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 Psychoanalytic Dialogues, 21:101–109, 2011
Copyright © Taylor & Francis Group, LLC
ISSN: 1048-1885 print / 1940-9222 online
DOI: 10.1080/10481885.2011.545331

Interfaces Among Neurobiology, Cognitive Science, and

Psychoanalysis: Implicit and Explicit Processes in
Therapeutic Change. Commentary on Papers by Allan
N. Schore, Wilma Bucci, and James L. Fosshage
Sandra G. Hershberg, M.D.
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The contributions of Allan N. Schore, Wilma Bucci, and James L. Fosshage in this issue highlight
the continuing efforts of these researchers to understand and illuminate the nature of implicit and
explicit processing and to construct theories based on their observations and their relationship to
therapeutic action. An examination of the core elements of each theory—Schore’s focus on right
brain processes and the importance of affect, Bucci’s further delineation of subsymbolic processes
that participate in the formation of emotion schemas, and Fosshage’s emphasis on the importance of
imagistic symbolic encoding and processing and the interplay of implicit and explicit processing in
creating two pathways to therapeutic change—is presented with emphasis on aspects of interpenetra-
tion and difference. Areas of further investigation that highlight the importance of implicit processes
are discussed. They include inference making, the supervisory paradigm as a means of promoting
change in clinical work, the use of videotapes in parent/child observation, and the interactive use of
images and memory triggers in an experimental design to assist Alzheimer’s patients.

The papers by Drs. Allan N. Schore, Wilma Bucci, and James L. Fosshage explore the ways
in which knowledge and research about the implicit and explicit domains, in the context of
relational experience, reconfigures concepts of memory, learning and a sense of self in the devel-
oping brain and, furthermore, contributes to a theory of mind. These findings, in the areas of
attachment, infant observation, cognitive science, and neuroscience, emphasize the primacy of
relational experience and inform our notions of how psychoanalysis leads to change.
In grappling with the complexity and often abstract nature of this material I was reminded
of my experience in watching Antonioni’s film Blow-Up (Ponti, Rouve, & Antonini, 1966). The
movie is about a photographer who believes that he has captured a murder in one of his pho-
tographs. As he enlarges the photograph to greater magnifications he moves from a sense of
clarity, to complexity, then uncertainty and back again. As I stretched to understand the range,
elusiveness, and difficulty of ideas in these papers that span intersecting literatures, I, too, shifted

A portion of this paper was presented at the Panel “How Do We Come to ‘Know’ and How Do We Change What We
‘Know,’ ” Spring Meeting of APA’s Division 39, April 11, 2008, New York City.
Correspondence should be addressed to Sandra G. Hershberg, M.D., 6317 Kenhowe Drive, Bethesda, MD 20817.
E-mail: hershbs@verizon.com
 102 HERSHBERG

from feeling the excitement of grasping these constructs and their implications, and my desire
for coherence to a sense of greater complexity and, at times, confusion and chaos in approach-
ing the reformulation of a model which integrates the relational origins of development, affect
regulation, and representations of thought and emotion in the developing mind.
In an effort to achieve a sense of balance between coherence and chaos, the papers by Schore,
Bucci, and Fosshage provide conceptual footholds of clarity and understanding as we consider
various aspects of the implicit and explicit domains. I first discuss Schore’s paper, followed by
Bucci’s and Fosshage’s, and then explore other implications of implicit processing.

SCHORE’S THEORY

Allan N. Schore (1994, 2003a, 2003b, 2004), in his meticulous and comprehensive project of
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integrating the implicit self, psychoanalysis, and neuroscience, concentrates on understanding

how it is that the right brain, the seat of the “implicit self,” processes implicit affect, implicit
cognition, implicit regulation, and implicit communication. The ways in which attachment
experiences change the neural substrate in response to nonverbal, para-linguistic, and bodily
expressions of emotion, organized around the primacy of affect and affect regulation lead rela-
tionally, through complex repetitive interactions, to the stabilization and/or destabiliization of
the implicit self. How can we use the implications of these findings to promote change in the
therapeutic process?
In his model Schore expounds on ways the developing infant’s and young child’s right brain
develops in coordination with the rhythmic structures of regulated and dysregulated states of
the caregiver. Emerging from attachment experiences of child and caregiver, Schore presents the
evidence indicating the right brain houses the neural circuitry for mainly imagistic symbolic and
Bucci’s subsymbolic processes. Affective nonverbal and paralinguistic communications of facial
expression, posture, tone of voice, physiological changes, are stored at an unconscious (noncon-
scious) level. Relationally emergent affective experiences profoundly influence the development
of self and interactional regulation. From a therapeutic and neurobiological perspective Schore
emphasizes that empathic immersion, sensing into the mind and state of the other in all its
dimensions—affective, cognitive, somatic, and communicative—is foundational in therapeutic
work. More specifically, Schore (2004) stated, “We recognize another individual’s emotional
state by internally generating somatosensory representations that simulate how the individual
would feel when displaying a certain facial expression” (p. 9). Transference/countertransference
exchanges and, often, enactments represent implicit co-constructed exchanges. In the revival
of thwarted developmental longings the possibility exists for recovery of dysregulated right
brain activity, or, put another way, a shift from disorganized to insecure or secure attachment
experiences mediated through the nonconscious (or unconscious) implicit systems that regulate
affective and bodily states. Thus Schore explicates a central proposition of the therapeutic task
speaking to his view of mind/body/embeddedness when he asserts, “The regulation of stress-
ful and disorganizing high or low levels of affective-autonomic arousal facilitates the repair and
reorganization of the right brain, the biological substrate of the human unconscious” (p. 90).
Although Schore makes a clear differentiation between left brain conscious verbal communi-
cation and right brain unconscious communication, I wonder if that is so clear. In Bucci’s system,
which I discuss next, the boundaries between these domains are less differentiated. Perhaps the
 COMMENTARY ON SCHORE, BUCCI, FOSSHAGE PAPERS 103

focus on right brain processes, previously, a more neglected and less well-delineated arena,
can now be consolidated with an explicitly exploratory approach, a major point in Fosshage’s
paper.

BUCCI’S THEORY

Wilma Bucci (1985, 1997, 2001, 2002, 2004) has proposed a theory of psychological orga-
nization or theory of mind organized around the interaction of different forms of thought or
representation, the multiple code theory. In elaborating this model and its implications she
addresses the following questions: How does the multiple code theory and its referential pro-
cess explain memory, learning, cognitive processing, and change? How is the understanding of
the referential process useful in psychoanalytic treatment? How does the process of dissociation
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operate in this framework?

The aim of the multiple code theory is to delineate the interplay “between different kinds
of psychic knowledge and experience, organized in different forms, registered as bodily experi-
ence, action and the imagery and memories of our lives, which may operate within or outside of
awareness” (Bucci, 2004, p. 6). Viewing the human mind as a multiformat, emotional informa-
tion processor, Bucci proposes two primary formats—subsymbolic and symbolic, with the latter
further divided into symbolic verbal and symbolic nonverbal. The subsymbolic mode is charac-
terized as “analogic, and processed as variation on continuous dimensions, rather than generated
through combining discrete elements as in symbolic forms” (Bucci, 2002, p. 769). The sub-
symbolic system functions at the implicit level. Although variably accessible to consciousness
subsymbolic thinking plays out in enactments, feelings, and nonverbal communications in the
treatment situation. Importantly, the nonverbal symbolic realm, corresponding with Fosshage’s
imagistic symbolic mode of encoding and processing, encompasses images in all sensory
modalities—vision, touch, smell, and taste.
The foundational body elements of what Bucci (1985, 1997, 2001, 2002) and LeDoux (1996)
call emotion schemas constitutes the affective core, consisting of subsymbolic sensory, somatic,
and motoric representations that accounts for the feeling of self across various emotional con-
texts. Emotion schemas are the memory building blocks which constitute one’s sense of self
and the range of self-with-other experiences. The referential process links the three systems,
subsymbolic, symbolic verbal, and symbolic nonverbal.
From my reading, Bucci’s expanded category of subsymbolic processes, comprising the
“affective core” of emotion schemas, corresponds to what Fosshage and others refer to as orga-
nizing patterns. These organizing patterns are developed in relational contexts, through lived
experience, and are experienced at implicit and explicit levels of awareness. Bucci states that
“subsymbolic experience is the guide to the uncharted terrain of the analytic interchange” (p. 50)
and in comparing the dance of the tango with wonderful Dardo as guide to the analytic tango the
emphasis is again on the subsymbolic. While the focus is on implicit processes, I question why
this is located in the predominantly subsymbolic realm as compared to the imagistic, nonverbal
symbolic domain, given the panoply of imagistic processes—visual, kinesthetic, tactile—that are
encompassed. Where does one end and the other begin? In describing the bodily experience of the
tango Bucci states, “The experience is conscious, focused, and organized, not implicit” (p. 46).
She further indicates that the use of metaphor and “movement vocabulary” are teaching and
 104 HERSHBERG

communicating tools primarily because of the difficulty in articulating the subsymbolic realm.
I would suggest instead that with the focused attention of a gifted teacher, like Dardo, the sensi-
bility and technique of becoming a “tango dancer” inevitably involves the intertwining aspects of
imagistic thought, moving between implicit and explicit processes, imbued with sensual/sexual
nuances along with subsymbolic processes.
Finally, Bucci, following Bromberg, emphasizes dissociated schemas that can be activated
in the analytic sphere, that is, a “normal and adaptive dissociated mode” in the analyst and the
patient—a change from the classical model where repression is the name of the game, with the
use of insight and interpretation the curative treatment.

FOSSHAGE’S THEORY
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James L. Fosshage’s paper is an exploration of “how the explicit and implicit learning and mem-
ory systems encode information, how encoding . . . affect[s] conscious . . . accessibility of implicit
processing, and the implications of encoding, learning processes, and . . . conscious accessibility
in delineating a theory of multiple pathways for therapeutic action” (p. 56). Drawing upon the
“revolutionary” finding of these dual systems, working at different levels of awareness, and, yet,
in tandem, Fosshage mines their import in the analytic process and in understanding the persis-
tent and often inflexible seeming nature of these problematic organizing patterns (see Fosshage,
2004, 2005).
Emanating originally from his work on dreams, Fosshage advances the notion of imagistic
symbolic thinking (equivalent to Bucci’s nonverbal symbolic thinking), that is, images gen-
erated in all sensory modalities—sight, smell, touch, taste, viscerally and motorically bodily
sensations—as basic to all thinking, underlining the very early capacity of the infant for imag-
istic symbolic processing, evidenced by the demonstration of REM activity in utero and the Dr.
Seuss study. Following Damasio (1999) and Paivio (2007), Fosshage underscores the central role
of imagery, leaving open but limiting the scope of a possible separate category of subsymbolic
processes, an important difference from Bucci’s model.
How does one’s understanding of relational procedural knowledge and its accessibility to con-
sciousness inform a theory of therapeutic action? How can devitalizing implicit mental models be
modified? Fosshage answers these questions by juxtaposing two pathways of therapeutic action
based on implicit and explicit processing and on the characteristics of implicit mental models.
Quoting Fosshage, “Rather than change taking place primarily through reflective explanation, the
traditional focus, or primarily through implicit relational learning, . . . this author is emphasizing
the interplay between the implicit and explicit systems for therapeutic change” (p. 71). Fosshage
takes issue with the Boston Change Process Study Group’s notion that procedural knowing of
relationships is encoded nonsymbolically (enactive representations). Fosshage, in turn, argues
that procedural knowledge, largely encoded imagistically (symbolically), achieves its potential
for access to explicit imagistic and verbal symbolic processing. He, thus, reintroduces the impor-
tance of the reflective/exploratory process affecting procedural knowledge, in addition to new
relational procedural learning.
Fosshage highlights the clinical import of understanding that relational procedural knowledge
fluctuates, depending on the process of formation and other factors, such as trauma, intensity
of affects, and frequency of repetition, as to potential accessibility to consciousness. In keeping
 COMMENTARY ON SCHORE, BUCCI, FOSSHAGE PAPERS 105

with Fosshage’s concept of implicit organizing patterns, Davis (2002) also noted that highly
entrenched mental states are apt to become less sensitive to specific contexts and seem to be
more independently generated.
Primary problematic procedures and their origins, Fosshage believes, are variably accessi-
ble to an explicit declarative focus. Thus, in clinical situations when procedural knowledge
is not accessible to consciousness, emphasis on relational experience or “noninterpretive pro-
cesses” will be more fruitful. However, if procedural knowledge can come into consciousness,
via explicit declarative focus, increased awareness gradually contributes to a capacity to sus-
pend momentarily intractable mental models to enable the registration and establishment of new
models, based on co-creation of new relational experience within the analytic relationship, into
long-term memory. Thus Fosshage asserts that there are two fundamental avenues for therapeu-
tic action that work in conjunction but vary in terms of which process is in the foreground in the
moment-to-moment clinical exchange.
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DISSOCIATION

One further point of discussion is Fosshage’s view of dissociation, which provides a difference
from Bucci. Rather than viewing dissociated states as “unsymbolized, unformulated, not me”
states that defensively emerge, Fosshage argues that many of these states can be more parsimo-
niously explained as the activation of implicit procedures, that is learned patterns of interaction,
symbolically encoded, that may or may not involve a defensive process. Schore conceptualizes
dissociation as “a dis-integration of the right brain emotional-corporeal implicit self, the biolog-
ical substrate of the human unconscious” (p. 81), in the face of escalating, unmodulated states
of hyperarousal, disrupting both conscious affective expression and the integration of external
stimuli and internal experience.

CONTRASTING AND INTERPENETRATING THEORIES

While all three papers have areas of interpenetration, the emphases are somewhat different.
Schore accentuates the critical importance of implicit unconscious affect as leading to thera-
peutic change. He states, “At the most fundamental level the implicit change mechanism must
certainly include a conscious or unconscious affective experience that is communicated to an
empathic other” stressing how “the regulation of stressful and disorganizing high or low levels
of affective-autonomic arousal facilitates the repair and reorganization of the right brain, the bio-
logical substrate of the human unconscious” (p. 90). Fosshage, who describes his paradigm as a
relational learning-based model, tilts toward cognitive/affective processing as evidenced in the
importance of affect laden imagistic symbolic mentation of the right brain. Fosshage emphasizes
the affective elements as well as the cognitive elements as he tracks closely the attributions of
meaning with his patient that evoke intense affective responses. Bucci stresses the importance
of affect laden experience and its translation into emotion schemas at subsymbolic and imagistic
symbolic levels.
With regard to the explication of the concept of intuition, Schore parses out the components
to include the sensory range of imagistic cognition and unconscious pattern recognition, which
 106 HERSHBERG

further includes interactional attachment patterns, which he locates primarily in the right brain.
At a point of rupture of the therapeutic relationship he describes the process of repair to include
the therapist’s need to self-regulate and to remain “psychobiologically attuned” to the patient in
the intersubjective moment. While the task, according to Schore, is for the therapist to discover
the subjective experience of insight in the right (emotional) brain, I suspect that there is also
left brain analytic cognitive processing at work. In Schore’s model, while the limbic system
communicates directly with the right hemisphere, there is a bidirectional flow between the right
hemisphere and the left hemisphere, and no direct connection between the left hemisphere and
the limbic system emphasizing the crucial importance of and interaction with right hemispheric
processes. Fosshage speaks to the fluid interplay of right imagistic symbolic processing and
left brain processes at an implicit (subliminal) level. Intuitive hunches emerge out of implicit
processes becoming conscious. Bucci would invoke subsymbolic processing as more relevant to
the experience of intuition, or a hunch.
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From my perspective, following Modell (2003), I propose that metaphor formation to be a

bridging implicit/explicit cognitive linguistic concept. Metaphors are imagistically generated
from multimodal bodily sensations that both shift meanings between disparate arenas and by
means of innovative rearrangements can transform and spawn new perceptions.
What has each contributor identified as crucial to his or her paradigm in understanding thera-
peutic action? Schore focuses on right brain processes and the importance of affect. Bucci posits
that therapeutic change depends on the integration of subsymbolic bodily experience and thus the
activation of emotion schemas, which connect to an image (nonverbal symbolic) and the use of
reflection in the verbal symbolic mode. Fosshage identifies two possible pathways to therapeutic
transformation—when implicit organizing patterns are able to be brought into conscious aware-
ness, then reflective exploration (explicit processing) can make psychological change possible.
On the other hand, when implicit procedural knowledge is not able to be brought into conscious
awareness, then implicit relational experience provides the avenue for change.

FURTHER EXPLORATION OF IMPLICIT PROCESSING

In identifying areas that may shed light on implicit processes, I highlight four areas for further
exploration and consideration from a range of clinical and research domains. These include (out
of awareness) inference making, the crucial importance of the supervisory paradigm in pro-
moting change in clinical work, the use of videotapes as a tool in parent/infant (and child)
observations to help parents expand their awareness of implicitly triggered patterns, and the
interactive use of images and memory triggers in an experimental design to assist Alzheimer’s
patients.
In an elegant study by Lenzi et al. (2008), 16 mothers had brain MRIs recorded while they
were watching and responding to the faces of their own and others’ infants, ranging from 6 to
12 months of age. Clear expressions of joy in the baby led to activation of the right limbic and
paralimbic area in the mother. (Schore’s right brain–to–right brain paradigm) However, ambigu-
ous expressions in the baby led to activation of higher order cognitive and motor areas in the left
brain, which likely reflects the cognitive effort engaged in making sense of expressions not so
readily decoded. This study adds complexity to the role of inference making (and the left brain) in
implicit and explicit processing by a responsive other, when affective expressions are confusing.
 COMMENTARY ON SCHORE, BUCCI, FOSSHAGE PAPERS 107

In a related way, the development of a dependable supervisory relationship, whose explicit

task is to examine the therapeutic relationship between supervisee and patient, provides an
opportunity for therapists to become increasingly aware of their blind spots, whether dissoci-
ated schemas (Bucci), or implicit organizing processes (Fosshage). The supervisor, fostering a
generative ambience, responds affectively and cognitively to a range of out-of-awareness verbal
and nonverbal processes in the supervisee. (I am not highlighting at the moment the aspect of
a bidirectional flow in this relationship.) Over time, a sensitive and responsive supervisor can
bring explicit attention to tracking particular sequences in the work and can modify repetitive
“devitalizing mental models” (Fosshage) in his or her supervisee. For example, an analyst whom
I was supervising, Dr. A., was feeling that a patient was disconnected. As a result, Dr. A. was
making increasingly, I felt, intrusive efforts to engage with his patient, who to my thinking was
actively engaged and brought in evocative material. When I let Dr. A. know how I experienced
the exchange, he recalled a memory from childhood in which a playmate experienced him as
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exerting pressure on him when Dr. A.’s intention was to communicate his desire to play. Dr. A.
became disappointed when his playmate eventually withdrew and went home early. Dr. A., a
very warm and reflective person, was aware of his need to feel more from the other person in
order to feel connected to himself. As a result, at least in part, of growing up with an author-
itarian and critical father and a fragile, depleted mother, he was able to recognize this specific
theme and the effects of his dysregulation, as one familiar to him and how he could be, in this
instance, out of touch with the patient. By attending to moments when he felt disconnected, he
was increasingly able to consider his own proneness to need more emotionally from the other in
order to feel a sense of himself and a connection to the other, and his repetitive attempt to elicit
that feeling in the interaction. At those times he endeavored to enhance his awareness by tracking
more carefully the patient’s affect to help him differentiate his feeling from that of his patient.
The use of videotapes in parent/infant (and child) observation provides a tool in which
the awareness of implicit processing can be used as a powerful (preventive) intervention. As
Fosshage states, “When implicit procedural knowledge and explicit attitudes are accessible to
reflective conscious awareness, then reflective exploratory work, as part of and along with new
implicit and explicit relational experience, facilitates psychological transformation” (p. 71). The
work of Stern (1985), Beebe and Lachmann (2002), Tronick (2007), Fivaz-Depeursinge and
Corboz-Warnery (1999), Fivaz-Despeursinge, Lavancy-Scaiola, and Favez (2010), and others,
in which small segments of the dyadic and triadic parent/infant interactions have been used for
research purposes, I propose, has enormous potential as an intervention and educational tool for
parents. In the hands of trained infant observers, who would tape and then review the videotapes
with parents, contextualized as part of well child pediatric visits, they can call attention to a range
of implicit interactions without pathologizing these interactions, and thus facilitate a beginning
process of reflective awareness for parents at a very early stage of parent/child development and
when parents’ motivation is so often heightened.
Lastly, utilizing a device called a Sensecam, which houses a digital camera and an apparatus
that measures movements and that can be interactively controlled by the patient, researchers are
exploring which memory cues most effectively enhance Alzheimer’s patients’ vivid recall of
experiences, the affective core (Bhattacharjee, 2010). Preliminarily, researchers found that there
was great individual variability in regard to which visual cue triggered vivid recollection in a
particular individual. In addition to numerous digital photographs, which can be pruned to a
smaller, more concentrated few, audio narratives can be added by family members in an effort
 108 HERSHBERG

to have the patient select those audio and visual images by tapping on a screen, which promotes
heightened recall of the experience, eliciting an expression of recognition, a smile or nod, or an
acknowledging, “I remember this.”

CONCLUSION

In closing, I refer to Piaget’s (1974) comments on Darwin’s creativity, in which he spoke of the
epistemology of theory building, which, I believe, informs the contributions of Schore, Bucci,
and Fosshage in which implicit and explicit domains are conceptualized cognitively, neurobi-
ologically, and psychoanalytically in thinking about what promotes change in the therapeutic
domain. Piaget states,
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The construction of a new theory is far from being reducible to the accumulation of data, but neces-
sitates an extremely complex structuring of interpretive ideas which are linked to facts and which
enrich them by framing them in a context. . .Every alteration at one point gives rise to a modifica-
tion of the system as a whole. This process maintains both the coherence of the system and at the
same time the adequacy of its fit to the data of experience and observation (a double dialectic of
external—subject x object and internal—relations among ideas and hypotheses). (p. viii)

With regard to “the mysterious passage from the implicit to the explicit in the creation of new
ideas,” Piaget reflects on Darwin’s elaboration of his fairly simple model, implicit in his thoughts
for many years as he aptly compares the complexity of the creative process to the developmental
aspects of thought itself. Piaget continues,
The passage from “implicit” schemas (that is, schemas already playing a role in certain acquired
structures, but unconsciously) to their reflective explication . . . is far from being immediate. This
delay establishes the point that making things explicit leads to the construction of a structure which
is partially new, even though contained virtually in those structures which precede it. . . . The need to
maintain a general equilibrium of the system or theory as a whole requires a difficult balance between
differentiations and integrations from which requirement derives the necessity of a certain rhythm.
(p. viii)

As Piaget (1974) describes the complexity of the task of constructing a theory that both inte-
grates and differentiates, that utilizes the data of the observed and the experienced along with the
relationship of ideas to each other, we can appreciate the scholarly contributions of Schore and
his theory of the implicit, right-brained self, Bucci and her further delineation of subsymbolic
processing as foundational, and Fosshage and his integration of explicit and implicit process-
ing, emphasizing the importance of imagistic symbolic encoding and processing, in an effort to
understand what leads to therapeutic change.

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CONTRIBUTOR

Sandra G. Hershberg, M.D., is Director of Psychoanalytic Training, Founding Member,

Training and Supervisory Analyst, Institute of Contemporary Psychoanalysis and Psychotherapy
Washington, DC; Faculty Member, Washington Center for Psychoanalysis, Washington, DC.