Enhancing Empathy in Emotion-Focused Group Therapy for Adolescents with Autism Spectrum Disorder: A Case Conceptualization Model for Interpersonal Rupture and Repair

Emotion-Focused Group Therapy for clients with ASD (see Robinson and Elliott 2017) is a small group format that addresses the core aspects of cognitive-affective empathy to enhance these skills in both intra-and interpersonal understanding. A main therapeutic tasks is repairing emotional hurt resulting from continued relational injuries through interpersonal conflict encounters. Autistic adolescents are vulnerable to trauma-related experiences due to a diminished sense of self and lack of self-agency within interpersonal engagement (Robinson 2018). To guide therapist focus in reducing trauma-related difficulties, a rational-empirical model is proposed (see Fig. 1). This process model is constructed from a grounded theory analysis of interviews, with 43 parents talking about their experiences of living with autistic adolescents coping difficulties during adolescence.

The focus in-session and across treatment is to facilitate exploration of self, share painful experiences and work through negative interaction cycles as a result of misempathy encounters. The therapists’ response to intra-and interpersonal relational difficulties are twofold: first in the moment, by scaffolding relational tasks; and, second, by Interpersonal Process Recall (IPR). Researchers have used the IPR method, as a video-assisted interview to access conscious yet unspoken patient experiences while engaged in professional services (Jones et al. 2016). Here, IPR was developed to support therapeutic tasks to deepen experiential processing of self and other within EFGT for clients with ASD.

The model begins (see top of Fig. 1) with the therapist creating a safe space by offering clients an empathic relationship. The therapist works moment to moment on both cognitive and affective empathy at two levels, by setting up intrapersonal (Self) and interpersonal (Other) tasks in session and to select edited moments for IPR recall to play in the subsequent session (see Fig. 1 moving to the next level to guide, deepen and develop). These moment-to-moment in-session tasks and edited moments used across treatment are aimed at developing a stronger sense of self with enhanced self-agency within interpersonal encounters, whilst building cognitive-affective empathy skills.

By guiding self-focus on a continuum of affective empathy, the therapist aims to move clients from an absent emotional experience to one that is internally located and encoded, which serves to strengthen the client’s sense of emotional processing. By guiding other-focus on a continuum of affective empathy, the therapist aims to move clients from lacking empathic attunement to being mobilised into action towards the emotion of other, which serves to heighten the client’s empathic attunement, allowing them to respond to the emotional needs of other. By guiding self-focus on a continuum of cognitive empathy, the therapist aims to move clients from an absence of sense of self towards a fluid and complex self, which serves to strengthen the client’s self-conception. By guiding other-focus on a continuum of cognitive empathy, the therapist aims to move clients from a position of projecting own thoughts onto others towards consideration of metacognitive thinking, which serves to heightening the client’s sense of appreciating the minds of others.

The model moves on to the final phase, which is the reduction of internalized reactive states (intrapersonal) leading to reduction in self-harm and depression, also to the reduction of externalized reactive states (interpersonal), leading to the reduction in anxiety and the need to control others. This strengthening of both the affective and cognitive sense of self and heightened understanding of the emotional needs and intentions of others reduces relational ruptures.

The following case conceptualization is a rational-empirical model of working through relational rupture and repair for ASD (see Fig. 2). It presents a clinical strategy consisting of several aspects within three phases leading to emotion transformation. During the first phase the therapist uses this framework to inform the dynamics of the client’s distress (see phase 1 Fig. 2) using this to identify indicators of attachment style and negative interaction patterns. Following this, the therapist supports working through primary maladaptive emotions, whilst holding fragile interpersonal encounters and relational rupture. For the client with ASD this can involve a lack of awareness of self-agency and subsequent impact within the interpersonal dynamic. Difficulties with intrapersonal understanding, with the projection of one’s own thinking onto other group members, can evoke emotional misunderstandings within group process, resulting in misempathy ruptures.

During the second phase the therapist uses these unprocessed misempathy ruptures as a therapeutic task to facilitate evocation and activation of emotions associated with the event. Once emotion activation occurs the therapist can help clients deepen their experience through engaging in experiential processing of these emotions. This deepening process can trigger intrapersonal challenges to self-symbolization as well as unregulated emotional collapse. The therapist can use these to lead the client towards focusing on the underlying core painful emotions. Once this core pain has been reached clients articulate the associated unmet need. During the third phase the therapist can aid emotion transformation by facilitating clients emerging adaptive intrapersonal emotions (see phase 3 Fig. 2) and interpersonal repair. Finally, these emerging adaptive emotions facilitate mentalization of self (theory of own mind) and other (theory of your mind) that strengthens intra and interpersonal agency. This case conceptualization model can be applied by therapists who encounter interpersonal ruptures during EFGT with clients with ASD.

This case conceptualization is a task analysis of EFGT-AS carried out by the author over 11 weeks. The group consisted of three adolescents (mean age = 14.0): two females (14 and 15 years) and one male (13 years) in secondary mainstream education. The adolescents were formally diagnosed with Autism Spectrum Disorder by a psychiatrist or clinical psychologist using Diagnostic and Statistical Manual-IV (DSM-IV) criteria (APA 2000). To illustrate markers extracts have been drawn from the participants across treatment. Drawn from Natalie (14 years), one of the female participants, and her experiential changes across therapy, with specific focus on her encounters with the other female, Jane (15 years). Natalie’s scores using the Client Emotional Processing Scale for Autism Spectrum (CEPS-AS; Robinson and Elliott 2016) for emotion processing, self-reflection, empathy and mental representation changed from low level processing at the beginning to moderate to high level processing at the end of treatment.

The following case conceptualization of relational rupture and repair shows how clients with ASD move through three phases (see Fig. 2) of emotion transformation. In EFGT-AS the first session involves engagement between group members for the first time. At this stage, clients begin to explore their own expectations for group therapy.

During the first session, the therapist is listening to hear if clients engage in negative self-treatment, current triggers and behavioural avoidance (Timulak and Pascual-Leone 2014). Often autistic people have experienced negative interpersonal encounters, resulting in negative self-conceptions and interpersonal fears. School‐aged youth with ASD were found to be at greater risk of school victimization than their TD peers (Maïano et al. 2016). The therapist is listening for such markers, as interpersonal encounters often become internalized as negative self-treatment. Autistic adults do engage in negative self-treatment, present a fragile sense of self and engage in self-critic dialogue (Robinson 2018). Similarly, autistic adolescents were found to engage in negative self-treatment, expressing self-blame for failed social interactions and fear of rejection based on their negative sense of self. The therapist is listening for examples of clients engaged in negative self-treatment dialogue, such as not being able to speak to people because of having a strong sense of being “weird”.

Initial stages of EFGT-AS clients begin by getting to know other group members. The therapist is listening to hear if clients share previous painful experiences that may indicate distanced trauma-related experiences of peer victimization. Often autistic people do experience peer victimization (Sreckovic et al. 2014), but may be unaware that they have unprocessed trauma-related experiences (Robinson 2018). The therapist is listening for examples of client awareness of such experiences which can be used to set up EFT intra-and interpersonal exploration and deepening tasks.

The initial session can indicate attachment style (see Fig. 2, phase 1). Utilising attachment theory as a lens to view presenting behaviours within the group context, each adolescent displays, to varying degrees, fearful-avoidant attachment style. Demonstrated by clients talking of painful interpersonal encounters from both childhood experiences and current social interactions with others. Fearful-avoidant attachment manifest through client dialogue with examples of restricting their behaviours or patterns of behavioural avoidance where they may potentially encounter people. This behavioural avoidance pattern is accompanied with dialogue that expresses rigidly held views of people through rejecting or protective anger. The therapist is listening for discourse that indicates client avoidance of social situations. These may stem from limits of communication, such as ‘not being able to talk to people’ preventing access to functional requirements, for example ‘I can’t go out to the hairdressers’. Or constricting life opportunities as a result of fearful restricted thinking and behaviours, such as ‘I can’t go out the house in case I see pupils outside of the school’. EFGT-AS supports fearful-avoidant attachment style by setting up therapeutic tasks to work through self–other cognitive- affective empathy.

Threats and triggers are constant for autistic adolescents who are struggling for social acceptance, but as a consequence of social-emotional processing differences, they encounter interpersonal confusion, leading to interpersonal conflict that ultimately results in social withdrawal or social exclusion. Further, due to limited emotional intrapersonal processing and interpersonal understanding autistic adolescents experience negative interaction cycles that result in the development of a fragile sense of self and lack of self-agency within interpersonal encounters (Robinson 2018). This repeated cycle leads to secondary emotions through a global sense of hopelessness, helplessness and unelaborated loneliness (see Fig. 2, phase 1).

Having friends has been found to be important to autistic females although socialisation is difficult and at times challenging (Vine Foggo and Webster 2017). Painful historical triggers are often interpersonal encounters that demonstrate repeated experiences of peer victimisation, which may include social-emotional injuries that are often a result of negative interaction cycles. In EFGT-AS, the therapist is listening for dialogue that illustrates a client’s desire for connection, such as ‘I’d like a best friend. I have friends, but not a best friend’; but listening for examples of rejection, such as ‘I had a friend who stopped talking to me for no reason after staying at another girls house’. The therapist is listening for shared experiences of social rejection and a fragile, negative sense of self, such as ‘oh yeah, normal people make you feel like that, like an outsider’.

EFT is marker guided and process directive. In EFGT-AS, the therapist identifies emotion markers in order to afford opportunities for affective intra-and interpersonal interventions. These emotion markers can be observed and changes can be tracked across an emotional processing continuum of cognitive–affective empathy (Robinson and Elliott 2016). In accordance with this skills continuum the therapist can identify low levels of emotional processing in four specific cognitive-affective domains. First, in affective empathy, the therapist is attentive to dialogue and or behaviours that indicates an absence of externalised and/or unregulated emotion experience as well as occurrences that demonstrate a lack of empathic attunement. Second, in cognitive empathy, the therapist is attentive to dialogue and or behaviours that indicate an absence of self or self-experienced through an autism-deficit lens, as well as occurrences that demonstrate projection of own thinking onto other group members. The therapist identifies a marker, such as difficulty in recalling emotions (self) or occurrences of when a client misses reading someone else’s emotion (other). This dialogue and or behaviours can act as a marker for further work on emotional processing.

Similar to EFT for couples the therapist listens for negative cycles and uses affect as the central force organizing couple’s interactions (EFT-C Woldarsky Meneses 2017). In EFGT-AS, the therapist listens to hear negative interaction cycles, which can be recalled experiences with peers, but these can also manifest between group members within therapy sessions. The therapist is listening to find and change negative interaction cycles, and uses affect as a central organizing force within cognitive-affective empathy. The therapist, through video analysis, identifies markers that signal difficulties arising from negative interaction cycles in-session (i.e., misempathy ruptures).

Once the therapist identifies such a marker, they can use it to set up therapeutic work across treatment. Hochhauser et al. (2015) found autistic adolescents possess fewer negotiation strategies when dealing with interpersonal conflict than their TD peers. Further, they state that autistic adolescents employ fewer interpersonal skills such as self-confidence, cooperation, communication, and compromise which leads to social avoidance. In EFGT-AS misempathy can occur in-session between group members resulting in interpersonal ruptures which can be known or unknown to group members. This is a key affect opportunity afforded to the therapist and one which the therapist is looking for in video material to edit and embed within an IPR segment.

IPR segments contains multiple markers for multiple members. The main marker being interactions that contain low levels of mentalization representation (theory of own mind projections), that lead to an interpersonal rupture (misempathy) between group members (see Fig. 2, phase 1). The therapist is listening for client dialogue that indicates low levels of self-reflection, such as damaged self-conception (negative self-treatment), an example ‘the way I’m acting now is not how normal people act’. This can be met with demonstrations of gentle reassurance, which may miss empathic attunement or misempathy of another group members experience, whilst projecting own thoughts onto the other, such as ‘but you are normal, just because you’re different doesn’t mean you’re not normal’. This continued lack of empathic attunement or misempathy between group members results in a negative interaction cycle which leads to an interpersonal rupture.

The case conceptualization moves to the next phase (Fig. 2, phase 2) where the therapist supports fragile interpersonal relations between group members. This is key to the prevention of client drop-out. Further, it aims to undo previous behaviour patterns of negative interaction cycles from repeated interpersonal ruptures and conflict encounters followed by social withdrawal. Cognitive empathy has been found to be impaired in autistic people but within the average range on affective empathy (Rueda et al. 2015). In EFGT-AS the therapy session is analysed to select moments of cognitive-affective empathy to set up mentalization of self-and-other tasks, utilizing IPR. In session, the therapist plays selected moments of misempathy, interpersonal ruptures and/or negative self-treatment and uses these to deepen the client’s self-experience through an empathic relational stance and for setting up intra-and interpersonal therapeutic work. The IPR edited segment has multiple markers embedded within it, such as a client engaging in negative self-treatment dialogue, a misempathy encounter or rupture between group members. The therapist plays the IPR clip and offers this to the group to respond to in the recall session.

During phase 2, the therapist uses IPR to guide the self-phase of the relational rupture task and invites clients to recall and respond to how they feel. In session, the therapist is process-guiding self-other awareness through cognitive-affective empathy and in IPR recall, a client may not possess the negotiation skills for relational repair and withdraw into self and shutdown giving no response. Following the IPR clip, a client may face a change in self-scheme (mentalization of self). The therapist is listening for such shifts in mental representation, such as ‘I don’t think I’m so strange now, because people like me and I thought I don’t really like people because they’ve always been mean to me because I’ve been weird’. These concrete experiences that occur outside the session can challenge self-conception and seeing self (in IPR) engaged in negative self-treatment dialogue can trigger reflection towards changing self-conception and emotional interpersonal understanding.

In recall, the client may miss the affective-empathy component within the unspoken relational rupture. The therapist is listening for these misses in affective-empathy in client responses which can be seen in illustrations that indicate focus on self as opposed to self-agency within the interpersonal exchange. Client responses may be evoked when viewing own dialogue in the IPR-clip which contrasts to their own experiences of engaging with others. This can trigger meta-cognitive challenges to their self-conception, which lead to cognitive appraisal of self, based upon the previous concrete experiences of interpersonal interactions with others. Although a client may retain their own sense of self, reappraisal can occur based upon interpersonal encounters through the process of IPR recall. The client’s mentalization of self remains unchanged, but there may be a shift in their sense and acceptance of their ‘difference’.

The next phase of relational repair uses IPR as a process guide in the other phase of the misempathy task. In recall, the therapist is listening for illustrations of the client engaged in cognitive-empathy processing in their emerging mentalization of other. This is followed by the client’s emerging desire for interpersonal connection. This can been observed when the client employs basic intersubjectivity skills, such as looking, smiling and inviting communicative interactions. If these tentative intersubjective approaches made by the client are not met with the desired interpersonal connection with a further misempathy exchange this can lead to emotion dysregulation.

From an EFT perspective, once people know what they feel, they reconnect to their needs and become motivated to meet these needs (Dillon et al. 2018). A fundamental aspect of this process is that emotional awareness involves feeling the feeling, not talking about it. It is essential for clients to experience the feeling, which can often be a challenge for autistic people in therapy. In EFGT-AS, an important component for emotion transformation is to capture visual moments of misempathy between group members so they can be offered as a process guide to set up self-other mentalization tasks. Process guiding segments appear important in activating change, both emotional change in self and empathic relating. This case conceptualization presents an emerging mentalization of other through realisation of self-agency within the interpersonal rupture. The therapist is listening for client metacognitive discourse that reflects this realisation, such as ‘I wonder if I scare her’. This expanding mentalization of other by the client is reflected by a growing insight into interpersonal self-agency leading to emotion dysregulation.

Clients are able to achieve partial resolution when they symbolize their insight and reorient their thinking to reflect understanding of the mental differentiation between self and other. Individuals with ASD have been found to have reduced cognitive empathy, yet intact affective empathy, when compared to typically developing (TD) individuals (Senland and Higgins-D’Alessandro 2016). An important step in relational repair is cognitive insight into self-agency (see Fig. 2, ending stage of phase 2). Mazza et al. (2014) found that autistic adolescents showed difficulty in cognitive empathy, whereas with affective empathy they were able to emphasize with the emotional experience of other people when they express emotions with positive valence, but displayed deficits for the negative emotional valence. This study found that clients do miss displays of negative affective empathy, where their own interpersonal engagement had a negative impact on other. The therapist is listening for client dialogue that reflects an awareness of their own interpersonal agency having a negative impact on other, such as ‘I’m not happy because I am probably scaring or worrying her’. To date, there is a dearth of research into emotional responses to self in ASD. This study found affective empathic responses to other which occur through insights into understanding that they may have caused pain to the other can lead to emotion dysregulation. The client may have an emerging realization of knowing I hurt you. This mentalization of self-agency can lead to an emotion dysregulation (collapse), which is a sadness for self (see Fig. 2, towards ending stage of phase 2).

Moving towards emotion transformation, first the client reaches their core emotional pain (see Fig. 2, end of phase 2). Maddox and White (2015) found that 50% of adults with ASD met diagnostic criteria for Social Anxiety Disorder (SAD). This co-occurrence of ASD and SAD is characterised by autistic adults being aware of their social difficulties and experience impairing social anxiety. This study found that as adolescents become aware of their own social difficulties this increased understanding is a step towards alleviating their social anxiety. Here, once an adolescent discovers and is able to express their desire for connection with people, this can reveal their insight into their own lack of understanding of how to be with people, thus revealing their core pain, fear. Within EFGT-AS, clients may display fearful-avoidant attachment style this can be played out in-session and revealed within a safe empathically nurturing context. This primary maladaptive emotion of shame stems from their primary adaptive emotion, which is hurt based on rejection and peer victimization encountered repeatedly throughout their development. The therapist is listening for client dialogue that demonstrates this core pain of fear, such as ‘I want to know how to be with people; I want to be able to talk without getting it wrong. I don’t know what I’m doing and that, that makes me scared to be around them’.

In EFGT-AS, IPR-Clips are played as processing proposal. The therapist is looking to see if clients have an immediate emotional response to seeing self within the interpersonal encounter. From an EFT perspective, the most important way of dealing with emotion in therapy involves the transformation of emotion by emotion (Dillon et al. 2018). Towards the end of phase 2, the client moves towards discovering their core emotion, which is fear and sadness for self. Moving into phase 3 (see Fig. 2, phase 3) the emotion transformation for the case conceptualization of relational rupture and repair begins. The emotion evoked is explored and the client is able to express their new adaptive anger emotion. This adaptive anger is triggered by their own realisation of their own self-agency within the interpersonal encounter. From this emerging realisation, the client discovers that, as the ‘aggressor’, they are the one who has caused pain and hurt to the other. This new insight comes from an awareness that they can hurt people and the emotion that comes is one of anger at self. The therapist is listening for client dialogue that shows this self-agency within the interpersonal exchange and the affective component, such as ‘I know now how that might be hurtful and now I’m angry with myself with that bit’. In EFT, the therapist expresses the client’s emotion. In EFGT-AS validating emotional experience acts to support autistic adolescents with emotion regulation, such as, Therapist: Its anger at yourself you feel…

Once the core pain is reached and the client feels the feeling, this is followed by meaning creation, which is linked to enhancing awareness of interpersonal skills. Autistic adolescents possess decreased use of negotiation strategies associated with their difficulty in attributing mental states to others, impacting upon their ability to deal with social conflicts and create positive interactions and rewarding relationships (Hochhauser et al. 2015). Towards the ending phase of task resolution for relational rupture and repair the therapist facilitates clients to cognitively create new meaning from experiencing their core pain. The therapist is listening for change moments that occur at both the cognitive and affective empathy level, where the client expresses their core pain, such as ‘It’s difficult to interact with her, she doesn’t talk much, I don’t know what I’m doing with her’. Therefore, changing how one views a situation, enhancing flexibility in perceptions of mental states of others or talking about the meaning of an emotional episode often helps people experience new feelings. The therapist is listening to changes that show insights, such as ‘It’s not just me, there are reasons why you can’t talk to people, it’s your anxiety’.

In EFT, the client utilizes the therapy relationship to generate new emotion. In individual therapy, this is with the therapist. In EFGT-AS, this is the therapy relationship and clients can also utilize group members to generate new emotion. In this final phase, a new emotion is evoked in response to new interactions. In EFT, asking clients when they are in their maladaptive state what they need to resolve their pain provides an opportunity for a corrective experience of emotion. The therapist guides the client to bring a need or a goal to a conscious self-organizing system that opens a problem space to search for a solution. At the affective level, it conjures up a feeling of what it is like to reach the goal, but in EFGT-AS this emotion can be experienced interpersonally between group members. Therefore, a key way of changing an emotion is to have a new lived experience that changes an old feeling. The final step in relational repair is providing opportunities for compassion responses offered by the others which acts to self-soothe hurt.

The process of emotion transformation as a therapeutic intervention is threefold. First, the therapist helps clients to make sense of what their emotion is telling them, second to identify the goal, need or concern that the emotion is organizing them to attain, and third to mobilize the action tendency and to use these to improve coping. In EFGT-AS the process of phase 1 involves discovering attachment style and identifying negative interaction cycles that play out across treatment, initiated by moments of misempathy between group members. The process of emotion transformation begins in phase 2 by discovering core pain, through the realisation of one’s own self-agency within interpersonal engagement. Being able to express one’s vulnerability as well as the need to be forgiven, accepted and liked by the other is fundamental, and this signifies the final phase of treatment (see phase 3 Fig. 2). The final phase of emotion transformation is shown when the client expresses their vulnerability to the other, such as their need or desire to be forgiven and the need to be liked and accepted by the other.

In EFT, optimum emotional processing involves the integration of cognition and affect. Experiencing emotion is one step in a process. However, once it’s achieved clients must also cognitively orient to that experience and explore, reflect on, and make sense of it. The process directive cognitive-affective empathy framework in EFGT-AS provides opportunities to set up mentalization tasks in session and across treatment. It also builds in a reflection session at the end of treatment. Reflection and transformation of core pain, helps to create new meaning, promotes the assimilation of unprocessed emotion into ongoing narratives, and helps develop new narratives to explain experience (Timulak and Keogh 2019). This final therapy session provides a space for clients with ASD to reflect upon their own process across treatment.

In summary, this case conceptualization demonstrates that autistic adolescents move from low levels to moderate and high levels of empathic concern for others, observed through their actions in response to others’ emotional needs. Autistic people can recognise that they are the cause of another person’s hurt and see how they could have acted differently to avoid such hurt.