Mentalization-Based Treatment for Pathological Narcissism

Psychoeducation for Pathologic Narcissism and Narcissistic Personality Disorder: A Review and Proposal for a Good Psychiatric Management-based Six-week Group Program

Pathologic narcissism (PN) and narcissistic personality disorder (NPD) are 2 common and stigmatized clinical constructs that are known to have large consequences for patients' functioning and mental health-related outcomes. To date, no treatment for these conditions has been empirically validated, but there is a relative consensus about the importance of psychoeducation. Here we present a model for a psychoeducational intervention for patients with PN or NPD. We start with a review of the current evidence on the role of psychoeducation in different treatment models for PN, and we discuss several aspects regarding the content and format of this type of intervention. Based on this review, we outline a 6-week Good Psychiatric Management-based psychoeducation group program that we developed. We also describe how such a psychoeducational intervention can be implemented individually, with fewer resources, in general care settings. Finally, we discuss the strengths and limitations of our approach and elaborate on the rationale for our proposal. We believe that this program proposal is a first step in the development of psychoeducational programs for PN and NPD that can be further corrected and enhanced.

Mentalization based treatment for a broad range of personality disorders: a naturalistic study

BACKGROUND

Several studies have observed that mentalization-based treatment (MBT) is an effective treatment for borderline personality disorder (BPD), but its effectiveness for other personality disorders (PDs) has hardly been examined. Additionally, the evidence supporting the claim that MBT improves mentalizing capacity is scarce. The present study examined whether (i) patients with a broad range of PDs enrolled in an MBT program would improve on several outcome measures (ii) mentalizing capacity would improve over time; (iii) patients with BPD would improve more than those with non-borderline PDs.

METHOD

Personality disorders, psychiatric symptoms, social functioning, maladaptive personality functioning and mentalizing capacity were measured in a group of individuals with various PDs (n = 46) that received MBT. Assessments were made at baseline and after 6, 12, and 18 months of treatment. The severity of psychiatric symptoms, measured using the Outcome Questionnaire 45, was the primary outcome variable.

RESULTS

Overall, enrollment in the MBT program was associated with a decrease in psychiatric symptoms and an improvement of personality functioning, social functioning for a mixed group of PDs (all p's ≤ .01). Bigger effect sizes were observed for BPD patients (n = 25) than for patients with non-BPD (n = 21), but the difference failed to reach statistical significance (p = 0.06). A primary analysis showed that the decrease in psychiatric symptoms was significant in BPD patients (p = 0.01), not in non-BPD (p = 0.19) patients. However, a sufficiently powered secondary analysis with imputed data showed that non-BPD patients reported a significant decrease in psychiatric symptoms too (p = 0.01). Mentalizing capacity of the whole group improved over time (d = .68 on the Toronto Alexithymia Scale and 1.46 on the Social Cognition and Object Relations System).

DISCUSSION

These results suggest that MBT coincides with symptomatic and functional improvement across a broad range of PDs and shows that MBT is associated with improvements in mentalizing capacity. As the study is not experimental in design, we cannot make causal claims.

CONCLUSION

Mentalization-based treatment may be an effective treatment for patients with a broad range of PDs.

TRIAL REGISTRATION

The study design was approved by the Leiden University Ethical Committee.

Adult ADHD and pathological narcissism: A retrospective-analysis

Adult attention deficit hyperactivity disorder (ADHD) is often associated with personality pathology. However, only few studies have been conducted on the link between ADHD and pathological narcissism (PN), with or without a diagnosis of narcissistic personality disorder (NPD). In order to fill this gap, PN and NPD were assessed in 164 subjects suffering from ADHD, with several other measures including ADHD severity, quality of life, depression, anxiety, impulsivity, and emotion dysregulation (ED). We found that a significant proportion of ADHD patients suffered from NPD, and that both narcissistic grandiosity and vulnerability were associated with ADHD hyperactivity and impulsivity symptoms, but not with inattentive symptoms. These two dimensions seemed to be negatively associated with well-being and positively associated with most of the other studied psychiatric dimensions except ED, the latter being only associated with vulnerability, even after adjustment on borderline symptoms. Overall, despite important limitations that limit the generalizability of our findings to the overall ADHD population (notably linked to selection bias), we believe that this exploratory study sheds light on the potential clinical relevance of narcissistic pathology in adult ADHD patients.

Can clinical and subclinical forms of narcissism be considered risk factors for suicide-related outcomes? A systematic review

BACKGROUND

Clinical and subclinical forms of narcissism may increase suicide risk. However, little is known and there are controversies on this topic. This systematic review aims at providing an overview of studies investigating this association.

METHODS

We used PubMed, Scopus, and PsycInfo databases and followed PRISMA. We focused on cohort, case-control, cross-sectional and case series studies. We referred to both clinical (i.e., narcissistic personality disorder (NPD) and/or NPD criteria) and subclinical forms (i.e., grandiose and vulnerable narcissistic traits) of narcissism. Moreover, we considered: Suicidal Ideation (SI), Non-Suicidal Self-Injury(s) (NSSI), Deliberate Self-Harm (DSH), Suicide Attempt(s) (SA), Suicide Risk (SR), and Capability for Suicide.

RESULTS

We included 47 studies. Lack of association between NPD diagnosis/criteria and suicide-related outcomes (SI) or mixed results (SA) were found. Higher homogeneity emerged when considering narcissistic traits. Vulnerable narcissism was associated with SI, less impulsive NSSI, and DSH. Grandiose narcissism was associated with severe NSSI and multiple SA with high intent to die, but it was protective against SI and SR. Vulnerable narcissism seemed to be associated with suicide-related outcomes characterized by low intent to die, while grandiose narcissism seemed to be a risk factor for outcomes with high planning and severity.

LIMITATIONS

Between-study heterogeneity and lack of longitudinal studies.

CONCLUSIONS

Assessing suicide risk in subjects with clinical or subclinical forms of narcissism may be useful. Moreover, considering the most vulnerable form of narcissism, and not just the grandiose one, may contribute to a more nuanced risk stratification and to the identification of distinct therapeutic approaches.

Societal costs of personality disorders among treatment-seeking patients in Norway: the relative contribution of specific DSM-5 categories

Personality disorders (PDs) are associated with high levels of societal costs, regardless of whether a single PD or a broad range of PDs have been studied. However, research on the relative contribution of specific PD-types on societal costs is limited. The aim of this study was to explore the possible contributions of the individual DSM-5 categories of PDs on the level of societal costs and its components (health service costs and productivity loss), while controlling for the impact of comorbid mental health and substance use disorders on these outcomes. Participants (n = 798) were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD-treatment units within specialist mental health services. The patients were referred to treatment in the time-period 2017-2020. Costs were assessed using a structured interview covering the 6-month period prior to assessment. Diagnoses were determined by semi-structured diagnostic interviews (SCID-5-PD and M.I.N.I.). Statistics included multiple regression analyses. The main result was that no specific PD had a unique contribution to the high level of societal costs generally found among treatment-seeking patients with PDs. Borderline PD (BPD) was the only PD with significantly higher health service costs than the other PDs, while BPD, avoidant PD, and unspecified PD were independently associated with enhanced productivity loss. The differential cost-effects of specific PDs on the cost components were small. Several comorbid mental health and substance use disorders were significant contributors to costs, irrespective of PD status. The results underscore the importance of developing and implementing effective treatments for a broader range of PDs, to reduce the high levels of societal costs associated with all PDs.

Mentalization Scale (MentS): Validity and reliability of the Iranian version in a sample of nonclinical adults

INTRODUCTION

Mentalizing incapacity is increasingly identified as a common factor in psychopathology. The Mentalization Scale (MentS) is a cost-effective measure built upon the dimensional model of mentalizing. We aimed to evaluate the psychometric properties of the Iranian version of MentS.

METHODS

Two samples of community-based adults (N1  = 450, N2  = 445) completed different batteries of self-report measures. In addition to MentS, participants completed measures of reflective functioning and attachment insecurities in the first sample and a measure of emotion dysregulation in the second sample.

RESULTS

Due to the conflicting results of confirmatory and exploratory factor analyses, an item-parceling approach was applied, which replicated the original three-factor structure of MentS, yielding Self-Related Mentalization, Other-Related Mentalization, and Motivation to Mentalize. The reliability and convergent validity of MentS were supported in both samples.

CONCLUSION

Our findings provided preliminary evidence for using the Iranian version of MentS in nonclinical populations as a reliable and valid measure.

Narcissistic Personality Disorder: Patterns, Processes, and Indicators of Change in Long-Term Psychotherapy

Change in treatment of narcissistic personality disorder (NPD) has been considered difficult to attain. Aspects of narcissistic pathology, including interpersonal enhancement, avoidance, aggressivity, and control, have contributed to challenges in forming a therapeutic alliance and pursuing treatment towards attainable goals for change and remission. This study, based on a qualitative review of therapists' case reports of individual psychotherapy with eight patients diagnosed with NPD, is the first to identify and explore patterns, processes, and indicators of change in pathological narcissism. All patients showed significant improvement in personality and life functioning, including engagement in work or education and long-term close relationships, with remission of the NPD diagnosis. The process of change was gradual, with some noticeable changes occurring in specific life contexts. Additional factors indicating and contributing to change included patients' motivation and commitment to psychotherapy, reflective ability, emotion regulation, sense of agency, and interpersonal and social engagement.

The dark side of empathy in narcissistic personality disorder

Narcissistic personality disorder is characterized by self-absorption, grandiosity, exploitation of others and lack of empathy. People with that disorder may switch from an overt form, mainly with grandiosity, to a covert presentation, with fears, hypersensitivity and dependence from others. Empathy represents a key point in detecting people affected by narcissistic personality disorder because, even if it is described as reduced, it plays a fundamental role in exploitation and manipulation. A systematic search of Literature without any language or time restriction, was performed combining thesaurus and free-search indexing terms related to Narcissistic personality disorder and empathy and produced 531 results. Fifty-two papers that analyzed possible issues in the empathic attitude of people with narcissistic personality disorder were included in this narrative review. Empathy is the capability of understating and feeling others emotions. It is not a unitary construct and can be distinguished in cognitive and affective. It might be channeled into prosocial and antisocial behaviors. A crucial trait identified in narcissistic empathy is affective dissonance that is closely related to rivalry as part of the dark tetrad (narcissism, machiavellianism, psychopathy, and sadism). Subjects affected by narcissistic personality disorder show greater impairment in affective aspects while their cognitive part of empathy appears preserved. Saving at least the cognitive aspects of empathy may contribute to therapeutic improvement of affective aspects.

Dimensional personality impairment is associated with disruptions in intrinsic intralimbic functional connectivity

BACKGROUND

Recently proposed alternative dimensional models of personality disorder (PD) place the severity of impairments in self and interpersonal functioning at the core of personality pathology. However, associations of these impairments with disturbances in social, cognitive, and affective brain networks remain uninvestigated.

METHODS

The present study examined patterns of resting-state functional connectivity (rsFC) in a sample of 74 age- and sex-matched participants (45 inpatients with PD and 29 healthy controls). At a minimum, PD patients carried a diagnosis of borderline PD, although the majority of the sample had one or more additional PDs. rsFC patterns in the following networks were compared between groups and in association with dimensional personality impairments: default mode network (DMN)/core mentalization, frontolimbic, salience, and central executive. Further, the extent to which variation in rsFC was explained by levels of personality impairment as compared to typology-specific borderline PD symptom severity was explored.

RESULTS

Relative to controls, the PD group showed disruptions in rsFC within the DMN/core mentalization and frontolimbic networks. Among PD patients, greater severity of dimensional self-interpersonal impairment was associated with stronger intralimbic rsFC. In contrast, severity of borderline PD-specific typology was not associated with any rsFC patterns.

CONCLUSIONS

Disruptions in core mentalization and affective networks are present in PD. Higher intralimbic functional connectivity may underlie self-interpersonal personality impairment in PD regardless of diagnostic typology-specific PD symptoms, providing initial neurobiological evidence supporting alternative dimensional conceptualizations of personality pathology.

Personality and mentalization: A latent profile analysis of mentalizing problematics in adult patients

BACKGROUND

The aim of this study was to investigate the relationship between patients' mentalizing problematics and their personality; specifically, it aimed to identify clusters of individuals characterized by specific patterns of mentalizing imbalances and to analyze the relationship between these and diagnosis of personality disorder (PD), nonmentalizing modes, emotion dysregulation, and interpersonal reactivity.

METHODS

Four hundred therapeutic dyads were recruited. A part of these (n = 183) only completed clinician-report measures, Mentalization Imbalances Scale, and Modes of Mentalization Scale, while others (n = 217) also completed patients' self-report measures, which were Reflective Functioning Questionnaire, Difficulties in Emotion Regulation Scale, and Interpersonal Reactivity Index.

RESULTS

A latent profile analysis enlightened the presence of four clusters with problematics in the dimensions of mentalization, indicated by cluster names: (1) Affective-self-automatic profile (ASA-P) (with higher percentage of PDs); (2) External profile (E-P) (with lower percentage of PDs); (3) Others-automatic-affective profile (OAA-P); (4) Cognitive-self-automatic profile (CSA-P). Multivariate analysis of variances confirmed that the four clusters differed in relation to the quality of mentalization, emotional dysregulation and interpersonal reactivity, with higher levels of nonmentalization modes, uncertainty about mental states and emotion dysregulation in ASA-P, higher levels of good mentalization in E-P, lower impulsivity in CSA-P, and greater empathic concern in OAA-P.

"It's not you, it's me": identity disturbance as the main contributor to interpersonal problems in pathological narcissism

BACKGROUND

Core impairments in self and other functioning typify individuals with personality disorder. While interpersonal dysfunction is a known element of narcissistic disorders, empirical research investigating intrapersonal elements is lacking. The aim of this study was to investigate the internal representations of individuals with grandiose and vulnerable features, as manifested through their attachment styles, and the specific role of identity disturbance in explaining the relationship between pathological narcissism and maladaptive interpersonal functioning.

METHODS

A sample of 270 university students completed the Brief Pathological Narcissism Inventory (B-PNI), the Severity Indices of Personality Problems (SIPP), the Relationship Questionnaire (RQ), and the Inventory of Interpersonal Problems (IIP-32).

RESULTS

Both vulnerable and grandiose narcissism were positively associated with both fearful and preoccupied attachment, and negatively associated with secure attachment, whilst grandiose narcissism was also positively associated with dismissive attachment. Furthermore, unstable representations of self, poor self-reflective functioning, and low sense of purpose fully mediated the relationship between interpersonal problems and grandiose narcissism while partially mediating the relationship between interpersonal problems and vulnerable narcissism.

CONCLUSIONS

Overall, our findings suggest that for individuals presenting with narcissistic features, capacity for adaptive interpersonal functioning is grounded by deficits in identity integration. Implications of these findings are discussed.

Narcissistic Personality Disorder: Progress in Understanding and Treatment

This review summarizes current knowledge about narcissistic personality disorder (NPD). Each section brings the reader up to date on advances in our knowledge during the last decade. In terms of NPD diagnosis, this review describes the addition of the dimensional model to the categorical model. The accumulating knowledge has led to the description of grandiose and vulnerable narcissism as well as their complex interrelationship. Strong support exists for co-occurrence of these presentations among people with high levels of grandiose narcissism. Studies have identified mechanisms, in domains such as self-esteem dysregulation, emotion dysregulation, cognitive style, interpersonal relations, and empathy, and possible developmental and temperamental antecedents of the disorder. Thus, it appears that NPD has a multifactorial etiology and pathogenesis, with numerous mechanisms associated with each area of dysfunction. Longitudinal studies support the view that these patients can improve, but such improvement is gradual and slow. Several treatments have been developed for the disorder, and a majority share commonalities, including clear goals, attention to treatment frame, attention to relationships and self-esteem, alliance building, and monitoring of countertransference.

A Cognitive-Behavioral Formulation of Narcissistic Self-Esteem Dysregulation

Narcissistic personality disorder (NPD) is a commonly encountered diagnosis, affecting approximately 1%-6% of the population, with no evidence-based treatments. Recent scholarship has focused on self-esteem dysregulation as a key component of NPD: Excessively high expectations for oneself and how one should be treated leads to brittle self-esteem and maladaptive reactions to self-esteem threats. The current article builds on this formulation, introducing a cognitive-behavioral model of narcissistic self-esteem dysregulation that clinicians can use in providing a relatable model of change for their patients. Specifically, symptoms of NPD can be seen as a set of cognitive and behavioral habits that serve to regulate difficult emotions emerging from maladaptive beliefs and interpretations of self-esteem threats. This perspective renders narcissistic dysregulation amenable to cognitive-behavioral therapy (CBT) in which patients learn skills that help them gain awareness around these habitual reactions, reshape cognitive distortions, and engage in behavioral experiments that serve to transform maladaptive belief systems that consequently free them from symptomatic reactions. Here, we provide a precis of this formulation and examples of how CBT skills can be used to treat narcissistic dysregulation. We also discuss future research that could provide empirical support for the model and test the efficacy of CBT approaches to NPD. Conclusions focus on the notion that narcissistic self-esteem dysregulation likely varies continuously in the population and transdiagnostically across disorders. Greater insight into the cognitive-behavioral mechanisms of self-esteem dysregulation could foster tools for ameliorating distress both in people with NPD and the general populace.

A Mentalizing Approach for Narcissistic Personality Disorder: Moving From "Me-Mode" to "We-Mode"

Narcissistic personality disorder (NPD) is a prevalent condition that frequently co-occurs with other diagnoses that bring patients into treatment. Narcissistic disturbances are not often the chief complaint, but they complicate the development of an adequate therapeutic alliance. Typical countertransference challenges, combined with stigma related to NPD, result in difficulty for the therapist to relate to these patients empathically. Mentalization-based treatment provides a means for therapists to reach these patients by taking a "not-knowing" stance with interest and curiosity in clarifying and expanding a shared awareness of the patient's emotional experiences. By understanding the attachment functions, mentalizing imbalances, and problems of epistemic disregard among patients with NPD, therapists can break through the self-centered "me-mode" of the therapeutic dyad, where the typical lack of engagement or power struggles prevail, to a "we-mode," where the patient and therapist are joined in attention to what happens in the patient's mind and in interactions with others.

Mentalizing Mediates the Association between Narcissism and Psychotherapeutic Treatment Outcome in a Mixed Clinical Sample

INTRODUCTION

Pathological narcissism has been a challenge for the success of psychological treatment, whereas mentalizing has turned out to be an important mechanism of change in psychotherapy. This study focused on the classic narcissistic self (CNS) (i.e., narcissistic grandiosity) as predictor of the outcome. It further investigated whether mentalizing mediates this relation.

METHODS

A mixed clinical sample of 205 patients was investigated. The CNS scale of the Narcissism Inventory and the Mentalization Questionnaire was used to measure the features of narcissistic grandiosity and the capacity to mentalize, respectively. The symptom outcome was assessed with the Hamburg Modules for the Assessment of Psychosocial Health.

RESULTS

Contrary to our expectations, we did not find a direct association between narcissistic grandiosity and a decrease in symptoms. However, mentalizing was found to mediate the association between the CNS as well as between the narcissistic furor and outcome.

CONCLUSION

Our results confirm the ambiguity concerning the clinical significance of narcissistic grandiosity. However, in order to improve the treatment outcome in patients with narcissistic features, especially narcissistic furor, individualized treatment plans might consider introducing interventions that enhance the capacity to mentalize.

Contemporary psychological perspectives of personality disorders

PURPOSE OF REVIEW

The aim of this study was to review the recent literature on contemporary psychological perspectives of personality disorders, including novel psychotherapeutic interventions aimed at these vulnerable individuals.

RECENT FINDINGS

Among the various psychological theories and models of personality disorders, still the most popular and researched are psychodynamic, cognitive and interpersonal perspectives. More specifically, object relations theory, cognitive schema conceptualization and interpersonal circumplex model have produced the most empirical investigations of personality disorders in recent years. Latest work has suggested that all three perspectives have contributed to and are compatible with the dimensional personality disorders framework in DSM-5-AMPD and ICD-11 (including level of personality functioning and personality traits). These models have yielded specific psychological treatments of personality disorders; although most psychotherapies have been constructed for patients with borderline personality disorder (BPD), there is an increasing number of treatment modalities aimed at individuals with other forms of personality disorder, such as those with narcissistic or antisocial traits/disorders. More research into their effectiveness and long-term benefits is necessary.

SUMMARY

Novel research keeps updating our knowledge on the cause, manifestations and psychological treatments of personality disorders, particularly from psychodynamic, cognitive and interpersonal perspectives.

A service evaluation of short-term mentalisation based treatment for personality disorder

BACKGROUND

People with personality disorder experience long waiting times for access to psychological treatments, resulting from a limited availability of long-term psychotherapies and a paucity of evidence-based brief interventions. Mentalisation-based treatment (MBT) is an efficacious therapeutic modality for personality disorder, but little is known about its viability as a short-term treatment.

AIMS

We aimed to evaluate mental health, client satisfaction and psychological functioning outcomes before and after a 10-week group MBT programme as part of a stepped-care out-patient personality disorder service.

METHOD

We examined routinely collected pre-post treatment outcomes from 176 individuals (73% female) aged 20-63 years, attending a dedicated out-patient personality disorder service, who completed MBT treatment. Participants completed assessments examining mentalising capacity, client satisfaction, emotional reactivity, psychiatric symptom distress and social functioning.

RESULTS

Post-MBT outcomes suggested increased mentalising capacity (mean difference 5.1, 95% CI 3.4-6.8, P < 0.001) and increased client satisfaction with care (mean difference 4.3, 95% CI 3.3-5.2, P < 0.001). Post-MBT emotional reactivity (mean difference -6.3, 95% CI -8.4 to -4.3, P < 0.001), psychiatric symptom distress (mean difference -5.2, 95% CI -6.8 to -3.7, P < 0.001) and impaired social functioning (mean difference -0.7, 95% CI -1.2 to -0.3, P = 0.002) were significantly lower than pre-treatment. Improved mentalising capacity predicted improvements in emotional reactivity (β = -0.56, P < 0.001) and social functioning (β = -0.35, P < 0.001).

CONCLUSIONS

Short-term MBT as a low-intensity treatment for personality disorder was associated with positive pre-post treatment changes in social and psychological functioning. MBT as deployed in this out-patient service expands access to personality disorder treatment.

Narcissistic Personality Disorder: Are Psychodynamic Theories and the Alternative DSM-5 Model for Personality Disorders Finally Going to Meet?

Narcissistic Personality Disorder is the new borderline personality disorder of our current era. There have been recent developments on narcissism that are certainly worthwhile examining. Firstly, relational and intersubjective psychoanalysts have been rethinking the underlying concepts of narcissism, focusing on the development of self and relations to others. Secondly, in the DSM-5, the Alternative DSM-5 Model for Personality Disorders (AMPD) was presented for a dimensional evaluation of the severity of personality disorder pathology. The combined dimensional and trait conceptualization of NPD opened the door to new integrated diagnostic perspectives, including both internal and interpersonal functioning. Finally, Pincus and Lukowitsky encourage clinicians to use a hierarchical model of pathological narcissism, as it opens up opportunities for shared points of interest in empirical research from different scholarly perspectives. As for most non-psychodynamic clinicians and researchers the DSM-5 clearly bears dominant weight in their work, we will take the AMPD model for NPD as our point of reference. We will discuss the narcissist's unique pattern of self-impairments in identity and self-direction, and of interpersonal disfunctioning (evaluated by assessing empathy and intimacy). Subsequently, we will examine how contemporary psychodynamic theories and the hierarchical model of Pincus and Lukowitsky additionally inform or contradict the AMPD. For us, one of the big advantages of the AMPD is the use of structured clinical evaluations of disturbances of the self and interpersonal functioning and the dimensional evaluation of severity. As psychodynamically oriented therapists, we are enthusiastic about the opportunities for inclusion of psychodynamic concepts, but we also discuss a number of sticking points.

Single-session Mentalization-based Treatment Group for Law Enforcement Officers

Law enforcement violence has emerged as a leading public health concern, and law enforcement officers are themselves at greater risk for a range of psychiatric disorders. Drawing on the significant empirical support for mentalization-based treatment (MBT), this paper explores the use of MBT as a transdiagnostic psychotherapy for law enforcement professionals. By helping patients to mentalize-that is, to "read," access, and reflect on mental states in oneself and other people-MBT could be useful as a dual-focus treatment, able to simultaneously impact psychiatric illness among law enforcement officers while also indirectly impacting the problem of law enforcement violence in the broader society. The core psychotherapeutic principles of MBT are reviewed, along with common vulnerabilities in mentalizing likely to arise for law enforcement professionals in the context of high emotional and interpersonal intensity. The authors outline a novel application of MBT which has implications for psychiatric treatment as well as police training: the single-session psychoeducation and psychotherapy group, where law enforcement officers practice both self-reflection and empathy in situations of relational conflict. Utilizing group process from a residential treatment program for first responders with mental health and substance use disorders, a case example is offered to illustrate this intervention.