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Empathic Confrontation in Group Schema Therapy

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 Empathic Confrontation in Group Schema Therapy

Joan M Farrell and Ida A Shaw

As the preceding chapters on individual schema therapy (ST) have well

described, empathic confrontation is a therapeutic intervention that is part of limited

reparenting and a mode change strategy in its own right. Empathic confrontation can be

defined as the therapist’s approach to addressing early maladaptive schemas and

dysfunctional mode behavior, with empathy for how they developed, balanced by

confronting these behaviors as needing to change for the patient to have a healthy life.

It is a critical intervention for accomplishing the overall goal of Schema Therapy- to help

patients get their adult needs met in a healthy manner – as it points out the negative

effects of their currently used unhealthy schema and mode driven behavior and assists

them in learning and using more adaptive behavior. Empathic confrontation is used in

response to the Maladaptive Coping modes. It is only effective in the context of a

limited reparenting bond with the patient. This chapter will discuss implementing

empathic confrontation in Group ST: the ways in which the unique therapeutic factors of

the group can augment the intervention and the additional considerations that are

necessary when the intervention occurs in front of others, rather than the privacy of

individual therapy.

The basic formula for empathic confrontation is the same whether done in

individual or group ST. Empathic confrontation involves the therapist empathizing with

the patients underlying pain and need while challenging the behavior of the mode. It

requires that you have enough connection with the patient for them to have some

amount of belief that you have their best interest at heart and are not being critical. In
 ©2013, Farrell & Shaw

Group ST it may be even more important to establish the therapist’s good intention to

avoid patients feeling shamed when empathic confrontation occurs in the presence of

others giving it an added social context. We reinforce our positive connection and our

intention by directly stating: “I am not saying this to be critical. I am saying it because I

am concerned that your old protective behavior will not get your needs met today”. We

acknowledge the origin of the behavior “I understand that because you were bullied as a

child your Bully-attack mode takes over when you feel hurt today”. Then we point out

why the MCM behavior will not get their need met, “but I am concerned that strategy

leads to people being afraid of you and avoiding you and your needs for companionship

and love are never met.” Then we offer a correction, a behavior that could meet their

need. “You could decide in the group to let safe people know when they hurt your

feelings and see if they meant to or if it was a misunderstanding before letting the old

coping behavior take over and protect you by hurting them. That way your need for

companionship has a chance of being met. The old way you will stay alone”. We offer

help with the correction behavior. “We can work on how to let someone know when you

are hurt and even role-play that in the group.”

So the “formula” or steps for empathic confrontation are:

1. Strengthen your connection with the patient and clarify your intent

2. Name the maladaptive behavior, (you may want to also name the mode if it is later in

treatment)

3. Empathy: acknowledge the reasons that the behavior developed (biographical

validation) and express concern that it does not get their needs met today (confront

the results of the behavior),

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 Empathic Confrontation in Group Schema Therapy

4. Assist in conscious decision making regarding changing the behavior

5. Offer a correction – a behavior that will get their needs met today

6. Offer them assistance in learning to make the correction and opportunities to

practice it.

All six steps are essential to the effective use of empathic confrontation. Other

approaches to psychotherapy tend to focus on steps two, four and five, skipping one

and three. Schema Therapy posits that you must have a limited reparenting connection

before the other steps can be effectively implemented. Step three is the part most

appealing to patients and motivating of change, as they feel understood and who does

not want to have their needs met? Our patients may feel that they do not “deserve” to

have their needs met, but will still respond positively to our efforts to help them get their

unmet needs met.

1. Step One: Reinforce or strengthen your connection with him/her and your
positive intention in questioning their behavior

Basic Verbal and Non-verbal Cues

The most basic ways to reinforce our connection with a patient in a group are: to use a

soft and gentle voice tone, a positive expression, ensure that you have eye contact and

increase your physical proximity to him or her. In many cases this simply requires

leaning forward in your seat toward a patient. It may require getting out of your chair

and physically moving toward him or her, particularly if you are combining limit setting

with empathic confrontation.

Experiential approaches to strengthen or represent your connection

 ©2013, Farrell & Shaw

In the group we use a number of exercises that connect patients and therapists with

connections that include the teleological level of development that patients can be at in

the innate child modes.

Example: the “Connecting Web Exercise”

In this exercise done in an early session, we toss a ball of yarn back and forth and

around the group, winding it around one’s hand each time it is caught, until it creates an

overlapping web of connections. Then we experiment with tugs on the web, loosening,

tightening, letting go, etc. always paying attention to what these variations in physical

connection feel like. We do a variation of this exercise with strips of very soft fleece,

reminiscent of a baby’s receiving blanket. We use these connections when we want to

connect with the Vulnerable Child mode safely or to help calm and ground the Angry

Child mode. The web can also be used to emphasize connection at a time when we are

empathically confronting a behavior involving the whole group or an individual patient.

Using the whole group’s connection can help the patient being empathically confronted

to still feel that they belong and the reminder of the group’s connection to that patient

can help them remain empathic. To emphasize or remind the patient of their connection

with us we ask them to look directly at us and at times add giving them the end of a

fleece strip to hold. This physical move has a big impact and seems to increase the

interpersonal connection. The web is an exercise for group ST, but the fleece

connection can also be used in individual ST. These physical connections act as a safe

way to underline the connections between members, with the therapists and with the

group as a whole.

Example: Using a tangible connection to reach the Angry Child Mode.

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 Empathic Confrontation in Group Schema Therapy

When patients are in the Angry Child mode they are not in a state easily reached with

words alone. We frequently pull out a towel or fleece strip and toss it to them. People

usually grab the end automatically and we initiate a “tug of war” briefly as a way to

communicate that we are there with them, paying attention and listening. This can

accomplish Step One strengthening the connection.

Step Two Name the patient’s maladaptive behavior

The next step, the confrontation part of the intervention, is one novice therapists often

find difficult. Group therapists tell us that they are afraid that this step will offend or

upset a patient and trigger them leaving the session and even the therapy. However,

pointing out mode based behavior that does not get needs met with empathic

confrontation or limit setting is one of the central interventions of limited reparenting. If

we do not confront our patients in group sessions they will continue behaviors that are

self-defeating and a central part of their personality disorder.

The modes with maladaptive behaviors that we use empathic confrontation for

are the Maladaptive Coping modes.

1. Avoidant Coping Modes For example, being in Detached Protector in the group

session whether just being spacey or the active pushing away of others of the

Angry-Protector mode;

2. Overcompensating Coping Modes: For example, Bully-Attack behavior that

frightens or intimidates others (sometimes even the therapist); Self-aggrandizing

behavior that risks that patient becoming a disliked scapegoat or others skipping

sessions out of annoyance with the patient and the therapist for not stopping the

behavior
 ©2013, Farrell & Shaw

3. Compliant Surrender Coping Modes: For example surrendering to schemas like

Self-sacrifice, which leads to no needs being expressed. As in the rest of ST,

different empathic confrontation is required depending upon which Coping mode a

patient is in.

In group sessions naming the behavior must be combined with limit setting if other

group members are being negatively impacted, for example with Bully-Attack mode

behavior. Combinations of empathic confrontation and limit setting will be discussed in

a separate section of the chapter.

Step Three: Empathize: acknowledge that the maladaptive behavior developed

for understandable reasons in their childhood when limited options were

available, but today it does not result in their need being met.

There are two main ways in the group modality to accomplish this – verbal

description and demonstration. The latter, which operates at the experiential level, can

have a bigger impact. ST integrates cognitive, experiential and behavioral pattern

breaking interventions, so all three are necessary components of empathic

confrontation.

Accomplishing the goal of Empathic Confrontation via group experiential

exercise

Example: the Group Mode Role play

This is a group experiential exercise (described in Reiss, Farrell & Shaw, 2013) in which

patients play the roles of various modes using scripts developed by the group. These

include one of the Dysfunctional Parent modes, one of the Maladaptive Coping modes,

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 Empathic Confrontation in Group Schema Therapy

the Angry Child mode, the Vulnerable Child mode, the Healthy Adult mode and the

Good Parent part of the Healthy Adult. Two patients play the Parent and Coping Modes

and two join the two therapists as “helpers or in training” of the Healthy Adult and Good

Parent. This arrangement can vary based upon the predominant modes in your patient

group. All eight group members play a role. The therapist playing the Healthy Adult acts

as the “director” and leads this experiential empathic confrontation. Chairs are set up

that represent the relationship among the modes: the Child and Parent modes face

each other about 12 feet apart. The Coping modes sit in front of the child modes facing

away from them. Their task is to try to protect the Child modes, but due to their focus on

the Parent modes they do not see the children. The Healthy Adult and Good Parent and

their assistants sit separated from the Child modes by the Coping modes. To start, the

Parent modes express punitive statements and the Child modes express Pain

(Vulnerable Child) and anger (Angry Child). This goes on for a few minutes. Then the

Coping modes “develop” so they join in an effort to protect the Child modes. This is Step

3 of empathic confrontation – demonstrating why the Coping modes developed. Next

the Parents are taken away literally and sent to the past where the therapist declares

that they belong. Now it becomes clear that when the Coping modes continue their old

protective behavior they are keeping the Good Parent and Healthy Adult away from the

Child modes. The Child mode needs are not met – this is the “point out that the old

behavior does not meet current needs” step. As the role play continues the Coping

modes are convinced to move aside to allow the Healthy Adult and Good Parent

access. This is the “correction”. After this happens, contact is made and first the Good

parent and later the Healthy Adult connect with the Child modes and meet their needs
 ©2013, Farrell & Shaw

by listening to and validating the anger of the Angry child and comforting the Vulnerable

child mode. Usually fleece strips are offered to both patients playing Child modes to

represent the new connections among the Healthy modes and the Child modes.

Patients tell us that this role-play captures their experience well. It acts as a very

effective empathic confrontation. Numerous variations are possible depending upon

which mode the maladaptive behavior you want to empathically confront is in.

Group Experiential Interventions to demonstration that the current behavior does

not meet the patient’s need.

Early in schema therapy treatment it takes more than a simple statement of the

therapist or group’s assessment that an old Coping mode behavior does not meet a

patient’s need to create doubt in them. We have developed a number of group

experiential exercises that demonstrate to patients based upon their experience that our

assessment is accurate.

Example: Demonstrating the effects of the Detached Protector in the group

This exercise has two or three patients volunteer to play the Detached Protector mode

by holding a piece of paper in front of their face as they sit next to each other in a block.

Their task is to not respond to any efforts of the group and therapists to influence them

to lower these paper masks. In the course of this exercise the other patients usually

move from straightforward requests that they rejoin us, to cajoling, to anger and

eventually to ignoring those behind the papers. The exercise accomplishes Step two of

empathic confrontation: demonstrate that the old Coping mode behavior does not allow

the current need to be met, and may even elicit anger and rejection – the opposite of

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 Empathic Confrontation in Group Schema Therapy

the need. It is possible to move from the exercise to the next steps of empathic

confrontation.

4. Step Four: Offer a correction – a behavior that will get the underlying need met
today in adult life
We frequently need to demonstrate to patients that a correction will lead to their need

being met, because the correction usually triggers feelings of vulnerability. The Mode

Role-play described acknowledged understanding of why the behavior developed and

demonstrated that a correction – in this case moving aside the Detached Protector –

would lead to the need being met. We assert that the correction of risking vulnerability in

the group and experiencing the outcome of needs being met is one of the critical

corrective emotional experiences possible in Group Schema therapy. The form of the

correction depends upon the mode involved and the patient’s abilities.

Example: Empathic confrontation for the Angry Protector but limit setting for the
Angry Child mode. The emotion expressed in both is anger, but the need
underlying the modes is different, thus requires a different correction
In response to a patient yelling and pointing a finger aggressively at the therapist in a

group session: Therapist: “I understand that you are very angry with me and want me

to hear you, but when you are yelling I cannot really hear your complaint. Can you lower

your voice a bit so that I can hear what you need from me?” The response to the Angry

Child mode includes encouragement to vent, but without yelling. This is the limit

setting correction needed for the Angry Child mode. In contrast, the correction of

empathic confrontation for the Angry Protector mode would not encourage venting.

In that case venting would strengthen the angry avoidance. It is important to distinguish

the Angry Child mode, which is a normal, instinctual expression of anger when needs
 ©2013, Farrell & Shaw

are not met, from maladaptive Coping modes like Angry Detached Protector or Bully

Attack. For the Angry Child, venting is therapeutic and meets their need to be heard.

For the Angry Detached Protector, empathic confrontation is what is needed and

therapeutic. With the Bully-Attack mode, venting will be directed aggressively at

someone and the therapist’s limited reparenting response in that case would combine

empathic confrontation and limit setting. >

Sometimes the correction can be the therapist assessing the underlying need and

taking an action to meet it despite the Coping mode behavior present.

Example: Offering connection to a patient in the Self-Aggrandizing mode

In a group session a patient with Narcissistic personality disorder features was

beginning a self-aggrandizing rant that included a disparaging attack directed at the

therapist leading an exercise and the interventions of Schema Therapy in general. The

other therapist sitting next to the ranting patient assessed that this Overcompensating

mode behavior had been triggered because he felt the loneliness of his Vulnerable

Child. Without saying anything she reached over and draped a strip of fleece over his

knee, smiling at him as she did so. He reflexively picked up the fleece and as he did his

face softened and he went from being rather puffed up to lowering his shoulders and

taking a deep breath. He said “That is what I needed. It really took the wind out of me”.

The group was able to go on to process this experience and determine that his old

Coping mode behavior had been pushing everyone away, while his lonely Vulnerable

Child needed connection. A simple correction was for the therapist to take an action that

made him feel more connected like the fleece strip. Sometimes, if neither therapist is

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 Empathic Confrontation in Group Schema Therapy

sitting next to the patient in such a mode, we toss a fleece strip to the adjacent patient

who knows we want him/her to make a fleece connection.

5. Step Five: Making the decision to change mode behavior is part of the correction

process of empathic confrontation - for example, constructing a “Pro and Con of a

Maladaptive Coping mode” list (handout in Reiss, Farrell & Shaw, 2013). Go over it with

the patient and let them decide whether to work on decreasing the frequency or

intensity of the mode. This step is discussed with handouts in other chapters.

6. Step Six: Offer them assistance in learning to make the correction

Example: Empathic confrontation via a demonstration for Compliant Surrender

to Self-sacrifice
This mode is one that others may not notice, but keeps the patient from getting his/her

needs met. It is the Coping mode that can lead to exploitation and even unwanted

sexual intimacy. We demonstrate the effects of Surrender to Self-sacrifice with an

exercise in which therapist and patient stand up and the patient indicates where the

boundary of her personal space is. The therapist asks the patient to tell her when the

boundary is reached. She then walks up to the boundary. A patient with this Coping

mode will usually say “it is there” in a soft voice. The therapist questions it by starting to

step over. The patient may or may not say anything. If she does not the therapist will

ask why she did not speak up. Next the therapist draws attention to some article of

clothing or jewelry and begins to comment on it and ask about it. In the process she will

move closer, over the defined boundary, getting as close as the patient allows her to

before saying stop. Typically Ida will comment on a piece of jewelry and “to see it better”

will keep moving in. At the end, she will ask the patient why she did not stop her at the
 ©2013, Farrell & Shaw

boundary. A usual response is “well, you were being nice and you were interested in

seeing it closer, so I thought my boundary did not really matter so much.” Ida replies “so

anyone who is nice and interested in you can step all over your boundaries.” This is

usually a good summary statement of that patient’s behavior. The next step is to

practice the correction. This can be done with help from the group in the form of saying

“stop” with her, standing with her or whatever support is needed.

In group we are able to provide interpersonal corrections directly with as much or little

coaching for the patient’s behavior.

Example: very specific coaching

Group members repeatedly attempted a direct empathic confrontation of what they

perceived to be Compliant Surrender to self-sacrifice in an adult peer, Karen, who

expressed unwillingness to confront her physically abusive adult brother. Group

members kept pointing out that her behavior was unhealthy and not meeting her need

for protection. She kept saying that she could “not talk about it”, that it was “impossible

to change”, that she was “doing it to keep the peace” in her family. This led to a

stalemate with negative feelings toward her developing in the group. One of the

therapists realized that it was also Karen’s need in the group to have peace and

acceptance. She went over to her and whispered suggestions of how to express her

feelings: “I don’t feel able to discuss it yet, I am too scared”. The patient said “I can’t talk

about it”. This was not enough information for her peers, who continued to push her.

After two more attempts by the therapist to give Karen words to express her Vulnerable

Child mode rather than a Coping mode, she was able to repeat the therapist ‘s words –

i.e., the correction. She told the group that she knew it was a problem, but it was too

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scary for her to deal with right now. This change elicited support from her peers instead

of confrontation. The group members realized that the Vulnerable Child does not need

empathic confrontation. Karen’s risking vulnerability led to a good outcome; her need for

acceptance and “keeping the peace” in group was met. The group was able to discuss

the process and understand that she went along and surrendered in childhood to

minimize abuse. Karen and the group saw that the correction behavior – expressing her

need in the group as an adult led to the outcome she needed, while the Coping mode

behavior did the opposite.

Issues specific to Group Empathic Confrontation

Should it be done in the group or in an individual session? As “parents” to a large

family, we must consider all of the “children”. For example, it is important to clarify the

boundaries for behaviors that can be frightening or hurtful like the expression of anger.

Raised voices can be very triggering of Coping modes. Empathic confrontation may

need to take place privately if an individual has little Healthy Adult mode and will feel too

exposed and vulnerable in the group particularly in early stages of the group bonding.

Other times, if a disruptive behavior has occurred repeatedly in the group, empathic

confrontation needs to take place there. When that is the case, we find it helpful to “set

the stage” before beginning an empathic confrontation. We establish groundrules about

using “I” statements that we actively enforce, and then allow space for other members

to get involved as long as it remains empathic and constructive. A therapist would need

to intervene if what starts as empathic confrontation turns into a “ganging up on” a

patient. The group can give a member feedback about how they are affected by a peer

in the Bully-Attack mode calling them a mean name. . Therapists can use selective self-
 ©2013, Farrell & Shaw

disclosure to give their feedback also. Therapist feedback may take the form of “we love

you, but feel hurt and angry about these repeated verbal attacks.”

An Example of problematic group confrontation In an early session, a patient called

therapists one a “bitch” when she did not like something that she said. The other

patients jumped in with their complaints about therapist one. Therapist two thought that

therapist one should respond, so he did nothing. Therapist one felt overwhelmed and

ultimately became defensive, telling the patients they were ungrateful. This fueled the

patients’ negative comments even more. Therapist two did not want to be perceived as

interfering with the interaction with therapist one. It was more important for one of them

to set a limit at once, and then empathically confront the Maladaptive Coping Mode

much earlier. Therapists have a right to empathically confront disrespect of themselves

also. In the group this is a necessary reparenting.

Example: Steps of a group empathic confrontation:

 The group gives feedback about how they are affected by the Bully-Attack mode in

group.

 Therapists use selective self-disclosure to give feedback also as to the effects on

them (for example, “I feel overwhelmed when you x” not “I feel angry and disgusted

with you when x”)

 Therapist feedback may take the form of “we love you and want you to be in the

group, but feel hurt and angry about these repeated verbal attacks.”

 A brief discussion of intent and effect and actor-observer differences in attribution

can be useful groundwork to provide for giving such feedback. In working in group

with personality disorder patients it is important at the cognitive level for them to

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 Empathic Confrontation in Group Schema Therapy

understand the difference between intent and effect and that they are still

responsible for the action they take.

 We coach the practice of more constructive, modulated expressions of anger, for

example milder expressions of anger for small irritants.

The therapists can emphasize that nothing can occur in the group that they cannot help

with in some way. As a last resort, there could be a situation in which one therapist

works with the individual patient and the other therapist responds to the needs of the

rest of the group until a point is reached where all can resume the group’s interaction.

There are situations where an avoidant patient’s response to empathic confrontation is

even more withdrawal and a therapeutic factor of groups – vicarious learning – provides

a more effective confrontation.

The simple fact is that when empathic confrontation is implemented in a group it has

social consequences for the patient just because peers are present. This can add extra

sensitivity in relationship to maladaptive schemas like defectiveness/shame. These

schemas can also distort the patient’s experience of what you have said to them, so it

should be checked if there is any doubt. This is done simply by asking “What did you

hear me say?” Often the patient’s answer is based more on maladaptive schemas than

consensual reality.

Example – Make sure the correction is accurately perceived

In the correction step of an empathic confrontation with an inpatient with severe

Borderline personality disorder I had included the statement “John (an ex-husband she

was on good terms with) cares about you” and “Joan cares about you”. I wrote both

statements on an index card for her and then sat back expecting a positive reaction
 ©2013, Farrell & Shaw

when she read it over. To my surprise, she looked even more distressed. I had a

moment of panic, fearing that I had miswritten the card. I asked to see it. It was written

correctly, but her schema distortion led to her actually seeing the words “do not care

about you” instead of what I had written. Ask patients to restate your words in an

empathic confrontation if their reaction suggests that they are not being accurately

perceived.

Vicarious Learning as an Experiential Empathic Confrontation

The Avoidance Coping modes in Borderline personality disorder patients often get

stronger when they are confronted directly, even when it is empathic confrontation. We

discovered that vicarious learning experiences in the group could act to reinforce

patients’ connection with therapists and group members and set the stage for the other

steps of empathic confrontation. For example, when a patient watches therapists and

peers in a mode role play they sometimes get caught up in the emotion or action and

are drawn out of their Avoidant Coping mode. This increases their connection and

provides a base for an empathic confrontation.

Example: Empathic Confrontation beginning with Vicarious Learning

Jane was very resistant to even acknowledge having a Punitive Parent mode, despite

the therapists knowing that she had been “rented out” for sex as a child by her adoptive

parents. Jane’s Coping mode tended to be Angry Protector. She began a group session

on the Punitive Parent in the Angry Protector mode. In the past, when in this mode she

responded to the therapist’s empathic confrontation intervention (however so gentle) by

either charging angrily out of the group session or by becoming more and more angry

and pushing us all away even more completely. One day when we had planned to do

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some Punitive Parent work she charged into the session announcing in an angry voice

directed at Joan “I am not answering any questions today”. Joan acknowledged hearing

her. The group did a mode role-play in which a patient, Diana, played her own Punitive

Parent mode and Joan played the Good Parent defending the Vulnerable Child mode

(played by another patient). After a short intense interaction, Joan said “It is time for you

to leave, you old bitch. Get out of here and leave Diana alone!” (This language and

approach were appropriate for the patient’s experience and the severe abuse from her

adoptive mother). The rest of the group applauded and the patient playing her Punitive

Parent mode nodded smiling. Ida asked her “what did you like best of what Joan said in

your defense?” Jane, who had been sitting at the edge of her chair while the “banishing”

was going on, jumped in immediately “I loved it when you said “get out of here you old

bitch”. She followed this with talking about how she wished she could do that with her

mother, but was afraid to. Diana said, “I can understand that, I was scared at first. I liked

everything Joan said to her and the “old bitch” was the best, because that is really what

they are. I am sick of living with her in my head; I want her out for good.” As the session

continued Jane shared some more information about her childhood that neither the

group nor the therapists had heard before. She said that she had no idea that anyone

else could understand her pain and anger at her adoptive mother. This allowed Ida to

point out that she had started the session pushing us all away, which did not meet her

need for support and acceptance. Now she tried a new behavior, sharing some of her

pain and anger, which allowed connection with the group and her needs being met.

Of course, vicarious learning occurrences are much less predictable than therapist

initiated empathic confrontation. They fall into the category of “experiential moments”,
 ©2013, Farrell & Shaw

which schema therapists are encouraged by Farrell & Shaw (2012) to be ready to seize

and make use of.

In groups, in addition to the therapist naming the problem behavior, vicarious learning

allows patients to observe what the old maladaptive behavior looks like and its negative

effects on others. Quite a few patients have told us that watching peers in the Self-

Aggrandizer or Bully-Attack mode had the biggest impact on them in terms of making a

decision to change their behavior.

Empathic Confrontation combined with Limit Setting

The effects of a patient’s maladaptive behavior on the group cannot be ignored. Many

such behaviors involve violations of groundrules that are part of the stable and safe

environment that the therapists must maintain for the group as a whole. Depending

upon the mode the ground-rule breaking behavior is part of, therapists must

empathically confront the patient, set limits or a combination of both. The Avoidance

and Compliant Surrender Coping modes operate more quietly, with less effect on

interpersonal relationships than the Overcompensating modes, which affect others

negatively and elicit negative responses from the social environment. Of course, all

three styles of the Maladaptive Coping modes are dysfunctional in getting the individual

patient’s needs met and will be empathically confronted in the course of schema

therapy. Limited reparenting interventions with the Bully-attack mode consist of limit

setting and empathic confrontation with escalating directness. As previously described,

empathic confrontation involves the therapist empathizing with the patients underlying

pain and need while challenging the behavior of the mode and setting limits on it in the

group. Patients in disruptive modes like Bully-attack are reminded of the group ground

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rules and warned that if the maladaptive mode behavior is not stopped, they must leave

the session for a time out or go to the designated safe space in the group room. The

“Safety corner” is a physical place in the group room that has pillows, blankets, stuffed

animals, etc. where patients can take a brief time out to get disruptive behavior or their

own distress level under control. It is an alternative to patient’s leaving the group and its

use is described fully in Farrell & Shaw (2012). Our position is that patients cannot be

expected to stop all maladaptive behavior just because they are in a group session, but

we do expect them to follow our instructions aimed at helping them get it under control

and if they cannot do this, they are expected to accept a time-out.

In group limit setting the therapist may need to stand up and physically block an

emotionally aggressive interaction between group members and focus first on just

stopping the interaction. A vocal tone which conveys warmth and genuineness is one

important medium for empathic confrontation, but so is a firm voice with increased

volume when limit setting is needed. Limit setting and empathic confrontation are used

in the group to insure that the inevitable conflict that arises leads to healing and growth

with therapist direction.

We refer to these maladaptive behaviors as “the elephant in the room”. Like a wild

elephant if it is ignored it may run rampant and disrupt or destroy everything. “Louder”

expression of needs by the Angry Protector mode or Overcompensating Coping modes

or the Angry or Impulsive Child modes require empathic confrontation and/or limit

setting from the therapist as in the examples of Jane, Ken and Jim. These modes,

particularly the Bully-Attack mode, are often too difficult for peers in group to

empathically confront. Limit setting must come from the therapists as it is unlikely to be
 ©2013, Farrell & Shaw

accepted from a fellow patient in groups with personality disorder patients. It can be

difficult for some patients to accept the therapists in the limited reparenting role. It is

even more difficult or impossible for them to accept peers.

Example: What happens when group therapists do not empathically confront

maladaptive and disruptive behavior?
In a group we supervised novice group therapists had great difficulty setting limits or

empathically confronting a male patient who spent a large percentage of the group’s

time in Self-aggrandizing mode behavior. Group members did not try to stop him and

the therapists’ attempts were not effective. The therapists were concerned about

offending him and were uncomfortable with the suggestions made in supervision. This

situation led to two of the group members dropping out, giving his monopolizing and

“running” the group as their reason. This dynamic did not change. Eventually all of the

group members dropped out prematurely except for the monopolizer. The entire group

was lost halfway through the planned course of treatment. The group members in a

debriefing session were angry with the therapists for not limiting this patient. They were

finally willing to express their negative feelings about him and the feeling that their

needs had not been met by the therapists. The conversation was productive and the

therapists ended it by asking if the members who had dropped-out would return. Their

answer was “no”. The absence of much needed empathic confrontation and limit setting

had gone on too long for them to trust that it would be any different if the group

resumed.

This is an extreme example, but we have seen some group members drop-out

for similar reasons in many groups. Empathic confrontation goes against social norms in

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 Empathic Confrontation in Group Schema Therapy

that it directly identifies a person’s behavior as maladaptive and problematic for them

and at times for the group. Adults give this right to police, judges, maybe their bosses

and hopefully come to give it to their therapists. As therapists we are at times called

upon to violate social norms in our therapy role. Doing this takes some practice,

confidence and being aware of one’s own schemas being activated – for example,

approval seeking, subjugation, defectiveness, failure. Empathic confrontation is an

intervention that can be particularly triggering and difficult for therapists. In the example

above, the therapists were significantly younger than the problematic patient, who was

closer to their parents’ age. That age disparity can trigger Surrender to approval seeking

or subjugation and prevent the therapist acting as a good parent to the patient. Such

schema activation and mode triggering for therapists can be more powerfully impacted

in groups where there are multiple patients who can remind us of others in our own lives

or histories. It is important to be aware of this when it is happening and as cotherapists

to be willing to point it out to the other therapist. Sometimes this is an opportunity for

some self-disclosure of one’s own reaction and at other times it will be important to find

a way to pull out of your Coping or even Vulnerable Child mode and access your own

Healthy Adult consciously. An example of the kind of self-disclosure that would be

appropriate and therapeutic for a group is the revelation that you are particularly

sensitive to a finger shaken in your face and that for a moment you were aware of your

Vulnerable Child. This could be followed by reaffirming the group’s groundrules

regarding this behavior. A self-disclosure that would not be appropriate to the group

would be that one of the patients so reminded you of your mother that you felt a lot of
 ©2013, Farrell & Shaw

animosity whenever interacting with her. The latter would be a topic for supervision, not

therapeutic self-disclosure.

Having the two therapists of GST is helpful for the combination of empathic

confrontation and limit setting. When both are both needed, one of the therapists can

take the empathic role and the other set limits. However, we think that it is important

that one therapist not always get the confrontation and limit setting role, but sometimes

be the one to provide empathy.

Example: A group member throws a chair

In the first session of a new group of Borderline personality disorder patients Karen

abruptly stood up and threw her chair toward the therapist sitting across the room from

her saying “this is bullshit. I’m leaving.” The therapist sitting next to her got up also, and

quickly put the chair back saying “it is not OK to throw things here – that breaks our

groundrules. It is not safe”. The other therapist said “please don’t leave; I don’t want to

lose my connection with you. You are an important part of this group.” Karen sat down

looking dumbfounded at the second response. Later in the session she said how much

that statement had impacted her and that it was the reason she felt able to stay. Her

original overcompensating response of throwing the chair and starting to leave was

discussed in terms of its childhood origins and the mistrust-abuse schema being

activated in a meeting with new people. The response of the second therapist provided

the necessary empathic response and the response of the first therapist was a

necessary limit to keep the group groundrules and safety. Both were important for the

individual patient and for the group. This sort of therapist intervention would be difficult

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without two therapists. The need for two in group schema therapy is elaborated in

Farrell & Shaw (2012)and we have preliminary evidence that leaving a BPD group with

one therapist may impact treatment effect sizes negatively Reiss et al., 2013.

Another example of a two therapist empathic confrontation combined with limit setting

follows.

Example Two Therapist Empathic confrontation of Bully-Attack Mode

A large, physically imposing male patient would sometimes sit up very big and tall (up to

his full six foot- seven inch height) and say “yes, I am in the Bully mode and I am

sending my knives out”. This statement was delivered with a scathingly angry look

directed very clearly at other patients. One of the therapists held her arms out with

hands stretched blocking some of Jim’s view saying “it is not okay here to send out

knives at others.” The other therapist was sitting next to Jim and patted his arm saying

“we know you get in Bully-Attack mode when you feel rejected and I know how much

pain you have experienced from rejections going back to childhood”. Jim “hmph’d”, but

turned away from the patients he had glared at and looked at the therapist next to him

instead, leaning a bit toward her. As the group went on the glares of Jim recurred and

the nearby therapist again patted his arm saying, “I know that you are feeling afraid. I

am right here with you”. Jim again stopped glaring and Ida patted his arm again at times

through the session. Therapist one made the general point for all that this was an

example of a coping style that developed for protection in childhood, but now kept

others away and left Jim feeling rejected. The group was able to discuss the incident

that had hurt Jim and the members involved explained that they had meant no harm

and they apologized for his hurt feelings. With two group therapists, therapist one could
 ©2013, Farrell & Shaw

set a limit, protect the group and later broaden the discussion to include other group

members experiences, while therapist two empathized with Jim’s pain, acknowledged

the origin of the maladaptive coping behavior and acted to meet some of his underlying

need for connection with the shoulder pats.

This is a good example of a gentle empathic confrontation combined with limit

setting. It also demonstrates the adaptation of empathic confrontation to the group

modality. The origin of the behavior must be explained to not just the target patient, but

also to the group and the correction behavior also includes the group. The empathic

confrontation of Jim also offered a vicarious learning experience for the rest of the group

and led to a productive discussion of their Maladaptive Coping modes. The empathic

confrontation in the example of Jim was met with a verbalization of “hmph”,

accompanied some acknowledgment of the limit set and some acceptance of the

understanding and empathy being offered. Jim did not disagree and he did “draw back

his knives“. Interventions like these by the therapist serve a number of purposes. They

set a needed limit to protect the group as a whole, let the patient know his/her feelings

will be accepted, but aggressive behavior will not be, and they provide words for some

of the feelings that underlie these maladaptive coping modes. Sometimes the therapist

stating the patient’s underlying need is enough to have the group respond with

compassion and understanding. This can be very effective in getting through the

Maladaptive Coping mode to reach the Vulnerable Child mode.

Group ST provides the opportunity for empathic confrontation from peers.

The empathic confrontations that group members give each other are one of the

therapeutic factors unique to Group ST that are thought to contribute to the

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effectiveness of this modality. They are part of the expansion of limited reparenting from

the dyad of individual ST to two “parents” and an entire “family” adding additional

interpersonal corrective emotional experiences. Empathic confrontations from group

members are sometimes more easily accepted than those coming from the “parent”

therapist. They can be perceived as less threatening and may not bring the risk of

therapeutic disconnections as intensely. At times the connection with a peer may be

stronger than that with the therapists. Therapists can facilitate peer empathic

confrontation, but cannot rely on them having the strength or skill to accomplish it.

When the group cannot empathically confront, the therapist “parent” must be the one to

take that role.

Example: Group Empathic Confrontation of Angry Protector Mode

Kris had a strong Detached Protector mode that at times took the form of a rather

passive-aggressive Angry Protector in group sessions. One session she sat in a

prominent position in the center of the room with headphones on writing a letter. As the

group began, no one commented on this obvious disconnecting behavior. Eventually

the therapist called her name a number of times, escalating in volume to get over her

headphones, and asked what she was doing. She replied in a rather hostile tone “just

listening to music – it helps me concentrate”. Joan pointed out that it took calling her

name three times to get her attention and that she was also writing a letter. She

questioned how much help Kris could get from the session if she continued with the

behavior. Kris responded with more excuses and escalating hostility. Fortunately, after

the therapist acknowledged Kris’s behavior group members got involved empathically.

One of them said “but we cannot reach you or know you if you keep cutting us off like
 ©2013, Farrell & Shaw

this”. Another said, “We want to know you. We have some of the problems you do also

and can work with you to get better.” Kris stopped writing, did not put the headphones

back on and told the group a little about a recent experience of rejection from her family.

Her response to the group was much more positive than to the therapist.

The group can be effective in empathically confronting the Avoidant Coping modes and

Compliant Surrender. The Overcompensating Coping modes, particularly the Bully-

Attack mode, are more difficult for peers to empathically confront (see the examples of

Karen and Jim described previously).

Using personal information in group when empathically confronting a

group member in a Maladaptive Coping mode. Sometimes the group does not have

adequate information to accomplish Step three. At those times the therapists must take

the lead and obtain permission to share personal information with the group.

Example: Therapist Empathic Confrontation of Angry Protector Mode in a group

session.

Ken said he was in the Healthy Adult mode, but sat with arms crossed across his chest

and a blank expression on his face. When peers gave him feedback that they were

worried about him and his lack of participation, he stated “I don’t need any of you, we

have nothing in common”. Peers continued expressions of concern seemed to bounce

off Ken with no effect. Since group members’ efforts at empathic confrontation were not

effective, the therapist had to step in. Ida asked him if he realized that he was pushing

everyone away with his disparaging comments. He said “yes”. She then asked if this

pattern of pushing others away was common and worked for him. Ken again answered

“yes”. Ida then became more confrontational (but still empathic as she acknowledged

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 Empathic Confrontation in Group Schema Therapy

the origin of this protective behavior) by referring to information about him that the group

had: “so pushing everyone away back home, having no people in your life and feeling

empty had nothing to do with the three times that you swallowed antifreeze to kill

yourself”. With this intervention he responded almost tearfully, “Yes, my family does not

care about me, but the people here don’t care about me either.” He then told us about

hurt feelings from a disagreement with the same group members who were now

expressing concern about him. He had risked becoming close to them and now felt

rejected. His expression of feeling hurt (vulnerability) allowed them to discuss the

disagreement, resolve it and reaffirm their caring feelings for each other.

One caveat to this approach is that the group therapist should only use personal

information that a patient has shared with the group unless explicit permission is

obtained. In the above example the information had been shared previously. Many

occasions arise in group where a piece of personal information that has not been

shared with everyone is the biographical context of the maladaptive behavior that the

therapist wants to empathically confront. The context may also be important for the

group to understand and empathize with a mode reaction. In that situation you can ask

a patient if it is alright to share something with the group by vaguely referring to the

information in a manner the patient will understand but does not reveal much to the

group. For example, “John, would you be willing to tell the group about the experience

you had that relates to what we are talking about? With a patient you think might be

reluctant to share this himself or will not know exactly what you are referring to you

could say, “John, would you tell the group, or would you like me to tell them about your

related experience?” We rarely have patients say “no“, even though it is clear that they
 ©2013, Farrell & Shaw

sometimes have little idea what experience of theirs we are referring to. Their

willingness to go along with what we suggest indicates that they trust us to have their

best interest at heart. It may also be that we intuitively do not try such interventions

unless we think there is enough trust.

Example: when the group needs more information

It is particularly important to ask the patient to share additional information if their

unexplained reaction is affecting the group negatively. In the session following an

exercise in which patients acknowledge each other’s strengths when we asked the

patients to return to that experience in imagery one patient, Annie, had a negative

reaction. The group had been particularly positive during the exercise, which was led by

Annie, a patient who is often in a leadership role. When Joan asked about the change

Annie declared, “It was all fake, you guys don’t know me”. She went on to question

many other things about the genuineness and value of the group. Joan knew that Annie

had just heard that her alcoholic father would not be visiting as promised for her 18th

birthday. They had reunited recently and she had discussed her love for him and hope

about this visit in a recent group session. In response to Annie’s declaration, the rest of

the patients went into Detached Protector or overt anxiety in the case of a patient with

comorbid Avoidant Personality Disorder. Joan saw this as an occasion for empathic

confrontation along with a request to share information. “Annie, I think something else is

going on here related to the news your received this morning. May I tell the group briefly

what happened?” Annie said “I don’t care”. After Joan told them, there was some

nodding from other patients and the tension in the room decreased. Annie went on to

first vent her Anger about her father in an Angry Child manner, then her Vulnerable

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Child hurt feelings about her father’s repeated abandonment and the repercussions of

this for her as an adolescent. This was information that she had not previously shared

with the group or therapists. Annie’s sharing stimulated the rest of the group to discuss

similar Vulnerable Child feelings related to abandonment themes with parents. The

group was able to close having moved back to a place of cohesiveness with everyone

understanding that Annie’s rejection of them had been the Angry Protector mode in

response to her father, not them.

When Empathic Confrontation is not effective

In group ST we have a rule of thumb that each of us tries twice with an empathic

confrontation before passing that task to the other therapist, who also tries twice. When

neither of us succeeds, we may need to move to limit setting as we did in the following

example. Part of limit setting can be asking that a patient return the respect that they

are given.

Example: A patient in group session one resists empathic confrontation efforts

In session one we usually use the web connection exercise. On this occasion

one of the patients, Sue, would not take the yarn when it was thrown to her. Ida

employed our usual response, which is to wrap the yarn around their chair leg saying

that we do not want to lose our connection with her. Sue’s response was “well this yarn

doesn’t mean anything”. The second time the yarn came to her she again refused. Ida

passed the yarn over to the woman next to Sue while Sue complained about it crossing

over her. As the session continued Sue made a few negative comments directed at

other members that Joan had to limit by reminding her that it violated our groundrules. A

few of the members began to express annoyance with Sue’s attitude and one began to
 ©2013, Farrell & Shaw

look fearful when Sue spoke. Ida used our “exaggerate empathy” intervention when Sue

said she felt no connection, saying “of course you don’t! You have never had a safe

connection, why would you just forget all of that and trust us.” Sue said “well, I don’t”.

This was Ida’s last effort for that session. We end the web exercise by giving each

patient a glass bead as a transitional object and to represent their membership in the

group. Sue refused the bead Joan attempted to give her. Joan said “We have respected

your decisions not to accept the yarn connection and to express your opinions about

what we were doing here. This time I would like you to respect me and accept what I am

giving you”. Sue responded, “Are you telling me that I have to take it?” Joan answered

“No, I am asking you to take it”. Sue said “why should I”. Joan said, “Well I know from

meeting with you that like all of the other group members you don’t have the

connections that you want in your life. I am concerned that if you keep rejecting the

connections we are offering you that situation will not change.” Sue responded, “OK I

will take it, but I still think it is silly”. Joan answered, “That is great – all I am asking you

to do is take the bead not to feel something about it other than what you do.” This was

an important intervention for Sue in terms of her position in the group. She was rapidly

drawing a lot of negative reactions in session one and could easily become a scapegoat

or a negative leader. Neither of these roles would have been therapeutic for her. If Sue

had not accepted the bead when she did, Joan would have said –“OK, I will just keep it

for you in case you want it sometime in the future.” She would not have kept pushing it.

Both therapists made a number of empathic confrontation efforts in this situation

because the issue of establishing connection, or at least having some openness to the

idea of it, is so important in Group Schema therapy.

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 Empathic Confrontation in Group Schema Therapy

It is not always possible to get through the Angry Protector mode even with

accurate empathic confrontation. When efforts to reach out seem to fall on deaf ears, it

is good to keep in mind that the patient’s Vulnerable Child behind this angry wall is

listening, watching, and longing for connection and that the Angry Protector is assessing

for safety. A warm and compassionate stance and tone is still being registered and

having an impact. Later in the session the patient’s mode may be moved by the group’s

work, or he/she may be able to stay and let the work of the group go on around him/her

until he/she is able to join in or the session ends. Since the needs underlying the

Maladaptive Coping modes are those of the Vulnerable Child mode, it is important to

remain flexible and creative in finding ways to meet the need. For example, the

therapist might give the patient a pillow to hold or a shawl to wrap up in with the

acknowledgment that it is okay to take care of him or herself and that they are welcome

to join the group again more actively as they are able to. Our invitation to add protection

always includes the rest of the group as they may be reacting to the Angry Protector

presentation. Sometimes we ask the patient in Angry Protector (same thing with Bully

Attack mode) to go into a safety bubble, (see Reiss, Farrell & Shaw, 2013 for bubble

exercise and handouts) while the group goes on. We do this in the hope that some

added external safety may allow them to drop their protective mode some. Other

patients can move their physical proximity, or one of the therapists will sit next to or in

front of patients who feel frightened. We always try to remember that, anything we do

with one member in a group, demonstrates to the rest what will happen if they have a

similar presentation or experience. The therapists as good parents want to demonstrate

that everyone can be helped to feel safe and that we will keep the group safe.
 ©2013, Farrell & Shaw

A patient in the Bully-Attack mode needs empathic confrontation plus firm limits

on behavior that hurts the group. Verbal attacks cannot be allowed and if a patient

cannot contain such expressions, as previously discussed, he/she may need to be

asked to leave the group temporarily. Safety and reinforcement concerns often must be

balanced by the therapist in making a decision about whether to accompany the patient

taking a time-out at least briefly. We rarely leave the group and if we do it is for not more

than 5 minutes. When the therapist returns, the group must be briefly informed, within

the bounds of confidentiality, about what happened. This is another situation where the

therapist needs to get the patient’s permission regarding what private information is

acceptable to be shared with the group. When the patient returns, he/she is expected to

wait for a break in the discussion and then acknowledge what has happened. If he/she

is no longer in Bully Attack mode, the underlying Vulnerable Child issue can be

acknowledged and responsibility taken for any residual negative effects on other

members (e.g. a sincere apology). Experiences like these are important emotional

learning opportunities – i.e., that vulnerability is responded to positively and not

punished and that the Vulnerable Child does not need the Bully-Attack mode to protect

them in an unhealthy way in the group. Sometimes a therapist sitting by a patient in the

Bully Attack mode can gently and empathically confront him/her by referring to the

feelings underneath the mode (e.g., fear or hurt) and remind the group as a whole of the

protective function of this mode, its need for limits and our willingness and ability to

provide them.

On rare occasions even firm empathic confrontation and limit setting fail. When this

occurs therapists, like good parents must sometimes do, may need to get help to

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 Empathic Confrontation in Group Schema Therapy

maintain safety. In our inpatient borderline personality disorder groups, as a last resort,

we will get nursing staff help to physically remove a patient who will not stop a verbal or

physical attack and does not respond to empathic confrontation or limits from the

therapists. We have not had this occur in an outpatient setting, but if it did, we would

seek help from other clinical staff and security if necessary. We will take whatever

action is necessary to protect the group family with its “vulnerable children”. Patients

who leave the group temporarily due to behavioral transgressions are allowed to come

back and make peace with the group including a recommitment to the ground-rules.

They are expected to have a plan to prevent a recurrence of the unacceptable behavior.

It is reassuring to group members to see that behaviors that hurt others are limited by

the therapists and, at the same time, that the person is still valued, not labeled “bad”

and that the group does not give up on them or kick them out. For some patients, it is an

example of how “good parents” would have protected them from bullies in childhood.

This is one more emotional learning experience provided by the group due to its family-

like function.

These examples demonstrate the efficacy of having two therapists to maintain safety

and effectively manage the multiple modes and needs of patients in groups. Taking

whatever action is needed to maintain safety and the group’s boundaries is an important

therapist behavior as it demonstrates that the therapists will do what they said they

would, and that they are capable of keeping the group safe. It is important to follow all of

the steps of empathic confrontation to completion. The conclusion of a successful

empathic confrontation in group requires that:

 ©2013, Farrell & Shaw

1. the Coping Mode and maladaptive behavior has been pointed out to the individual

and the group in an empathic manner,

2. the origin of the behavior has been identified, and the pain or fear empathized with

3. it is clear that this old behavior does not get the patient’s current need met,

4. the patient has made the decision that he/she wants to change their Coping mode

behavior to one that will be effective

5. a correction has been supplied that will meet the need

6. the steps of that correction have been identified and possibly practiced in the group.

Understanding the relationship between maladaptive behavior and Coping modes and

the biographical origins of the modes are what allows a group to tolerate the inevitable

times with when these behaviors occur in groups with patients with personality

disorders. The view taken in empathic confrontation facilitates group cohesiveness,

which leads to group members feeling acceptance and belonging. It gives them a way

to understand their maladaptive coping behavior and make the decision to try new

behaviors that will more effectively meet their needs. As this chapter and the book

demonstrate, empathic confrontation is an essential intervention of Schema Therapy

that all schema therapists must master. This chapter describes the aspects of Group

ST that make empathic confrontation more complex and challenging and the

adaptations needed to implement it successfully nonetheless. It also describes the here

and now experiential opportunities and corrective emotional experiences that Group ST

offers that can augment empathic confrontation and add to its effectiveness when they

are utilized.

Do not distribute without written permission.

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