100

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 1935% 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 afrms his or her right
to continue to hold the oor. In psychotherapy, mm-hmm reafrms the patients
right to an extended conversational turn and the therapists 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
A
S 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
chiey 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 eld 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 clarication, or an interpretation, but mm-hmm. Re-
search suggests that mm-hmms make up approximately 1935% of thera-
pists utterances (Ferrara, 1994). Popular culture is well aware of this,
often portraying the therapist as a mysterious gure 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 dont 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: Ones construal of the intentions and meaning of another
persons behavior is necessarily inexact. As a result, our moment-to-
moment responses to another persons relational movements are built on
a shaky foundation of conjectures about what the others behavior might
mean.
In the present article, I examine one particular piece of local-level
fuzziness: the meaning of mm-hmm in the therapists speech. Although
mm-hmm may appear to be a mundane vocalization, it is mysterious and
meaningful. Mm-hmm is, to use William Blakes 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-
nicance 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 Patients Confrontation
Although I have been vaguely curious about the signicance 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 abbergasted. 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 reect on her speech. If so, didnt it follow that I ought to be re-
ecting 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 didnt have one. To simply tell her that I didnt
know, in this instance, felt unfair and dismissive. To inquire about what
THE MEANING OF MM- HMM 103
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 Im still here and am listening. She nodded but looked skeptical. I
added, Itd be hard for me to not say mm-hmm, because Im not sure
how else I would do that from moment to moment. But I could try to say
it less often, and see what thats like.
For the remainder of the session, I tried to inhibit my mm-hmms. Do-
ing so was difcult 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 difcult to say anything other than mm-
hmm without interrupting herand 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 nave. 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 difcult to get them into awareness and keep them there.
Furthermore, mm-hmms are often packed with emotional meaning.
Perhaps precisely because they are difcult 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.
104 KYLE ARNOLD, Ph.D.
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 xed 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 reection 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 weve 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 partys 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 therapists 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 Im trying to be with you, be-
cause I have not yet understood enough and need to understand more,
because I dont have anything to say yet, because I dont know where
youre headed, or because I need more time. They also give other ex-
amples of uh-huh, which, they conjecture, indicates that the therapist is
THE MEANING OF MM- HMM 105
waiting for material to unfold, and encouraging the patient to continue to
nd 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 innitely
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 oor, and his or her speech is primary. The back-
channel comprises brief utterances that the listener emits as feedback to the
speakers 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 chiey 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 ow 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 oor. Utterances like mm-hmm, Ferrara argues, consti-
tute a minimal conversational turn on the therapists part that reafrms the
patients 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 Ferraras 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-
106 KYLE ARNOLD, Ph.D.
nation, elongated syllables, and phrases such as you know. By these
signals, patients communicate that it is the therapists 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 patients 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 afrmed, even if we dont 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 expressionits intona-
tion, volume, and cadence. Indeed, the standard function of mm-hmm
may require it to be void of intrinsic meaning. Utterances with more
specic 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 others remarks are accept-
able (or, if used ironically, that they are not acceptable). It has a nalizing
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 patients 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 lled out with transferential material. During my psy-
THE MEANING OF MM- HMM 107
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 supercial 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 gure 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 Sheas uh-huhs, aggressively saying
Youre a shrink all right, yeah youre 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 patients 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 denition, backchannels do not require acknowledgement
108 KYLE ARNOLD, Ph.D.
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 patients narrative, think about
which variation of mm-hmm we should vocalize to encourage him or her
to continue. Under most circumstances, mm-hmm is reexively 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
Sullivans (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 Sullivans 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 others 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 difcult 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-
ouaged as a seemingly appropriate backchannel to the therapeutic
communication, but also serving the same dissociative function as Sulli-
vans tic. Below, I examine a few variations in mm-hmm that can indicate
unconscious issues in the therapeutic relationship.
THE MEANING OF MM- HMM 109
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 patients speech.
Mistimed Mm-Hmms
If, for example, the cadence of mm-hmm is asynchronous with that of
the patients speech, it may function as an interruption. Ordinarily, our
mm-hmms are synchronized with transitions in the patients 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 patients utterance of
and, but would probably not be experienced as an interruption. It
would match the cadence of the patients speech, and would mean
something like Im 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 patients 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 therapists criticism of the pa-
tient. By disrupting the patients 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.
110 KYLE ARNOLD, Ph.D.
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 moreanything loudercould 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 therapists 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 patients 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 patients 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 patients 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-
dent, offhand way that belied what it must have been like to be locked
in. Part of this patients dynamic was to protect herself from feelings of
painful vulnerability by dissociating from them and assuming an arti-
cially condent and offhand attitude. An unconscious identication had
occurred in which I had unwittingly assumed the patients 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
THE MEANING OF MM- HMM 111
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 conicted can
easily retreat into silent passivity in sessions rather than actively working
to be present. Sometimes, Hirsch points out, the therapists retreat can be
an avoidance of the patients 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 therapists with-
drawal. It is as if the withdrawn therapist was saying, No, Im really
here, really listening, believe it, even if it doesnt look or feel like Im
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 afrm her presence. Shea (1998) calls such implied encouragement of
a patients digressions leading the wanderer.
Mm-hmm as a Token of Absent Therapist Understanding
In addition to a token of presence in the therapists emotional absence,
mm-hmm may be a token of absent understanding. This can emerge as a
compromise during difcult 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 ow 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
112 KYLE ARNOLD, Ph.D.
handled the traumatic material by uttering token mm-hmms as the pa-
tient initially recounted his experiences, and waiting until the patients
initial report was nished 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 reected back and expressed appreciation for the few as-
pects of what my patient said that I could understand, and mm-hmmd
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 patients 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 difcult 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
THE MEANING OF MM- HMM 113
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 patients narrative, and energetically encour-
aging the patient to proceed. They suggest that the therapists 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 conict 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 therapists 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 Roberts 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.
114 KYLE ARNOLD, Ph.D.
Robert was placed under observation and released. When Robert re-
turned to work, the teasing escalated. Roberts 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. Roberts supervisor
considered him to be irrational, and red 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 Roberts 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 reective 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 Roberts 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 dont want you to
think Im 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 reected on his
fear that I would think he was crazy, and realized that for Robert, seeking
therapy must have been a conrmation 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-
erts interactions with his supervisor. I realized that whenever Robert
THE MEANING OF MM- HMM 115
withdrew into silence, I became distressed. Like Roberts 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
friends 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
friends 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 rst 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 Roberts 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.
116 KYLE ARNOLD, Ph.D.
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 nd 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
identied 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.
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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, #1
Brooklyn, NY 112172208
kyle.arnold@nychhc.org