International Journal of Integrative Psychotherapy, Vol. 8, 2017 26 Intersubjective Aspects of Relational Group Process: From Exclusion to Integration Jose Manuel Martinez Rodriguez Abstract: Through the use of Relational Group Process (Erskine, 2013) the therapist(s) and group members join together to build an intersubjective environment a co-constructed group experience. This process encourages people to respectfully listen and inquire of each other, to move out of the role of simply being observers of group dynamics, and to stop engaging in judgmental assessments of the others. The intersubjective aspects of Integrative Psychotherapy are essential components for achieving the goal of integration. The set of relational methods outlined in Integrative Psychotherapy provide a comprehensive guide for intersubjective treatment. When these methods are applied to the group setting in the format of relational group process, they allow the integration of different experiences in the group matrix. The more the group matrix holds individual experiences, the more internal and external contact of group members is fostered. A case study illustrating these concepts and dynamics is presented. Key Words: Relational Group Process, Integrative Psychotherapy, intersubjectivity, relational psychotherapy, inquiry, attunement, involvement, group psychotherapy. ---------------------------------------- Introduction I have always valued the intersubjective aspects of Integrative Psychotherapy in clinical practice with groups. From my point of view, the set of relational methods delineated in the Key Hole (Erskine &Trautmann, 1996; Erskine, 1997; Erskine, Moursund &Trautmann, 1999; Moursund & Erskine, 2003) provide an intersubjective paradigm of group psychotherapy. The reflections presented in this article come partly from my group practice of Integrative International Journal of Integrative Psychotherapy, Vol. 8, 2017 27 Psychotherapy in public and private mental health settings, as a psychiatrist for adults, children and adolescents, and also from the relational training and supervision groups I lead at the Institute of Transactional Analysis and Integrative Psychotherapy (IATPI) in Valladolid, Spain. . Relational Group Process and Intersubjectivity in Groups Relational group process (Erskine, 2013) is based on the philosophical and theoretical principles of Integrative Psychotherapy and promotes the development of intersubjective dynamics in group psychotherapy. The practice of inquiry, attunement and involvement in a group format generates an intersubjective approach and presents new therapeutic opportunities. As the Self only develops within a relationship (Erskine, 1991) relational group process (Erskine, 2013) offers the person a chance to express his/her unmet relational needs that may have been previously repressed, split or dissociated, in order to achieve greater levels of integration in the here and now with others (Martín y Martínez, 2009). An intersubjective approach differs from an “objective” analysis of the other group members, in that it underlines the difficulty and challenges of every member of the group to become truly “neutral” and “objective,” as their mutual perceptions contribute to a kind of co-construction. There is no way to separate the observer from the observed, for the role of “observer” modifies the observed field. Through the use of relational group process (Erskine, 2013) group members can expand beyond just the observer role of group dynamics, to the role of participant observers (Stolorow & Atwood, 1979). The interventions of group participants can build an intersubjective environment where they become aware that the group experience is co-constructed, and reparative on a relational level. This is very different from treating others as isolated minds, about which we may unconsciously state some value judgments coming from our script beliefs or introjections (Stolorow & Atwood, 1979, 1992; Atwood & Stolorow, 1984; De Young, 2003). An intersubjective approach, which Integrative Psychotherapy holds in common with other schools of psychotherapeutic thought, analyzes the factors that contribute to a co-constructed relationship. This approach requires that the therapist(s) and group members take into account their own script beliefs, their mutual countertransferences, and the way they activate the transference of others. An intersubjective approach also requires the willingness of the therapist(s) and group members to be open and to resonate with the experiences of their group co- members. The set of relational methods delineated in Integrative Psychotherapy provides a guide for intersubjective treatment - a set of clear, precise relational methods that make self-restoration possible, especially through the therapist’s International Journal of Integrative Psychotherapy, Vol. 8, 2017 28 attunement and involvement, and by means of respectful inquiry applied time and again on deeper levels of experience. The Social and Intersubjective Brain as the Foundation of Group Interventions Group therapy is designed to provide a “natural,” in vivo environment to help people improve their relationships. It strives to provide an arena for expressing and satisfying the needs for stimulus, relationship and structure. Additionally, the social nature of human kind is deeply rooted in the brain. The central nervous system serves two main functions: internal regulation and relation to the environment. I consider the brain to be a result of consecutive relational solutions encountered by our species to multiple environmental, ecological and social challenges. I consider it both the result and the foundation of the universal need for relationship. Some researchers consider brain development to be linked to the size of the group (Dunbar, 1998). Neuronal networks seem to be developed in order to predict and evaluate the behavior of the others, an advantage achieved through evolution (Cozolino, 2006). We can say that the brain is a relational and social organ. Siegel (2006), writing about the deep social nature of the brain, thinks that our minds are the result of the entanglement and integration of seemingly disparate aspects of reality: physical, interpersonal, social and body aspects. He believes that when two minds feel connected, there is increased possibility of integration. The firing of each participant`s brain improves the chance of increased integration and coherence. The activation of the body, of limbic circuit areas and even cortical representations of intentional states of the other enter into a kind of resonance, in which both participants match each other. In addition, several neurobiological and neuroimaging studies show that the essence of the brain is deeply intersubjective (Fuchs, 2004). Mirror neurons have been proposed as being the substratum of intersubjective attunement (Rizzolatti et al., 1995; Rizzolatti et al., 1996; Rizzolatti & Arbib, 1998; Wolf et al, 2001; Gallese, 2003; Iacobini & Siegel, 2004; Pally, 2007). Mirror neurons provide a device to “acknowledge” actions. The actions of the agent are reproduced in the premotor cortex of the observer. In group therapy, this resonance implies a change in physiological, affective and intentional states of the participant observers as determined by the perceptions of the other members of the group. Trevarthen´s theories of primary and secondary intersubjectivity (1974, 1978, 1980, 2004, 2011) can help us better understand the need to participate at group and social levels. His ideas demonstrate that the primary intersubjectivity of International Journal of Integrative Psychotherapy, Vol. 8, 2017 29 babies, their need for attachment and of sharing actions and learnings with their caregivers, is the foundation of social groups and the motivation to build a cultural narrative that works as a “home” (Trevarthen, 1979, 2011). Trevarthen (2004, 2011) comments that human beings are born not as individuals but as social beings in search of other human beings willing to participate in reciprocal imitation and the mutual regulation of life activities. In this regard, intersubjectivity can be shown to be the basis for understanding the rhythmic motivation for comradeship at different levels of intimacy in social groups. Groups can synchronize self- regulatory subjective mental states to share goals, interests and feelings (Trevarthen, 2009). This helps us to understand group narratives, cultural learning and the emotional group regulation of moral attitudes within communities. Trevarthen´s research (1974, 1978, 1980, 2004, 2005, 2011), suggests that people have an innate conversational mind from birth, and that mother and baby behave in a rhythmic way, generating cycles of affirmation and understanding, and of stimulation and response. Throughout these cycles mother and child celebrate the fluctuations between effort and pleasure and share an affectionate comradeship. Cozolino (2006) has developed the concept of “social synapse” to talk about the way we link together into larger organisms such as groups, families, tribes, societies and the human species as a whole. It is the way people, like neurons, excite, interconnect and link together to create relationships. This opens many interesting interpersonal possibilities. Since the brain has been shown to change in response to experience, we influence the long-term construction of the brains of others, by impacting each other´s internal biological and emotional state. Cozolino (2006) has eloquently described the complex social engagement system of the brain and its neurochemistry as a foundation of psychotherapeutic interventions. Siegel (2006) thinks that being empathic with patients goes far beyond just helping the other to “feel better,” but can in fact help build a new state of neuronal activation that improves the self-regulatory capacity of the individual. External contact may provide some relief to inner tensions. Therapeutic relationship may become a chance to learn and incorporate new self-regulatory patterns in order to better tolerate and integrate traumatic childhood experiences in the here and now. The access to the awareness of formerly warded off and split ego states is easier when the patient has developed, within the therapeutic relationship, new self- regulatory capacities that were previously inaccessible. What initially begins as a way of interpersonal contact with the therapist through the sharing of affective and cognitive states, evolves into a form of internal integration in the patient. These theories regarding the need for relationships, are linked to the social nature of the brain which helps us to better understand how intersubjectivity works at the group level. Intersubjective communication connects our brain in co- International Journal of Integrative Psychotherapy, Vol. 8, 2017 30 operative or competitive mental states and creates a kind of shared intelligence, which is now called the “social brain” (Adolphs, 2006; Dunbar, 1998). In this context, relational group process (Erskine, 2013) may foster intersubjective communication at the group level. Co-construction at the Group Level The group may be a good environment to help clients achieve increased levels of integration. Groups provide stimulation, and the possibility to restructure personal script beliefs and change old attachment patterns. In order to facilitate these objectives, it is important that the group therapist be aware of the intersubjective dimension in the group setting. Groups allow participants to see with increased clarity that the quality of experience within the group atmosphere, and the history of events in the group, are not dependent on anybody in particular, but are instead the result of a co- construction. This can be observed both in small and in big groups at many social levels. Berne (1963, 1966) demonstrated the similarities between small groups, psychotherapy groups, and both middle-sized and large social organizations. He also described the way they share some structural and functional principles, especially what he called internal and external group processes. These dynamics are in part the result of the temporary unconscious confluences and alliances between what Berne called “individual proclivities,” that is, the unconscious wishes of the group members, and on the other hand, of the survival need of the groups. The existence of dynamics that go beyond the conscious will of particular individuals is something that can also be appreciated in professional groups. Beside the existence of common interests, there are relational aspects of security, mutuality and recognition that appeal to individual members. Professional groups can be a meeting point where members aspire to exchange views in a friendly way, with the comradeship of people who hold in common principles and tasks, personal learning, experiences and surprises. Every participant can offer his/her knowledge for the common service and to receive the other´s feedback. The constructive dynamic of these groups is promoted by the interest in the professional experience of other colleagues and by the sharing of learning. The conflicting dynamics may come from conflicts between the individual and collective interests, or the difficulties of the group to evolve among other professional and social collectives. The practice of relational group process psychotherapy (Erskine, 2013) helps to build an intersubjective environment where group members may become aware that the group experience is co-constructed. When this happens, it becomes International Journal of Integrative Psychotherapy, Vol. 8, 2017 31 clear that the wish of group members to know each other can also become an opportunity to understand themselves better through the interactions, feedback and inquiry of others. The message of a person inquiring of someone else is, “I want to get to know you with my questions. At the same time my questions may be good for you as you can get to know yourself better through your answers and reactions.” Table I delineates this process. If we consider group interactions from an intersubjective point of view, we must seriously take into account the fact that the person chosen for an inquiry may have likely been for some minutes a stimulus for the other´s question. It might be that his/her silence, verbal content of statements, or non-verbal communications have strongly stimulated the other´s intrapsychic process, reactions, feelings, memories and expectations. This intrapsychic process has ended up stimulating a question from the other, which at the same time may be a question about him/her. So, in the intersubjective process the message of the person making an inquiry may be, “My questions are to you, and they are also telling you about me. You can get to know me better through them.” On the other hand, the person giving feedback to the other communicates something like, “What I am experiencing with you helps me to ask questions of myself about my present and my past.” The new questions that a group member starts to ask of himself/herself may help increase awareness of discounts in present relationships, rememberences of past warded off memories, developmental longings, discounts, or traumatic experiences. Similarly, someone´s experience in the group may be a key that opens unconscious areas belonging to the warded off experiences of other Table I Intersubjectivity in the Relational Group Process  “I want to get to know you with my questions. My questions may be good for you as you can get to know yourself better through your answers.”  “My questions are telling you about me. You can get to know me better through them.”  “What I am experiencing with you helps me to ask questions of myself.”  “Your experience might be a key to open my unconscious.”  “Me becoming conscious might be a key for you to get in touch with your unconscious.”  “Together we will get to know ourselves better and celebrate our shared experience.” International Journal of Integrative Psychotherapy, Vol. 8, 2017 32 members. In this way, someone else’s working through process, and the resulting increased awareness, may facilitate the opening of unacknowledged areas for another group member, as s/he connects with forgotten, repressed, split or dissociated aspects of their own history. In addition, it is also important to take into account the expression of the perceived and expressed relationship of individual group members to the group as a whole. It is often expressed as “I feel proud of belonging to this group,” “I missed this group,” and/or “I take this group with me.” All of these comments are ways of expressing the feelings of an individual regarding the group, validating the group activities and acknowledging the impact of the group on him/her. Every member may be impacted by these expressions, as the group receives good feedback that strengthens group cohesion and the group culture. Conversely, we can find individual transferential relationships to the whole group, and/or to the therapist, and/or to some members, that may be only inner reactions, or overt transactions in the group (Berne, 1966, Erskine, 1991). All these transferential reactions and transactions build an intersubjective matrix that provides a stimulus for each individual. There is the risk of contact with some script experiences that limit the perception of the other group members’ reactions and the options of the person involved. For example, a violent member may stimulate traumatic experiences in some group members, and/or an experience of shock or reaction from defensive introjections. From exclusion to integration The group therapist holds the tasks of being sensitive to individual vulnerability and being aware of the risk of shame, humiliation or fragmentation, all of which are more difficult in the group setting (Martínez, 2001). The therapist must remain attuned to both the individual and the group as a whole. Within the group setting there may be inevitable ruptures in empathy. Livingston & Livingston (1998) have shown the factors that make it difficult to keep an empathic position in the group. For example, difficulties may occur when two people simultaneously need to express themselves, be listened to and/or validated. There are also some situations where some members might try to force another member to play a role in the service of an unconscious dynamic. Case Study Henry is 31 years old. He has been admitted to the emergency room of our hospital and then hospitalized by order of a judge because of a public order offense. He has taken a large amount of cocaine due to his fear of abandonment by his wife and now has delusions of persecution. International Journal of Integrative Psychotherapy, Vol. 8, 2017 33 The treatment team discusses the needs of the patient and the risk of violence inside the Crisis Unit. He is afraid. The other patients reject him and in doing so, reinforce his script beliefs and heighten the risk of his defensive rage. During the first few hours there have been several situations between Henry and other people very difficult to manage. The therapist invites him to take part in the Transition Entry Group (Aroian & Prater, 1988; Martínez, Quiroga, Pérez, San Miguel et al., 1997) of which the function is to ease the patient´s adjustment to mental health hospitalization. Henry accepts. The group meets for 90 minutes each day from Monday to Friday. The group is open and new members join at each session. In the first session Henry sits next to the door. There are twelve other members and the therapist in the group. All of them have suffered humiliation, shame and violence in their lives. Some of them have experienced acute traumas and/or some other cumulative traumas in their childhood. At the beginning of the session Raymond expresses his rage against Henry and demands that Henry not be allowed to enter the group. “In this Unit we are a family joined in the pain and we support each other. He has come to destroy our peace.” Henry suddenly stands up and shouts loudly in an angry way, “Don`t tell me what to do!” There is a risk of an angry confrontation between them. The silence of the other members in the group serves to acknowledge and support Raymond´s demands. The therapist reminds the group of its rules. Participants are allowed to express anger but are not allowed to act out. The group is invited to respect each other, to listen, to be empathic, to connect with inner experience and to give room for each other’s experience without exclusion. As a result of his own menacing behavior, Henry is re-experiencing well- known rejection and is at risk of reinforcing his script beliefs. He has been excluded from the important decisions in his family, and has been criticized and closely monitored by his relatives. Now, he is experiencing being excluded by the other group members. Additionally, his admission to the group might activate traumatic memories for the other members. There is a risk that group members will try to make him the reason for their anxiety, instead of accepting the anxiety as a signal of the reactivation of traumatic memories. During the stormy session, the therapist makes interventions to give room, to acknowledge and to validate both the anger of group members and the feelings of the new arrival. Henry´s anger conspicuously decreases when the therapist asks him about his experience the day before, of being taken to hospital by the police and being admitted compulsorily by order of a judge. The group members have International Journal of Integrative Psychotherapy, Vol. 8, 2017 34 not had the opportunity to take this part of his experience into account. Henry´s reduced tension in response to this inquiry, helps the other members to reduce their own fear and defensive anger and their opposition to Henry’s presence in the group. At the end of the session Henry apologizes. His behavior changes and he is able to work through some of his rejection fears in subsequent sessions, and connect these fears with some childhood experiences. Raymond is able later on to become aware of the memories of shame and humiliation that are reactivated by Henry´s anger. He is able to talk about his fear of his contemptuous, scornful father, and how he didn´t give room to his son in his family. The other members are able to talk about suspicion, mistrust and jealousy in their relationships. They talk about their script beliefs of having something wrong inside them, being crazy or feeling different. One member speaks about her reinforcing sensory experiences through “inner voices” telling her not to trust others and keep secret the abuses she experienced in her childhood. Most of the participants increase their ability to accept their inner shame and memories of humiliation in different contexts. Conclusion Group therapy is an effective treatment for the reparation of relational difficulties. Relational group process as delineated by Richard Erksine (Erskine, 2013), provides for the universal needs of stimulus, relationship and structure required by the social and intersubjective nature of the brain. These brain “needs” are demonstrated by many studies on the origin of intersubjectivity in child development (Meltzoff & Moore1977, 1994, 1997); Trevarthen & Hubley (1978); Trevarthen (2004, 2005, 2011); Stern (1971, 1977, 1985); Stern et al. (1985). Modern neuroscientific research also supports the presence of social brain “needs” (Rizzolatti et al.,1995); (Rizzolatti et al.,1996); (Rizzolatti & Arbib,1998); (Pally 2000); (Wolf et al.,2001); (Gallese, 2003); (Iacobini &Siegel, 2006); (Cozolino, 2006). Relational group process allows participants to see with increased clarity that the quality of interpersonal experience, group ambience, and history of group events are not dependent on anybody in particular, but are instead the result of an intersubjective co-construction. Through the use of relational group process group members are encouraged to move beyond the role of simply being observers, making subjective assessments of others, mediated by their own script beliefs and introjections. In relational group process, the therapist must remain sensitive to individual vulnerability, while also being aware of the risk of group members feeling shamed, humiliated or fragmented within the group process. The therapist must remain International Journal of Integrative Psychotherapy, Vol. 8, 2017 35 attuned with each member and simultaneously with the whole group (Martinez, 2001). As the relational group process gives room for acceptance and mutual respect, while also supporting inquiry, mutual attunement, acknowledgement of experience, validation and presence, the individual has the opportunity to feel held by the group. The person can then give inner voice and outer expression to his/her unmet needs that have been repressed, split or dissociated earlier in life, and achieve greater levels of integration in the here and now (Martín y Martínez, 2009). Genuine support is shown through understanding, acceptance and acknowledgement of each of the members of the group. In addition, the validation and normalization of behavioral patterns, and the attuned presence of group members and therapist, are valuable tools in reducing the fear of approaching and processing warded off experiences. It is in the co-created therapeutic process and shared group experience through which individuals can be acknowledged, validated, restored and celebrated. 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