INSPIRE 2022 FEATURED KEYNOTE PRESENTATION

The Art of Empathic Confrontation: Fortifying the Therapy Relationship 

by Wendy Behary

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When postured in a sturdy (healthy adult mode we are better able to effectively address complex issues and confront the patient who may be unrelentingly avoidant of emotion-focused work in treatment, or to set limits with a patient who has escalated into an angry, highly critical, or demanding/entitled mode.  

Anxious patients may utilize distraction to avoid engaging vulnerability—fearful of  emotional experiences, consequential rejection or loss of control—through the use of content-loaded, detailed storytelling or they may report an inability to recall emotional experiences.  Other clients (especially narcissistic types) may avoid painful emotional material for fear of exposing shame and insecurity. They can become supremely intellectual, defiantly detached, and may even become critical when asked to make a commitment to the therapy relationship, i.e., respectfulness, timeliness, payment, and participation. 

In order to secure the therapy relationship for healing and adaptive change, we begin with a stance of curiosity and discovery, imagining ourselves stepping into the patient’s skin-felt experience; an attempt to resonate with their emotional reactions and behaviors vis-à-vis their personal narratives, early life experiences, unmet emotional needs, the onset of the activation of early maladaptive schemas, and prevailing conditions that continue to trigger schemas and modes.     

This collaborative sense making of the client’s experiences and habituated maladaptive coping styles and modes, as well as the moment-to-moment events in the therapy relationship, readies us to artfully apply the strategy of empathic confrontation.  The use of an empathic prelude when initiating a confrontation can be very effective in calling the patient’s attention toward you as they start to drift into defensive, detached, or interruptive counter-reactions.  

When we start with genuine empathic statements like: “Of course you’re upset about...” or “I know how much you value… “ or “I understand this is a difficult thing to hear… must be especially hard given what you learned from your father…” or “I know you didn't mean to be hurtful...” we have a greater chance to inspire, in the patient, a sense of feeling “known”, “gotten”, “seen”, “understood”, and a greater chance of being heard by us as we follow it with a needs-based confrontation.   

The opportunity for cultivating a heightened awareness and for reducing the intensity of schemas and modes appear to be the essence of a needs-based confrontation, one that follows an empathic prelude; one specifically designed to target the unmet needs of the patient’s vulnerable child, by confronting the presenting mode.  The empathic prelude can dilute and evacuate the intensity of defensive reactions related to schema activation, while the use of the term “but” targets the presenting mode and the patient’s outstanding problem –  the unacceptable and maladaptive reactions, the impact of offensive behaviors on others, the obstacles we are facing together in the healing process. The use of the term “but” also aims to predict the known trajectory of self-defeating life themes like, “You are so competent, Joe, and your ideas can be an asset to your team. It’s not your fault that you rush in with your one-sided decisions, it’s what you learned you must do—to compete, control, and prove yourself worthy of status and recognition.  But, when you just take over the project without discussion or collaboration, your good intentions and capacities become overshadowed by that nagging old need to control and to perform and all they see is a bully.”

Empathic confrontation allows for the patient to receive benefit-of-the-doubt while asking them to take stock of their behaviors and to appreciate the impact on others as well as themselves. With narcissistic patients – this can be quite effective in promoting accountability, especially when setting a limit where the patient’s insults, criticisms, or anger cross a line and present a threat: “I know you may not intend to be threatening, but right now I’m feeling uncomfortable and this is unacceptable. I have rights and you have rights. And this feels like a violation of my right to feel safe and respected.”

The empathic alliance with the patient’s underlying suffering and intended message can fortify the therapy relationship and promote a greater sense of trust and secure the connection while addressing the most challenging obstacles in treatment, and for weakening self-defeating schema content and coping modes.

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