the
psychotherapist. In this connection, certain myths continue to thrive. These
are at least two-fold: first, that the analyst is, for the most part, extremely
passive, spends too much time saying nothing, does not intervene actively,
and does not use himself in the treatment process; second, that the analyst
pays little attention to the reality of the patients past and current life
experience. Both these myths perpetuate an image of the psychoanalyst at
work in an ivory tower. The further implication is that confrontation is clearly
outside the province of the psychoanalyst insofar as he has separated himself
both from the real life of the patient as well as from any kind of activist
position in respect to his therapeutic relationship with the patient.
Again, in this active historical period, active consideration of the
patients reality and active intervention by the use of the self in the treatment
process too often come to mean that it is the job of the therapist to determine

Confrontation in Psychotherapy

what the reality is for the patient. It follows then that he is to tell the patient
how he should conduct his life. Is it not a better teaching method with more
effective reverberations in the patient if the therapist limits himself toward
helping the patient discover which new choices or alternatives previously
obscured or unknown to him because of his neurotic distortions are now
open to him? Is it not for the patient to make the choice as to the direction he
will take? He may choose to continue as he always has or he may choose a
new direction. Whichever he does choose must be of his own doing and
responsibility. The patients privilege of maintaining his own individuality
must be secure even if it means making no change at all and even if we do not
ourselves like the kind of change he chooses to make. The freedom to change
and the wish to change will flow from the relationship with a therapist who
explains so that the patient better understands and who, in his
confrontations, offers a model of gentle, caring concern. We need not concern
ourselves with the concept of 100 percent neutrality in the therapist since
such a state simply cannot exist in any kind of sustained relationship,
therapeutic or otherwise.
It is not an unusual experience to find that our well considered,
affectively appropriate explanations are met by a so what from the patient.
This type of response is too often accepted as an invitation to the therapist for
action, to do something about it and not just talk. There is enormous
temptation as well as culturally sanctioned inclinations for the therapist to

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10

respond with action. The danger lies in the fact that it becomes too easy to
read into this an appeal to force as the missing ingredient in psychotherapy,
let alone psychoanalysis, today. Too much emphasis may be unwittingly
placed upon teaching by a system of rewards and punishments. This may
readily lead to the misuse of such a system so that the eventual result
becomes control of the patient and identification of the patient with the
aggressor model. Unknowingly, we may find ourselves adherents to a variant
of the Skinnerian model. Such a state hardly leads to the kind of inner
freedom to choose that speaks for mental health; rather it directs the patient
toward social adjustment, and the nature of the social adjustment is dictated
by the therapist according to his lights. The cry of certain groups today that
psychiatry and psychoanalysis are means of brainwashing young people may,
as is usually true in delusions, have its small core of truth. Characteristic of
the contradictions that exist in these very same groups is the fact that it is
these same groups that seem to seek most the instant change suggested by
the various kinds of encounter groups in operation. Basic to this is the wish
for magical solutions to problems, and it behooves us to be careful ourselves
that we fall prey neither to their demands nor to our own wishes to exercise
some magic.
There is much to say for the voice of reason tempered and softened with
compassion and even with passion. How can we combine objectivity and
passion at the same time? Since no one therapist of any persuasion has the

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11

one correct answer, each of us seeks to find his own way. Nevertheless, in any
discussion of confrontation in psychotherapy or in psychoanalysis, the weight
lies heavily in favor of a concept in which gentle, caring concern becomes our
guide. Such concern does not mean passivity, nor does it mean avoiding
confrontation; but it does mean that we leave the way open for our patients to
learn to make their own choices, as much as is possible in the light of their
own wishes rather than ours. All varieties of psychotherapy and of
psychoanalysis are processes of reeducation, of reteaching. The issue then is
whether we choose to teach by explanation, to enhance understanding
coupled with offering ourselves as a model, or whether we choose to teach
mostly by a system of rewards and punishments centering on a core of
coercion. The more we experience increasing pressure and coercion in our
everyday environment, the more must we guard against taking it out on the
patient under the guise of treatment.
Of course, every patient brings to the treatment situation attitudes
about and reactions to rewards and punishments. Only the use of some kind
of mechanical speaking device could avoid the communication by the
therapist of some degree of approval or of disapproval. Each of us does have
the moral and ethical and human judgments by which we live and in which
we express our sense as individuals. After all, gentle, caring concern is itself a
reward.

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The problem becomes one of deciding on which of the three aspects of

teaching shall the therapist attempt to place greatest emphasis. Each of the
three is complex; each plays upon the past history of the patient, and each is
so related to the other as to be impossible of total separation. Explanation and
gentle, caring concern as a method of confrontation, in good times and in bad,
will lead to identification with a model that, more than anything else, will
allow the patient freedom of choice. Such a result speaks for the highest order
of both teaching and learning. This result is the proper goal of confrontation.

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