arnold, kyle - humming along - the meaning of mm-hmm in psychotherapeutic communication

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Contemporary Psychoanalysis, Vol. 48, No. 1. ISSN 0010-7530© 2012 William Alanson White Institute, New York, NY. All rights reserved.

KYLE ARNOLD, Ph.D.

hUmminG alonG:THE MEANING OF MM-hMM IN

PSYCHOTHERAPEuTIC COMMuNICATION*

Abstract. Ferrara (1994) estimates that 19–35% of the utterances by psychothera-pists in session are variations of mm-hmm. However, there has been little discus-sion of this phenomenon in the literature. According to linguistics theory, mm-hmm constitutes a backchannel response to a speaker that affirms his or her right to continue to hold the floor. In psychotherapy, mm-hmm reaffirms the patient’s right to an extended conversational turn and the therapist’s role as listener. Be-cause mm-hmm is unobtrusive and ambiguous, however, unconscious issues in the therapeutic relationship can be communicated through its variations. Psycho-therapists should understand the function of mm-hmm in maintaining the struc-ture of the therapeutic relationship and be aware that it can be easily enlisted in the service of unconscious communications.

Keywords: backchannel, linguistics, psychotherapy, mm-hmm, language, nonver-bal, communication, countertransference

AS THERAPISTS, WE MOSTLY BELIEVE it is a good thing to pay atten-tion to what we say. Some clinicians spend hours tweaking the

wording of an intervention until it is just right. Even the least obsessive among us tends to be curious about the import and impact of the words we use, even if only in retrospect. In discussions of cases, we spend a great deal of time talking about what to say or what we have said. We may have different reasons for doing so: the ego psychologist may be chiefly concerned with tact and precision, whereas the relational thera-pist may be more curious about what her words say about the counter-transference. But despite these differences of focus, we all attend to what we say. Even the most tactless therapist, the linguistic bull-in-a-china-shop, tends to care about that tactlessness if it is brought into her or his awareness. A talk therapist who does not care about his or her talk might

* The author wishes to thank Kathleen Savino, MFA, for her invaluable comments on previ-ous drafts of this article.

THE MEANING OF MM-hMM 101

be an interesting therapist to study, but that is not the kind of therapist most of us would like to be.

Indeed, there is a variety of types of talking that we are accustomed to think about. We wonder about our questions, whether they are open ended or close ended, whether they are demanding or freeing. We con-sider how our metaphors may allude to unspoken dimensions of the therapy process. We worry about whether our interpretations are incisive or rambling. We think about our words’ denotations and connotations. Linguistically, therapists have an enormous number of things to which to pay attention.

Oddly, however, the field has had little to say about the most common utterance therapists make in a session. What therapists say most often is not a question, a clarification, or an interpretation, but “mm-hmm.” Re-search suggests that mm-hmms make up approximately 19–35% of thera-pists’ utterances (Ferrara, 1994). Popular culture is well aware of this, often portraying the therapist as a mysterious figure behind a couch who says little more than mm-hmm, maybe interspersed with the occasional “Tell me about your mother.” Yet, we seem to think little of our mm-hmms. We rarely speak of them in case presentations, despite the fact that they are glaringly prevalent in nearly any full transcript of a therapy session. Trainees do not take their mm-hmms to supervision and are not asked about them. Many of us know, I think, that we say mm-hmm quite a bit. But, for the most part, I don’t think we know why. As Gerhardt and Beyerle (1997, p. 21) put it, mm-hmm and similar utterances “have slipped through the grid of what shows up as meaningful to the thera-peutic process.” Borrowing a concept from existential thought, we might say that mm-hmms are unformulated by and constitutive of psychothera-peutic discourse. Mm-hmm is an ignored background of conscious thera-pist speech.

Contemporary psychodynamic thought has placed increasing empha-sis on such ignored details of the moment-to-moment psychotherapeutic interaction. The Boston Process of Change Study Group (Nahum, 2005) argues that much of psychotherapeutic interaction transpires in the do-main of nonverbal and nonconscious relational memories that sublimi-nally shape how people relate to each other, especially on the local level. Crucial to their conception of nonconscious interaction is the notion of sloppiness: that the second-by-second movements of interaction in ther-apy are necessarily indeterminate and imprecise. Sloppiness, the Boston Process of Change Study Group argues, is partly a result of fuzzy inten-

102 KYLE ARNOLD, Ph.D.

tionalizing: One’s construal of the intentions and meaning of another person’s behavior is necessarily inexact. As a result, our moment-to- moment responses to another person’s relational movements are built on a shaky foundation of conjectures about what the other’s behavior might mean.

In the present article, I examine one particular piece of local-level fuzziness: the meaning of mm-hmm in the therapist’s speech. Although mm-hmm may appear to be a mundane vocalization, it is mysterious and meaningful. Mm-hmm is, to use William Blake’s famous phrase, a “world in a grain of sand” (cf. Stern, 2004). There are innumerable ways in which mm-hmm may be uttered, including variations in intonation, facial expression, volume, cadence, and timing. These variations may have sig-nificance for the interpersonal process in a session. Conversely, some aspects of mm-hmm appear to be invariant and universal, and these too can be informative.

A Patient’s Confrontation

Although I have been vaguely curious about the significance of mm-hmm for some time, I was encouraged to attend to it focally during a session with an extremely creative and thoughtful patient. The patient, a young woman with a keen awareness of the nuances of my behavior, was offering some complaints about my therapeutic style. She com-plained that I behave like a stereotypical therapist, asking her things like “How do you feel about that?” when I ought to realize how she feels. She then said, with an amused but piqued tone, “And why are you saying ‘mm-hmm’ to everything I say? Why do therapists always do that?” I sud-denly realized that I had been saying mm-hmm in response to all of her complaints, for nearly 15 minutes, and had been completely unaware of doing so.

I was flabbergasted. I had no idea what to tell her. Why was I saying mm-hmm? What was I doing? Her question was fair. I did seem to say mm-hmm quite a bit, not only to her but to all my patients. I felt embar-rassed. After all, I had often asked her, implicitly and explicitly, to attend to and reflect on her speech. If so, didn’t it follow that I ought to be re-flecting on my own speech as well? What business did I have examining what she was doing, when I had no idea what I was doing? I thought she deserved an answer, but I didn’t have one. To simply tell her that I didn’t know, in this instance, felt unfair and dismissive. To inquire about what


was behind the question, although potentially productive, felt like yet another stereotypical therapist maneuver. I took a moment to think, and gave her the best explanation I could muster. What I said was something along the lines of: “I guess the main reason I say mm-hmm is to show that I’m still here and am listening.” She nodded but looked skeptical. I added, “It’d be hard for me to not say mm-hmm, because I’m not sure how else I would do that from moment to moment. But I could try to say it less often, and see what that’s like.”

For the remainder of the session, I tried to inhibit my mm-hmms. Do-ing so was difficult and felt unnatural. My effort to suppress mm-hmms, however, drew my attention to the moments when they wanted to emerge. And I certainly seemed to want to say mm-hmm a lot. I felt pulled by her speech, which was bashful and self-deprecatory, to reas-sure her that I was hearing her. Silence felt rejecting. It felt like I needed to say something. On the other hand, I found that my patient talked with so few pauses that it was often difficult to say anything other than mm-hmm without interrupting her—and to interrupt her also felt rejecting. Mm-hmm, I noticed, could be said while she was talking without consti-tuting an interruption. My mm-hmms were evidently part of an ongoing enactment in which my patient skirted around our own and each others’ vulnerabilities. They were the tip of a relational iceberg.

I intend the above vignette to illustrate several points. For one thing, we can be unconscious of our mm-hmms. The fact that any therapist could repeatedly make an utterance for 15 minutes without any aware-ness of it is, to my mind, astonishing. To be sure, some of the reasons for my inattention to my mm-hmms are clearly linked to the particularities of the clinical dyad. My inattention was, in part, defensive. It was more comfortable not to see our interpersonal lock-up than to see it, at least in some respects. Maybe I was also being naïve. From this perspective, I simply was not curious enough about what was going on in the room. That may be true, but there is more. Mm-hmms, I will argue below, are inherently more refractory to analytic attention than most other utter-ances by therapists. They are harder to look at. As a result, they are par-ticularly easy prey for counterresistances, enactments, and even simple incuriosity. It is difficult to get them into awareness and keep them there.

Furthermore, mm-hmms are often packed with emotional meaning. Perhaps precisely because they are difficult to notice, mm-hmms are ever-ready vehicles for unconscious actions and communications. When they are attended to, they can reveal a rich substrata of clinical meaning.


Finally, and perhaps most important, our lack of curiosity about our mm-hmms puts us at a clinical disadvantage. Whether or not it is a good idea to tell a patient why we say mm-hmm, we ought to think about why. Our frequent use of mm-hmm, as Ferrara (1994) noted, is a dra-matic departure from social convention. For that reason, in my opinion, our incessant mm-hmms come across as odd to many patients. Thera-pists have some grasp of their other departures from social convention. For example, we have thought a lot about why we express curiosity about things that are uncomfortable to talk about, why we do not social-ize with our patients, why we end sessions at a fixed time, and why we do many of the other odd things that therapists do. When patients ask us about these things, we ordinarily have years of reflection and an entire clinical literature to draw upon in formulating our thoughts. Whatever we choose to say or not to say, we have a rough idea of where we stand and what we are doing. Our responses may be “canned,” confusing, or un-helpful, but at least we can show that we’ve been thinking about them. This is not often the case with mm-hmm.

The universal Functions of Mm-hmm

After informally asking other therapists about why they say mm-hmm so much, I received a variety of responses. Some claim that they mm-hmm to let the patient know they are listening, as I said to my patient. Others have told me that mm-hmm has all sorts of different functions that vary depending on the context in which it is uttered. Sullivan (1954) reports using a soft growl to facilitate transitions from one topic to another in the initial interview. Havens (1986, p. 43) proposes that the similar utterance, “huh,” is often used to “indicate attention,” and constitutes what he calls a “sort of minimal empathy.” (Shea [1998] says the same thing about “uh-huh.”) In a study of psychoanalytic process, Bucci and Maskit (2007) sug-gest that mm-hmm is an indicator of the listening party’s presence. The Boston Process of Change Study Group (Nahum, 2005) analyzes several examples of uh-huh in a clinical transcript. They suggest that one such example, a therapist’s response to the patient who mentions a dream that appears pregnant with meaning, may fuzzily communicate several varia-tions of “go ahead”: go ahead, “because I’m trying to be with you,” “be-cause I have not yet understood enough and need to understand more,” “because I don’t have anything to say yet,” “because I don’t know where you’re headed,” or because “I need more time.” They also give other ex-amples of uh-huh, which, they conjecture, indicates that the therapist is


waiting for material to unfold, and encouraging the patient to continue to find her or his own way through the material.

Although none of these views of the functions of mm-hmm is incor-rect, all are limited. The brusque mm-hmm uttered with an exasperated tone and a roll of the eyes does not indicate that I am listening, but that I am impatient and want you to move on. The mm-hmmmm that is slowly drawn out, given a gradually rising intonation, and is accompanied by a narrow-eyed gaze, does not indicate empathy but skepticism. As the Bos-ton Process of Change Study Group implies in Nahum (2005), mm-hmm can bear a variety of meanings. Its meaning, however, is not infinitely malleable. Throughout all of mm-hmms’ varied iterations, a common re-lational function is operative.

Linguistics researchers conceptualize mm-hmm as a backchannel (Yngve, 1970). At any given moment in a conversation, the communica-tions of the speaker are considered to occupy the front channel insofar as the speaker holds the floor, and his or her speech is primary. The back-channel comprises brief utterances that the listener emits as feedback to the speaker’s talk. Common backchannels in English include utterances such as yeah, right, mm-hmm, and okay. These short responses are elective and do not demand acknowledgment by the speaker. They chiefly signal that the speaker may continue talking, although they can also communicate understanding, attention, and acknowledgment. Backchannels are some-times divided into lexical (word) and nonlexical (nonword) categories. Mm-hmm, then, is linguistically categorized as a nonlexical backchannel.

Drawing upon a linguistic study of therapists’ speech, Ferrara (1994) concludes that a therapist uses backchannel cues like mm-hmm to regu-late the flow of therapeutic conversation. According to linguistics, a basic dynamic of any conversation is taking turns. I talk, and then give you a more or less equal chance to talk. Psychotherapy, however, is different. As part of the framework of therapy, conversational turns of therapist and patient are unequal. The usual conventions of conversation are suspended and the patient is granted an extended conversational turn. In effect, the patient is given the floor. Utterances like mm-hmm, Ferrara argues, consti-tute a minimal conversational turn on the therapist’s part that reaffirms the patient’s right to a turn of extended length. In this sense, mm-hmm is re-lated to the type of intervention that Gabbard (2004) calls an encourage-ment to elaborate, roughly equivalent to “tell me more.”

According to Ferrara’s research, patients often test the therapeutic framework by signaling that they are prepared to yield the conversa-tional turn to the therapist. For example, they may use a downward into-


nation, elongated syllables, and phrases such as “you know.” By these signals, patients communicate that it is the therapist’s turn to speak. At such moments in the therapy session, the therapist may utter mm-hmm to signal that they do not plan on taking a conversational turn and that the patient may instead continue talking with an extended turn. In this sense, mm-hmm repeatedly reestablishes the therapeutic relationship of speaker and listener. The utterance of mm-hmm and similar backchan-nels are a basic building block of the therapist-patient relationship.

The Ambiguity of Mm-hmm

From the patient’s perspective, mm-hmm is inherently ambiguous be-cause it is brief and nonlexical. Its meaning is almost completely context-dependent rather than intrinsic. Compare mm-hmm with “yes.” Yes has a meaning independent of context. Even without context, we know that something is being agreed to or affirmed, even if we don’t know what. Mm-hmm by itself does not take a position, does not convey a meaning: all it does is indicate that someone else may continue talking. The mean-ing of mm-hmm is all in the context and style of expression—its intona-tion, volume, and cadence. Indeed, the standard function of mm-hmm may require it to be void of intrinsic meaning. Utterances with more specific meanings could not function as effectively as cues to take an extended conversational turn.

We might compare mm-hmm to verbal utterances that can serve simi-lar functions. “Okay,” for example, can also be a backchannel cue for an extended turn. Because okay is lexical, however, it carries additional se-mantic baggage. Okay literally means that the other’s remarks are accept-able (or, if used ironically, that they are not acceptable). It has a finalizing quality like a punctuation mark. It does not encourage elaboration as precisely as mm-hmm. Imagine, for example, that a patient is talking about a painful experience, such as the death of a family member. As the patient talks about her or his memories of the deceased and her or his feelings of sadness, the therapist responds by repeating okay, okay, okay during pauses in the patient’s speech. It is possible that the therapist who repeated okay in such a context would be perceived as brusque and in-sensitive, whereas the therapist who repeated mm-hmm would be more readily perceived as sensitively hearing the patient out.

Nevertheless, precisely because mm-hmm is an information-poor ut-terance, it is easily filled out with transferential material. During my psy-


chotherapy training, a patient gave me a powerful lesson in how this characteristic of mm-hmm can contribute to ruptures in the therapeutic alliance. In one session, an anxious student began by talking in a pres-sured way about superficial interactions with other students, praising their intelligence and potential. Aware that my patient was behaving de-fensively but unsure of how to proceed, I simply listened carefully and punctuated my listening with mm-hmms. The patient became visibly more anxious, and after a few minutes accused me of a “power game.” When I explored what the patient meant, the patient reported that he felt I was dominating him by “not saying anything” and “going mm-hmm, mm-hmm.” He had perceived my ambiguous vocalizations as deliber-ately withholding and hostile. He was much older than me, and felt that I had no business acting like a “doctor” to him. He seems to have felt that I was pompously posing as an authority figure by declining to equalize the relationship by taking a conversational turn. He did not perceive mm-hmm as an unproblematic encouragement to elaborate. Rather, the ambiguity of mm-hmm elicited his hostile projections.

Shea (1998, p. 85) states that with hostile patients in general, vocaliza-tions like uh-huh can be counterproductive. He reports one incident in which he interviewed an intoxicated patient in an emergency room. This angry patient responded by imitating Shea’s uh-huhs, aggressively saying “You’re a shrink all right, yeah you’re a shrink.” A few minutes later the patient physically attacked a staff member.

Mm-hmm is Refractory to Awareness

What is mm-hmm, exactly? A verbal utterance? No. Although mm-hmm is a vocalization, it is not a verbalization (Bucci & Maskit, 2007). Mm-hmm is not a word. Mm-hmm is almost musical, almost a hum. It as is if the therapist hums along to the patient’s song, creating a background tune. Mm-hmm is technically a nonverbal communication, like a shrug or a nod. Unlike these forms of nonverbal body language, however, mm-hmm cannot be seen with the naked eye. It is a vocalization that includes no visible lip movement, merely a vibration of the vocal chords. Mm-hmm is an invisible nonverbal, bypassing the sensory modality by which we recognize most nonverbal communications: sight.

Moreover, because mm-hmm is an instance of backchannel feedback to a speaker, it is designed to take a backseat role to the talk of the speaker. By definition, backchannels do not require acknowledgement


or response in a dialogue (Ward & Tsukahara, 2000). They are designed to slip just barely under the radar. It is precisely by slipping under the radar that backchannels are able to perform their essential function: en-dorsing the continuing speech of the speaker without interrupting it (cf. Bucci & Maskit, 2007). Backchannels necessarily exist on the margins of a conversation. That is where they belong.

Finally, we cannot easily control mm-hmm. Mm-hmm typically comes unbidden. We do not, while listening to a patient’s narrative, think about which variation of mm-hmm we should vocalize to encourage him or her to continue. Under most circumstances, mm-hmm is reflexively elicited as a reaction to patient speech, rather than a deliberate intervention (Ger-hardt & Beyerle, 1997). In this sense, mm-hmm could be compared with Sullivan’s (1940) conception of the “tic.” Sullivan considered tics to repre-sent gesturally expressive actions that are felt to be personally meaning-less and mechanical. According to Sullivan, however, these seemingly meaningless tics are dissociative expressions of interpersonal impulses. Mm-hmm is similar in that it is largely automatic and is not experienced as meaningful. Unlike Sullivan’s tic, however, mm-hmm feels mechanical not because its meaning is always defensively dissociated, but because it comprises a kind of conversational echo of the other’s speech. Mm-hmm can never occur in the aftermath of silence, nor can it initiate conversa-tion. It is almost purely reactive. If the talk of the speaker were “Marco,” the mm-hmm of the listener would be “Polo!” Mm-hmm is an automatic part of the conversational game. We utter it to keep the ball rolling.

For these reasons, mm-hmm is intrinsically difficult to attend to. Be-cause it is a nonverbal vocalization, we cannot listen to it in the way we listen to speech, and cannot look at it the way we can look at body lan-guage. Because mm-hmm is a backchannel, its basic function places it in the background of the dialogue. It is meant to be ignored. Because mm-hmm is automatic, it tends to appear meaningless to the speaker. For these reasons, mm-hmm can function as a hidden communicational con-duit built into the basic structure of the therapeutic relationship. Through the back channel, unconscious countertransferential messages can be smuggled, incognito.

Put differently, one can conceive of mm-hmm as a tic-like action cam-ouflaged as a seemingly appropriate backchannel to the therapeutic communication, but also serving the same dissociative function as Sulli-van’s tic. Below, I examine a few variations in mm-hmm that can indicate unconscious issues in the therapeutic relationship.


The Interrupting Mm-hmm

As I mentioned previously, mm-hmm can be uttered simultaneously with patient speech without being perceived as an interruption. This is not invariably the case, however. Sometimes mm-hmms may interrupt pa-tient speech. In these cases, the mm-hmms’ backchannel function is compromised. Instead of being a background signal for the patient to continue speaking, mm-hmm emerges into the foreground as a disrup-tion of the patient’s speech.

Mistimed Mm-Hmms

If, for example, the cadence of mm-hmm is asynchronous with that of the patient’s speech, it may function as an interruption. Ordinarily, our mm-hmms are synchronized with transitions in the patient’s speech. We are not usually compelled to utter mm-hmm when the patient is in the middle of a thought. If a patient says to me, “I was thinking about what I told you yesterday about my father criticizing me, and I realized that I also feel criticized by you,” I would most likely utter mm-hmm during the transition (marked by the comma) between “me” and “and.” That mm-hmm would occur simultaneously with the patient’s utterance of “and,” but would probably not be experienced as an interruption. It would match the cadence of the patient’s speech, and would mean something like “I’m with you, go on.”

What if I were to instead utter mm-hmm as the patient said “criticized?” In this case, mm-hmm would do something different. It would disrupt the natural cadence of the patient’s speech and obscure the word “criti-cized.” Both of these effects might lead us to wonder if the mistimed mm-hmm might be an enactment of the therapist’s criticism of the pa-tient. By disrupting the patient’s speech, the therapist may implicitly con-vey to the patient something like, “What you are saying is not acceptable and I do not want to hear it.” The mistimed mm-hmm might also repre-sent an unconscious resistance to the enactment, an unwitting effort to defend against critical feelings toward the patient with an overly encour-aging mm-hmm. If so, attending to the mistimed mm-hmm could be of use in revealing a hostile interaction between therapist and patient.

It is worth considering whether mistimed mm-hmms always indicate therapist hostility. Certainly, mistimed mm-hmms indicate some kind of misattunement between therapist and patient. They are mismatches be-tween therapist and patient speech.


Too-Loud Mm-Hmms

Occasionally, after uttering mm-hmm, I have found that its volume was unusually loud or muted. Muted mm-hmms may be a compromise between an urge to provide minimal empathy and a concern that any-thing more—anything louder—could be intrusive. Sometimes, they are uttered when the patient is in the middle of an especially painful story. Conversely, mm-hmms that are too loud, like mistimed mm-hmms, may be signals of hostility on the part of the therapist. Sometimes, they may also be expressions of the therapist’s excitement at interesting material, an excitement that threatens to spill over the boundary that ordinarily prevents the therapist from seizing a conversational turn.

In one session, a patient and I were on the trail of fruitful material as-sociated with the patient’s pervasive experience of feeling trapped in jobs and relationships. After some initial cognitive work on automatic thoughts linked to these experiences, the patient began to recall childhood experi-ences of having been locked in a closet by caregivers as punishment. Excited by the new material and its relationship with the patient’s pre-senting problem, I responded by loudly vocalizing Mmm-hmm ! I was disciplined enough to refrain from seizing the conversational turn, but not self-aware enough to keep my excitement from leaking through the backchannel. Although the patient did not appear to notice the loud mm-hmm, I recognized it and, in exploring it, became aware that I was dis-connected from the painful emotional content of the patient’s experience of having been locked in a closet. Part of the reason for my emotional disconnection was that the patient was reporting the experience in a con-fident, offhand way that belied what it must have been like to be locked in. Part of this patient’s dynamic was to protect herself from feelings of painful vulnerability by dissociating from them and assuming an arti-ficially confident and offhand attitude. An unconscious identification had occurred in which I had unwittingly assumed the patient’s favorite defen-sive operation when listening to her painful memories. The too-loud mm-hmm was a manifestation of my counterresistance.

Mm-hmm as Placeholder

Mm-hmm can function as a placeholder, as a substitute for therapist speech that is called for in the therapeutic interaction but, for whatever reason, is not actually spoken. Like silence, mm-hmm can be a method


of buying time when one does not know what else to say, or cannot say what one wishes to say.

Mm-hmm as a Token of Presence in Therapist absence

Hirsch (2008) illustrates how psychotherapists who feel conflicted can easily retreat into silent passivity in sessions rather than actively working to be present. Sometimes, Hirsch points out, the therapist’s retreat can be an avoidance of the patient’s anger. Discomfort with his or her retreat may compel the emotionally absent therapist to defensively offer tokens of his or her presence, to cover this retreat. These half-hearted signals of presence function to conceal and compensate for the therapist’s with-drawal. It is as if the withdrawn therapist was saying, “No, I’m really here, really listening, believe it, even if it doesn’t look or feel like I’m here.” Mm-hmm can be one such token. Patients whose speech is rapid and tangential can pull for this dynamic. One patient of a therapist I su-pervised would begin sessions by complaining about interactions with members of her family, and when asked about her feelings about these interactions, proceeded to provide detailed stories about each family member, which digressed to unrelated information about their clothing or shopping habits, which in turn led to further digressions to other con-cerns. Instead of offering a cogent narrative of her experience, the pa-tient presented an unfolding series of digressions. Whenever the thera-pist interrupted the patient to try to focus the discussion, the patient became enraged and exclaimed that she needed the therapist to know all of the information she provided so as to best understand her point. The therapist responded by withdrawing, while emitting frequent mm-hmms to affirm her presence. Shea (1998) calls such implied encouragement of a patient’s digressions “leading the wanderer.”

Mm-hmm as a Token of absent Therapist Understanding

In addition to a token of presence in the therapist’s emotional absence, mm-hmm may be a token of absent understanding. This can emerge as a compromise during difficult situations when the therapist feels an obliga-tion to understand the speech of the patient, but is unable to do so. For example, a patient with a history of trauma had a tendency to report on shame-ridden traumatic events with a rapid flow of speech that was too fast and unremitting to be immediately understood. If he were inter-rupted in any way during this report, however, he took the interruption as criticism and became unable to continue. In light of this pattern, I


handled the traumatic material by uttering token mm-hmms as the pa-tient initially recounted his experiences, and waiting until the patient’s initial report was finished before going back and clarifying what he had said. In effect, my mm-hmms were taking out a line of credit against a presumed future understanding.

Sometimes, I have found myself awkwardly uttering mm-hmm when attempting to listen to psychotic material I cannot comprehend. One pa-tient, an isolated man diagnosed with schizophrenia, told me that he was a “master code breaker” who was playing games with chickens and other animals. These animals could be substituted for one another, or for other things, in certain patterns. For example, one might substitute a chicken for a goat, an orange, or a rainy day. The rules of the substitutions, if there were any, were unclear. It was evident that the patient had devel-oped an elaborate symbol system and was eager to present it to me. It felt like he needed me to understand his system well enough to appreci-ate its sophistication. However, the system was too complex and cryptic for me to follow, and my patient was not able to explain how it worked without providing more complex examples from the same system. I felt like I was being given a wonderful work of art that I lacked the compe-tence to appreciate. Moreover, I knew that the patient would not be able to explain his system to me no matter how diligently I worked to under-stand it. So, I reflected back and expressed appreciation for the few as-pects of what my patient said that I could understand, and mm-hmm’d the rest.

In this case, my mm-hmms were disingenuous. I knew that the patient wanted me to understand his system, and if I provided an ambiguous response after expressing my appreciation, he would read the ambiguity as understanding. In effect, I had colluded in a passive deception of my patient. I did not actually expect to understand his symbol system, but had played along with his illusion that I did. Mm-hmm was a compro-mise between my need to convey appreciative understanding and the fact that I lacked a real understanding. In retrospect, it occurred to me that within the patient’s grandiose narrative of being a master code breaker, there was an internal contradiction. To prove that one is a mas-ter code breaker, one must have an impossibly difficult code to crack. In this case, that code was generated by the same individual tasked with breaking it. If one is both the code breaker and the code generator, one is in the paradoxical position of creating a code system so complex that it eludes understanding, and then cracking that same code. Perhaps my


patient did not understand his own self-generated symbol system, and my passive deception of him echoed a self-deception in his own narra-tive. If so, allowing my patient to falsely believe that I understood his code was an enactment in the consulting room of his grandiose notion that he was a master code breaker. For a moment, I, like my patient, was the faux code breaker who could not comprehend the code I was sup-posed to have cracked.

The Accentuated Mm-hmm as a Facilitatory utterance

Shea (1998) discusses how uh-huh is often used as a facilitatory utter-ance. Facilitatory utterances are the opposite of tokens of presence. They indicate a therapist who is fully engaged, wholeheartedly involved in prizing and understanding a patient’s narrative, and energetically encour-aging the patient to proceed. They suggest that the therapist’s feelings about the patient are positive and genuine. Although these utterances are ambiguous, they are far from neutral. They are often uttered relatively loudly, with a rising pitch, and are often accompanied by a head nod. An acquaintance of mine went to a therapist whose approach, a structured cognitive-behavioral technique, was in conflict with his preference for a more nondirective psychotherapeutic process. However, the therapist nodded and vocalized encouragement frequently and enthusiastically during the sessions. For this reason, my acquaintance felt that the thera-pist “really got him” and he continued to attend sessions, eventually com-pleting a productive course of therapy even though the therapist’s overall clinical technique was not in harmony with what he believed his needs to be.

Sometimes, however, even the most seemingly facilitatory use of mm-hmm can turn out to be an unconscious enactment on closer inspection. One patient of mine, Robert, was a young man who had been depressed for several months after losing his job as an accountant. Robert had been teased viciously by his coworkers, and had frequently complained to his supervisor. His supervisor responded by skeptically pressuring Robert for details, which left Robert feeling invalidated and criticized. The supervi-sor confronted Robert’s coworkers, but they responded by escalating their bullying. Over time, the supervisor became increasingly frustrated as her efforts to defuse the situation proved ineffective. At one point, Robert, who had been pushed to his limit, broke down in tears to his supervisor, who overreacted and escorted Robert to an emergency room.


Robert was placed under observation and released. When Robert re-turned to work, the teasing escalated. Robert’s coworkers called him names like “lunatic” and “nut.” Robert increasingly withdrew from his coworkers, who in return became more aggressive. Eventually, Robert could stand it no longer. He confronted several of his coworkers and loudly exclaimed that they should leave him alone. Robert’s supervisor considered him to be irrational, and fired him.

Robert was referred to me after an unsuccessful course of therapy at another clinic. In sessions with me, Robert alternated between periods of relative talkativeness and withdrawn silence. When Robert’s speech was halting and slow, I often repeated mm-hmm, mm-hmm to encourage him to open up more. Although I also asked many questions and used a lot of reflective listening as well, mm-hmm was a prominent part of my interaction with Robert. I believed that I was being warm and encourag-ing. I was concerned, however, when Robert’s depression did not lift af-ter several months. As I explored this issue, Robert reported that he felt worse rather than better after therapy sessions. He said he was not sup-posed to be depressed and should have been better by this time. He also said that his wife often expressed concern about him from leaving the house on his own because she was afraid that he might “wig out.” As Robert spoke, the words tumbled out of him. He seemed to need to ex-press his feelings about these issues. As I explored these concerns fur-ther, however, Robert became increasingly withdrawn. I asked him how he felt about speaking about these issues with me. “I don’t want you to think I’m crazy,” he said. That session ended with Robert slumping out of the room, looking defeated.

While considering my next course of action, I conjectured that because Robert seemed to feel the need to express his feelings, it was not his self-expression that made him so uncomfortable. Rather, there must be some-thing gone awry with how he felt I was hearing him. I reflected on his fear that I would think he was crazy, and realized that for Robert, seeking therapy must have been a confirmation of his coworkers’ abusive re-marks about him. By pursuing psychotherapy, Robert must have felt that he was validating his coworkers’ slander of him as a “nut.” When I ut-tered mm-hmm again and again, Robert must have felt that I, like his supervisor, was pressuring him to display more of his craziness. More-over, the entire interaction with me was probably a reenactment of Rob-ert’s interactions with his supervisor. I realized that whenever Robert


withdrew into silence, I became distressed. Like Robert’s supervisor, I felt increasingly frustrated as my continual efforts to help were ineffective. I felt disempowered and defensive, as it seemed that I was being rejected and ignored. My efforts to encourage Robert to speak had unconsciously communicated my negative feelings in tone and cadence.

Armed with these formulations, I began the next session by reassuring Robert that I thought he was doing good work on himself and that, un-like his coworkers, I did not think of him as “crazy.” I explained to him that many people enter therapy to work on themselves, and there is no shame in that. I emphasized that I was not like his coworkers, and that I admired people who work on themselves. I even disclosed to him that I had spent many years in psychoanalysis working on myself. In response, Robert made a disclosure. He reported that he had hidden something from me throughout the entire previous session. Robert, who was highly intelligent and sensitive, told me that he was thinking about helping a friend’s son with his homework. He said that he was terribly worried that I would think that he was not capable of safely interacting with his friend’s son or for any other child. Robert was certain I felt he was too disturbed to be near children. I reassured him that this was absolutely not the case and I thought that he would be an excellent tutor. I let him know that if I was not his therapist and had any children, I would be perfectly comfortable having him tutor them. Robert was relieved to hear my reassurances. He brightened up. This was the first session in several months of therapy in which Robert left the consulting room feeling better than when he had arrived. From that point onward, the therapy became markedly more successful. By the conclusion of treatment, Robert had been able to secure a new job and develop solid relationships with his coworkers.

In my work with Robert, I had consciously intended mm-hmm as a facilitatory utterance, while unconsciously reenacting Robert’s traumatic relationship with his supervisor. By pressuring Robert to tell me more with mm-hmm, I unwittingly acted out the part of his supervisor who responded to his trauma by interrogating him. Exploring the enactment in a traditional analytic manner was not effective, as Robert experienced any inquiry or interpretation as an implicit message that he was crazy. I was only able to breach the enactment by explicitly and repeatedly reas-suring Robert that I viewed him differently than his abusive coworkers had.


One Effect of Analyzing Mm-hmm

Over the course of writing this article, I had a notable and unanticipated experience. It seemed that the more I wrote about mm-hmm, the fewer clinical examples of its functioning appeared in my practice. Although I have not done a quantitative study of the frequency of mm-hmm in my practice, my sense is that I utter it much less than I did before undertak-ing this project. I previously uttered mm-hmm a lot; now I utter it only a little. To some extent, it has lost its grip on me as a therapist and faded away. I often find that in moments in which I previously might have been tempted to utter mm-hmm, other interventions feel better to me. I still backchannel, of course, but in more varied and less stereotypical ways. There may have been something problematic about how often I used mm-hmm, although, on the other hand, it may also be that having identified it, I am now self-conscious about using it. Regardless of the cause, nowadays my mm-hmms rarely escape my attention. I feel that my overall practice has been enriched by better understanding this back-channel communication, and I encourage other clinicians to undertake the journey.

REFERENCES

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Ward, N., & Tsukahara, W. (2000). Prosodic features which cue back-channel responses in English and Japanese. Journal of Pragmatics, 32, 1177–1207.

Yngve, V. (1970). On getting a word in edgewise. Papers from the Sixth Regional Meeting, Chicago Linguistic Society, 568.

Kyle Arnold, Ph.D., is a psychologist at Kings County Hospital in Brook-lyn, NY, and a clinical instructor at SUNY Downstate Medical Center. He is a candidate in focusing-oriented psychotherapy at the Focusing Insti-tute. His previous publications include articles on Theodor Reik, the un-conscious, and psychobiography.

215 Wyckoff Street, #1Brooklyn, NY 11217–[email protected]

arnold, kyle - humming along - the meaning of mm-hmm in psychotherapeutic communication

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