Becoming Aware of Feelings: Integration of Cognitive ...

Neuro-Psychoanalysis, 2005, 7 (1) 5

Becoming Aware of Feelings: Integration of Cognitive-Developmental,Neuroscientific, and Psychoanalytic Perspectives

Richard D. Lane (Tucson) & David A. S. Garfield (North Chicago)

A fundamental ingredient of psychoanalytic treatment is the ability of the analysand to become consciously aware of his or her ownemotional responses. We propose that the conscious awareness of emotion is a type of information processing that can be viewedas a separate domain of cognitive function, that the transition from unconscious (implicit) to conscious (explicit) aspects ofemotion can be understood developmentally in the manner described by Piaget for cognitive functions generally, and that explicitemotional processes have a modulatory effect on implicit processes. We then present a parallel hierarchical model of the neuralsubstrates of emotional experience supported by recent neuroimaging work. We describe how the neural substrates of implicit andexplicit aspects of emotion are dissociable, and we discuss the neural substrates of implicit aspects of emotion, backgroundfeelings, focal attention to feelings, and reflective awareness of feelings. This framework constitutes an alternative to traditionalpsychoanalytic understandings of insight. We conclude by discussing the implications of this model for psychoanalysis, includingthe nature of clinical change, the psychological processes involved in change with and without insight, and a framework forconceptualizing how to promote emotional change in a variety of clinical settings.

Richard D. Lane: Professor of Psychiatry, Psychology, and Neuroscience, University of Arizona College of Medicine, Tucson, Arizona, U.S.A.; DavidA. S. Garfield: Professor of Psychiatry, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, U.S.A., and Advanced Candidate,Chicago Institute for Psychoanalysis.

Correspondence to: Dr. Richard D. Lane, Department of Psychiatry, 1501 N. Campbell Ave. Tucson, AZ 85724–5002, U.S.A. (email:[email protected]).

Acknowledgment: The authors thank Kateri McRae, B.A., M.S., for her assistance with the review of the functional-neuroimaging literature.

The discovery of implicit cognitive processes (Kihl-strom, 1987) was a source of considerable excitementfor many psychoanalysts. For the first time, mainstreamscience was demonstrating that unconscious mentalprocesses really do exist. Nevertheless, while tantaliz-ing, a significant gulf remained between the types ofphenomena addressed by this new domain of cognitivescience and the types of complex clinical realitiesencountered in the psychoanalytic consulting-room. Inparticular, given the centrality of affect in dynamicmental life, the focus on cognition constituted a barrierto clinical applicability. This paper, however, beginswith the proposition that insights about the distinctionbetween implicit and explicit cognitive processes areapplicable to emotion (Lane et al., 2000). Furthermore,results from recent studies of brain function includingneuroimaging reinforce the neuroanatomical distinc-tion between implicit and explicit emotional processes.As such, new opportunities exist to bridge the gapbetween psychoanalysis and that aspect of cognitivescience dealing with affect.

Eric Kandel, a psychiatrist and Nobel Laureate, hasdiscussed the importance of a two-way dialogue be-tween psychoanalysis and neuroscience (Kandel,1999). Kandel points out that psychoanalysis can beof benefit to neuroscience by focusing on importantphenomena that are worthy of scientific exploration. Infact, the work on levels of emotional awareness pre-sented below is inspired by the fundamental psycho-analytic concept guiding analytically oriented workthat it is therapeutic to help patients become con-sciously aware of their own emotions. Why this isuseful, and how it works exactly, are much moredifficult questions to answer. Nevertheless, this foun-dational clinical observation highlights the criticalimportance of understanding the transition from emo-tional responses that are not conscious to those that areand the neural processes that mediate this transition.

Conversely, new knowledge generated within thefield of cognitive neuroscience can be useful to psy-choanalysis in both general and specific ways. Ourunderstanding of how the brain works is expanding at a

6 Richard D. Lane & David A. S. Garfield

very rapid rate, and the insights gained can have animportant influence on our understanding of phenom-ena that are important to psychoanalysis. Examplesinclude memory, dreaming, and affective processesgenerally, to name a few. Although useful, neuro-scientific findings in these areas remain somewhatdistant from the actual clinical encounter. Rather, weintend to use new knowledge about the cognitive neu-roscience of emotion in a very specific way—to selectfrom the multitude of psychoanalytic perspectives onaffect to identify those that are consistent with modernneuroscience, and to explore the implications of theassociated neuroscientific findings for the actual prac-tice of psychoanalysis. As such, our approach to thepsychoanalytic literature will be selective rather thancomprehensive.

As a neurologist, Freud’s original goal was to un-derstand the biological basis of mental life. As weknow, he abandoned his “Project for a Scientific Psy-chology” (Freud, 1950 [1895]) because, given the toolsavailable in the late nineteenth century, it was simplynot possible to develop an in-depth understanding ofneurobiology relevant to psychoanalysis. This has nowchanged, because functional neuroimaging is ideallysuited for studying the function of the large-scaleneural networks that mediate complex cognitive andemotional functions (Mesulam, 1998). The focus ofthe current paper is therefore eminently Freudian inthat we are using insights gained from neurobiologicalresearch to inform psychoanalytic thought.

It should be noted, however, that the way in whichwe propose to use neurobiological understanding inthis paper is quite different from Freud’s approach.Merton Gill (1976) pointed out that Freud’s meta-psychology (e.g. drive theory) derives from prior bio-logical assumptions. These biological concepts, such asinstinctual drives, were not essential to the clinicalpractice of psychoanalysis. This insight has contributedto an effort by Gill and others to disentangle psycho-analytic metapsychology from the clinical psychologyof psychoanalysis. We are taking as our starting-point acentral clinical observation—that it is useful to becomeaware of one’s feelings—and are using this as thestepping-stone to delve into relevant neurobiology.Thus, our exploration of neurobiology follows from theanalytic observations. To the extent that these findingscan then extend psychoanalytic understanding, we willhave come full circle. It is our hope that the applicationof these principles to the psychoanalytic domain willenable analysts to refine their ability to help patientsbecome aware of their own affective states and willenhance their understanding of both the mechanismsand the importance of this process.

Emotion from the perspective ofpsychoanalytic theory

Although affect played an important role in Freud’smetapsychology, Freud’s theories of affect were inconstant evolution, he did not treat the topic directly inany systematic way, and he never formulated a coher-ent theory of how affect contributes to mental disordersor how affect changes during the course of psycho-analysis. A variety of analytic theorists have subse-quently addressed the topic, and important advanceshave been made. Nevertheless, the absence of a coher-ent psychoanalytic theory of affect (Basch, 1976, 1991;Joseph, 1975; Rapaport, 1950, 1953) has been consist-ently noted over the last half-century, and these sameauthors proclaim that there is a desperate need for sucha theory.

This is readily understandable given the centralityof affect in the field. In almost every account ofpsychoanalytic success, the idea that the patient haschanged, affectively, is central to the proof of change(Abend & Nersessian, 1989; Garfield, 1995; Kantro-witz, 1997; Spezzano, 1993; Valenstein, 1962). Onereason why such a theory does not exist is becausepsychoanalytic theorists have been interested in howthe mind works more generally, and how affect fitsinto a general model of mental life. A psychoanalytictheory of affect would need to explain how the affectsystem develops and works in normality, how it goesawry in psychopathology in interaction with othermental operations, and how therapy can correct abnor-malities—a tall order indeed, given our current state ofknowledge. The difficulty of such an undertaking isevident when it is considered that within the domainof affect science, a universally accepted theory ofemotion or affect does not exist (Ekman & Davidson,1994). A primary reason for this lack is that knowl-edge about the different facets of emotion is tooincomplete to allow for a meaningful integrationat this time. Emotion consists of several different com-ponents including the biological (physiological), psy-chological (behavioral and experiential), and social(expressive). Laboratory studies examining corre-spondences across domains (e.g. the correlation be-tween self-reported emotional experience and auto-nomic indices of arousal) typically reveal modest orinsignificant findings (Bradley & Lang, 2000). Al-though loose coupling between components may beideal for adaptive flexibility (Thayer & Lane, 2000), ithas not yet been possible to account for such a lack ofcoherence. Together these considerations make it clearwhy such a coherent theory does not exist withinpsychoanalysis. For the time being, we need to be less

Becoming Aware of Feelings 7

ambitious and more focused in our theoretical ap-proaches to affect.

Given the need to be selective, the domain of con-scious emotional experience may be the one mostrelevant to the clinical practice of psychoanalysis.Psychoanalysis can broadly be conceptualized as atechnique that uses the conscious mind to access andintegrate unconscious processes. The ability to con-sciously experience affects associated with unresolvedissues is a key goal in the psychoanalytic process.Thus, the relationship between conscious and uncon-scious emotion is critically important clinically andwill be an important component of any future compre-hensive psychoanalytic theory of affect.

Psychoanalysis began in 1895 with the seminalstudies of hysteria by Breuer and Freud (Freud, 1895).In their model, “strangulation of affect” was the maincause of hysteria. The memory of the traumatic eventwas associated with affect that could not be adequatelyprocessed at the time of the trauma. Neurotic symp-toms were a result of this failure to express the emo-tions that the patient was presumed to have felt at thetime of the trauma. At that time the unexpressed emo-tion was thought to be symbolically expressed in asomatic symptom. Based on this conception, it natu-rally followed that abreaction (emotional discharge)would enable patients to free themselves from theaffect that was causing their psychological condition.

At that early stage in his work, Freud conceived ofaffect as psychic energy that needed to be released andthat created problems if it was not. The notion of affectas a quantifiable substance (hydraulic model) quicklyshifted. The second role that Freud postulated foraffect in mental life was that of a “safety valve.” Whenconfronted with situations that were overwhelmingand resulted in a sense of helplessness, affect couldkeep the psyche from disruption by attaching to fan-tasy, as in a wish. Thus, affect could be discharged informs such as wish-fulfilling dreams. Here affectmoved from one set of ideas to another in order toavoid a dangerous “psychoeconomic” imbalance. Inthis setup, affect still retains its energic cast but isembedded in an ideational matrix.

Freud’s theory of affect had a third phase, in whichaffect was viewed as an information-containing struc-ture (Spezzano, 1993). As Freud developed the tripar-tite model of the mind to replace the topographictheory, he similarly moved his concept of anxiety andaffect away from an energic notion (the “actual neuro-ses”) to one of structured information. The signaltheory of anxiety (Freud, 1926) conceives of affect asinformation. The ego can take appropriate defensivemaneuvers to avoid a situation in which the accom-

panying affect signals danger. The danger has to dowith the potential to experience stronger affects thatmay be unbearable. The ego, like a forward scout,reads the information contained in the upcoming affectstate to be dangerous, and, thus, the affect state “sig-nals” the ego, via anxiety, to take evasive action.

As noted above, Freud’s writings on emotion wereby no means comprehensive, systematic, or internallyconsistent. The at-times fragmentary and contradictorynature of his writings on this topic have been reviewedin some detail in this journal (Solms & Nersessian,1999). Nevertheless, one can glean a progressive evo-lution and complexity in Freud’s thinking about affectfrom pure energy, to energy infusing ideas, to affecthaving a particular cognitive meaning. Over time theimportance of the cognitive content of affective re-sponses became progressively important in Freud’sthinking. In his volume on affect in psychoanalysis,Spezzano (1993) credits Freud with recognizing themental aspect in affect and seeing that “a feeling is notsimply a physical sensation that must be taken intoaccount psychically but is inherently psychological asan idea” (p. 62). The signal theory also included theidea that emotion could be friend or foe—potentiallyhelpful or potentially disruptive. However, duringFreud’s lifetime affects were still viewed as derivedfrom instincts and were embedded in a highly complexmodel of the mental apparatus as a whole. Further-more, the prevailing Cartesian view that emotion andcognition opposed one another, that emotion corre-sponded to animalistic instincts while cognition rep-resented man’s most refined and noble abilities(Damasio, 1994), no doubt contributed to the difficultyin carrying the cognitive meaning of emotion muchfurther. This situation has been altered with the re-newed appreciation of the Darwinian perspectivewithin scientific psychology that emotions primarilyserve an adaptive, as opposed to disruptive, function(Frijda, 1994).

In the post-Freudian era, the move away from drivetheory to object relations, and more recently to self andrelational psychology, has witnessed the progressive“unhooking” of affect from the instincts. Freed fromthe theoretical constraint of instinct, an appreciation ofthe adaptive nature of affects has gradually emerged inpsychoanalytic writing. Ego psychology and object-relations theorists have attempted to understand thenature of the differences in the mental experiences(including affect) of patients with different degrees ofpsychopathology and how the process of psychoanaly-sis and psychotherapy leads to clinical change (Gedo& Goldberg, 1973). An organizing concept that hasbeen found to be especially useful is that of psychic


structure. From a clinical rather than metapsycho-logical standpoint, psychic structure refers to the de-gree of differentiation and integration of the contentsof mental activity (Stolorow, 1978). The concept hasachieved its greatest clarity and clinical applicabilityas it is applied to self and object representations(Stolorow, 1978). Given that differentiation and inte-gration are central organizing concepts in Piaget’sapproach to cognitive development, it is not surprisingthat a cognitive-developmental approach to object rep-resentation has been developed and has proven useful(Blatt, 1974; Greenspan, 1979).

Object-relations theorists have for some time recog-nized an association between the structure of objectrepresentation and the structure of emotion or affect(Mahler, Pine, & Bergman, 1975; Novey, 1961;Schmale, 1964). However, the discussion of emotionfrom a cognitive-developmental perspective has notyet been clearly differentiated from object-relationstheory. Similarly, among ego psychologists, Blanckand Blanck (1974, 1979) postulated a developmentalline of progressive differentiation of affects in associa-tion with progressive maturation of ego functions. Theconstruct of levels of emotional awareness that wediscuss below aims to describe a developmental ap-proach to emotional experience that is independent ofthe related phenomena of object representations andego functions in the sense that one need not invokethese other complex concepts in order to understandthe theory involving emotion.

More recently, the study of emotional develop-ment in infants and young children has led to anappreciation of the nonverbal, procedural organiza-tion of emotion and its implications for therapeuticchange in the absence of insight. Stern (1985) haswritten extensively about the nonverbal interactionsand attunements that take place between mother andchild, how these interactions contribute to the child’semotional development, and how related processesoccur in the analytic situation. Beebe and Lachmann(1988) have explored how nonverbal interactions be-tween mother and child shape self and object repre-sentations and how similar processes in adults canlead to therapeutic change. Bucci’s (1997) multiple-code theory of emotion schemas in the verbal andnonverbal domains addresses similar phenomena andhelps to explain the clinical phenomenon of somatiza-tion. Clyman’s (1991) work on the “procedural organi-zation of emotion” is particularly relevant to thecurrent paper. Clyman focuses on how emotion isencoded, unconsciously, into automatic proceduresduring childhood for the purpose of promoting mainte-nance of one’s emotional equilibrium. He points out

that a thorough knowledge of how implicit and ex-plicit memory works is central to understanding thevarious avenues through which analytic change cantake place.

These four psychoanalytic writers have each dis-cussed phenomena that can be considered expressionsof implicit vs. explicit cognition and their importancein emotional development. The levels-of-emotional-awareness construct, to which we now turn, addressesthe relationship of these cognitive phenomena to emo-tion by showing how the implicit–explicit distinctionapplies to emotion. Furthermore, by adopting a cogni-tive-developmental perspective and applying the fun-damental psychoanalytic concept that individualdifferences in adulthood can be explained by arresteddevelopment at differing points along a developmentalcontinuum (A. Freud, 1965), the levels-of-emotional-awareness model addresses how the relationship be-tween the implicit (including procedural) and explicitaspects of emotional life can be used to characterizeadults at various levels of adaptation.

Levels of emotional awareness

The preceding review of the psychoanalytic literaturedemonstrates that cognitive-developmental approacheshave proven useful in the domain of object-relationstheory. There has also been frequent reference in thepsychoanalytic literature to the concept of emotionaldevelopment. Nevertheless, for the reasons notedabove, a general psychoanalytic theory of emotionaldevelopment does not exist. The levels-of-emotional-awareness framework is an attempt to partially addressthis deficiency by focusing on the domain of emotionalexperience. The model provides a framework for un-derstanding developmental changes within individualsor developmental differences between individuals inthe domain of emotional experience.

The first theoretical paper on levels of emotionalawareness appeared in 1987. Lane and Schwartz(1987) proposed that an individual’s ability to recog-nize and describe emotion in oneself and others, calledemotional awareness, is a cognitive skill that under-goes a developmental process similar to that whichPiaget described for cognition in general. A fundamen-tal tenet of this model is that individual differences inemotional awareness reflect variations in the degree ofdifferentiation and integration of the schemata (el-ementary knowledge structures) used to process emo-tional information, whether that information comesfrom the external world or from the internal worldthrough introspection.


The model posits five “levels of emotional aware-ness” that share the structural characteristics ofPiaget’s stages of cognitive development (Piaget,1937). The five levels of emotional awareness in as-cending order are awareness of physical sensations,action tendencies, single emotions, blends of emotions,and blends of blends of emotional experience (thecapacity to appreciate complexity in the experiences ofself and other).

Emotional awareness is considered to be a separateline of cognitive development that may proceed some-what independently from other cognitive domains. Theconcept that development can proceed at differentrates in different domains of knowledge is known ashorizontal decalage. In principle, it is entirely possiblethat a developmental arrest can occur in one domainwhile development in other domains of intelligencecontinues unabated.

The five levels therefore describe the cognitive or-ganization of emotional experience. They describetraits, although they may also be used to describestates. The levels are hierarchically related in thatfunctioning at each level adds to and modifies thefunction of previous levels but does not eliminatethem. For example, blends of emotion (Level 4 experi-ences), compared to action tendencies (Level 2 experi-ences), should be associated with more differentiatedrepresentations of somatic sensations (Level 1). Thefeelings associated with a given emotional responsecan be thought of as a construction consisting of eachof the levels of awareness up to and including thehighest level attained.

The development of representational schemata isfacilitated by the language or other semiotic mode usedto describe emotion. This perspective draws on Wernerand Kaplan’s (1963) work on symbol formation whichmaintained that the way the world becomes known toan observer is influenced by the way in which it isrepresented symbolically. Thus, the nature of con-scious emotional experience, and the ability to appreci-ate complexity in one’s own experience and that ofothers, is influenced by how emotion is represented.

This position is also consistent with that of Piaget’sfollowers such as Karmiloff-Smith (1992), who holdsthat the development of knowledge proceeds through aprocess called “representational redescription.” In es-sence, cognitive development from this theoretical per-spective consists of the transformation of knowledgefrom implicit patterns (procedural, sensorimotor) toexplicit representations (conscious thought) throughuse of language or other semiotic mode. This transfor-mation renders thought more flexible, adaptable, andcreative. This viewpoint is consistent with the theory

that the way language is used to describe emotionmodifies what one knows about emotion and howemotion is experienced consciously.

The five levels of emotional awareness can there-fore be mapped onto the distinction between implicitand explicit processes. Level 1 (physical sensations)and 2 (action tendencies) phenomena, viewed in isola-tion, would not typically be considered indicators ofemotion, but when emotional responses occur these arefundamental components of emotional responses. Theperipheral physiological arousal and action tendenciesassociated with emotion are implicit in the sense thatthey occur automatically and do not require consciousprocessing in order to be executed efficiently. If onefocuses conscious attention on a somatic sensation oraction tendency in isolation, emotion is implicit in thesense that the specific quality of experience (an emo-tional feeling) needed to call it an emotion is lackingand requires processing at higher levels. Levels 3, 4,and 5 consist of conscious emotional feelings at differ-ent levels of complexity. These conscious feelingsconstitute explicit aspects of emotion in the sense that(a) they are conscious and (b) they have the requisitequalitative characteristic needed to unequivocally clas-sify these experiences as emotional feelings. The lev-els-of-emotional-awareness framework therefore putsimplicit and explicit processes on the same continuumand, at the same time, distinguishes between types ofimplicit (Level 1 vs. Level 2) and explicit (Level 3 vs.Level 4 vs. Level 5) processes.

Implicit aspects of emotion can be conceptualizedas the automatic motor expressions of emotion that getmodulated by emotion-regulation strategies. These in-clude the autonomic, neuroendocrine, and somato-motor (gestures, facial expressions, action tendencies,and procedural scripts) components of emotional re-sponses. They include rule-based schemas for behavioror procedures that operate automatically (i.e. they donot require conscious thought, and the factors thatcontribute to the etiology and maintenance of thebehavior are typically not consciously accessible) suchas how to express love, obtain love and reassurance,handle anger, get attention, and joke around. As such,they serve the very useful function of permitting themanagement of emotional responses without requiringthe use of limited resources for conscious, executiveprocessing.

The application of the implicit–explicit distinctionto emotion has been independently proposed by Kihl-strom, Mulvaney, Tobias, and Tobis (2000). In theirview, as in ours, implicit aspects of emotion consist ofthe physiological and behavioral components of emo-tion, whereas explicit aspects of emotion consist of


conscious feelings. As such, Stern’s, Beebe’s, Bucci’s,and Clyman’s work, which has already been acceptedwithin the psychoanalytic literature, has addressed thesame phenomena but differs from our account and thatof Kihlstrom and colleagues primarily in that the phe-nomena are not labeled in the same way. An advantageof the current approach is that it is clear that we aredealing with emotion and its various manifestations, atopic that has been both central and elusive for psy-choanalysts and, as such, establishes a foundation forconceptualizing the nature of the transformations thatoccur in emotion as one becomes aware of feelings.An additional advantage, as we discuss below, is thatby establishing links to cognitive neuroscience andthe fundamental principles of that field, it informsthe search for the neural substrates of these phenom-ena.

The Levels of Emotional Awareness Scale:psychometric findings

Empirical evaluation of the emotional-awarenessframework has been made possible with the Levels ofEmotional Awareness Scale (LEAS). The LEAS is awritten-performance measure that asks a person todescribe his or her anticipated feelings and those ofanother person in each of 20 scenes described in two tofour sentences (Lane, Quinlan, Schwartz, Walker, &Zeitlin, 1990). Scoring is based on specific structuralcriteria aimed at determining the degree of differentia-tion in the use of emotion words (the degree ofspecificity in the terms used and the range of emotionsdescribed) and the differentiation of self from other.The scoring involves essentially no inference by raters.Because the scoring system evaluates the structure ofexperience and not its content, individuals cannotmodify their responses to enhance their score, as is thecase with some self-report instruments. A glossary ofwords at each level was created to guide scoring.

Each the 20 scenes receives a score of 0 to 5corresponding to the cognitive-developmental theoryof emotional awareness that underlies the LEAS (Lane& Schwartz, 1987). A score of 0 is assigned whennonaffective words are used, or when the word “feel”is used to describe a thought rather than a feeling. Ascore of 1 is assigned when words indicating physi-ological cues are used in the description of feelings(e.g. “I’d feel tired”). A score of 2 is assigned whenwords are used that convey relatively undifferentiatedemotion (e.g. “I’d feel bad”), or when the word “feel”is used to convey an action tendency (e.g. “I’d feellike punching the wall”). A score of 3 is assigned

when one word conveying a typical, differentiatedemotion is used (e.g. happy, sad, angry, etc.). A scoreof 4 is assigned when two or more Level 3 wordsare used in a way that conveys greater emotionaldifferentiation than would either word alone. Re-spondents receive a separate score for the “self” re-sponse and for the “other” response ranging from 0 to4. In addition, a total LEAS score is given to eachscene equal to the higher of the self and other scores.A score of 5 is assigned to the total when self andother each receive a score of 4 and are differentiatedfrom one another; thus, a maximum total LEAS scoreof 100 is possible.

The LEAS has consistently been shown to have highinterrater reliability and internal consistency (Lane etal., 1998). The test–retest reliability at 2 weeks hasbeen shown to be quite good. Norms for age, sex, andsocioeconomic status have been established.

A variety of studies support the construct validity ofthe LEAS. The LEAS correlates moderately positivelywith two cognitive-developmental measures: the Sen-tence Completion Test of Ego Development byLoevinger (Loevinger & Wessler, 1970; Loevinger,Wessler, & Redmore, 1970) and the cognitive com-plexity of the description of parents by Blatt andcolleagues (Blatt, Wein, Chevron, & Quinlan, 1979).These results support the claim that the LEAS is meas-uring a cognitive-developmental continuum and thatthe LEAS is not identical to these other measures.Greater emotional awareness is associated with greaterself-reported impulse control, consistent with thetheory that functioning at higher levels of emotionalawareness (Levels 3–5) modulates function at lowerlevels (actions and action tendencies at Level 2).Greater emotional awareness is also associated withgreater openness to feelings (Lane, Quinlan, Schwartz,Walker, & Zeitlin, 1990) and greater emotion recogni-tion ability (Lane et al., 1996; Lane, Sechrest, Riedel,Shapiro, & Kaszniak, 2000). The LEAS correlatespositively with empathy ability, certain subtests of anew measure of emotional intelligence, the tendency toseek help for emotional problems, and the actualamount of social support that a person has. Addition-ally, in an important experimental validation in healthyvolunteers, judgments of general well-being were notinfluenced by transient mood induction in high LEASsubjects, whereas in low LEAS subjects transient in-duction of a negative mood state was associated withlower ratings of general well-being (Ciarrochi, Caputi,& Mayer, 2003).

A key question is whether the LEAS is simplyanother measure of verbal ability. The LEAS corre-lates moderately positively with the verbal subtest of


the WAIS (Lane et al. 1990). In all studies performedto date, women score higher than men on the LEAS,even when verbal ability is statistically controlled(Barrett, Lane, Sechrest, & Schwartz, 2000), suggest-ing that this sex difference is a highly stable andgeneralizable finding. Furthermore, in the study ofemotion-recognition ability, the LEAS correlated posi-tively with performance on a purely verbal task as wellas a purely nonverbal task (Lane et al., 1996). TheLEAS is therefore more than simply a measure ofverbal ability. A modified version of the LEAS hasbeen created and administered to children ages 10–11.As expected, children scored lower on the LEAS thanadults. Consistent with adult studies, girls scoredhigher than boys on the LEAS, and sex differencesremained when variance due to verbal ability wasremoved (Bajgar, Ciarrochi, Lane, & Deane, in press).

Evidence for the discriminant validity of the LEASis provided by the finding that the LEAS is not cor-related with the intensity with which affect is ex-perienced (Larsen & Diener, 1987) or the tendency toexperience negative emotions such as depression(Beck, Rush, Shaw, & Emery, 1979) or anxiety(Taylor, 1953). Together these findings support theclaim that the LEAS is (a) a measure of the cognitive-developmental schemata used to process emotionalinformation, whether the information is verbal or non-verbal; (b) a measure of the complexity of emotionalexperience; and (c) not merely a measure of verbalability.

Clinically, it has been shown that patients withborderline personality disorder score lower on theLEAS than age-matched control subjects (Levine,Marziali, & Hood, 1997). In a study of 40 patients withirritable-bowel syndrome, pain severity and LEASwere inversely correlated; in a study of 40 patientswith fibromyalgia, the LEAS was inversely correlatedwith nonspecific (i.e. unrelated to fibromyalgia) so-matic complaints; and in a study of 250 inpatients in apsychosomatic inpatient unit in Germany, LEASscores of patients with somatoform disorders werelower than those with mental disorders (e.g. depres-sion, anxiety) on admission. After 3 months of multi-modal treatment including insight-oriented therapy,the LEAS scores of somatoform patients, but not thoseof other patient groups, increased significantly relativeto admission (Subic-Wrana, Bruder, Thomas, Lane, &Köhle, in press). The specificity of the latter findingssuggests that the LEAS is tapping into deficits inemotional awareness as opposed to a dysphoric moodstate. All of these clinical findings are consistent with apriori predictions and support the clinical applicabilityof the levels-of-emotional-awareness framework.

Neural correlates of emotional awareness

The neuroscience of affective processing is an excitingand rapidly advancing field. The field has advancedbecause tractable phenomena such as the neural basisof the perception of emotional expression in faces andaversive conditioning have become amenable to studyin animal models, healthy volunteers using functionalneuroimaging, and patients with discrete brain lesions.The study of interactions between emotion and cogni-tion with functional neuroimaging have become in-creasingly sophisticated, including increasing interestin emotion regulation (Ochsner, Bunge, Gross, &Gabrieli, 2002), and the interpersonal dimension hasbeen added recently in the newly emerging field ofsocial neuroscience (Cacioppo et al., 2002). At thesame time there has been an acceptance within thescientific community that conscious experience is alegitimate topic of scientific inquiry (Hameroff,Kasniak, & Chalmers, 1999). It is not surprising, then,that the neural basis of conscious emotional experiencehas become a topic of considerable interest, with someseminal contributions from Damasio (1994, 1999,2003) and others.

The brain and emotion literature has been the topicof a number of other published volumes (e.g. Lane,Nadel, Allen, & Kaszniak, 2000; LeDoux, 1996;Panksepp, 1998; Rolls, 1999) and is far too vast to besummarized here. Nevertheless, it may be helpful toput the current model in context by comparing andcontrasting it with the work of several others.

For example, Davidson (1995) has focused on theconcept of emotional style and studied the relationshipbetween asymmetrical activation of dorsolateral pre-frontal cortex and the predisposition for emotionalstates associated with approach or avoidance. Tucker(1981) has proposed an alternative model that takes thelateralization of cortical and subcortical structures andtheir interactions into account, while Ross, Homan,and Buck (1994) has focused on the predominance ofthe right hemisphere in social emotions. Our modeldiffers from all of these by focusing on medial ratherthan lateral systems and by emphasizing the verticalrather than the horizontal dimension.

MacLean’s triune brain model (1990) resembles thecurrent model by emphasizing the hierarchical organi-zation of brain structure that emerged during thecourse of evolution. MacLean, like Panksepp (1998),has proposed that activation of limbic and other sub-cortical structures alone is sufficient for the consciousexperience of emotion. For reasons that are addressedat some length below, we take the view that corticalparticipation is necessary for emotional experience.


Finally, Mayberg and colleagues (Mayberg, 2003;Mayberg et al., 1999) have written persuasively abouthow functional activity within the neural network me-diating mood becomes dysfunctional in the clinicalcontext of depression. Although we are similarly inter-ested in the changes in emotional functioning thatoccur in clinical situations, our focus is on the neuralbasis of the transformations that occur in emotion asone becomes aware of feelings during psychoanalysis,and, relatedly, what happens when emotions are acti-vated in the absence of subjective feelings.

In this section we address the neural correlates ofemotional awareness. A systematic survey of the neuralcorrelates of each of the levels of emotional awarenesshas not yet been undertaken, either in between-subjectsor within-subjects designs. Nevertheless, it is still pos-sible to examine the neural substrates of certain aspectsof the conscious experience of emotion. In this sectionfour different aspects of the conscious experience ofemotion are considered: implicit aspects of emotion,background feelings, focal attention to feelings, andreflective awareness of feelings. These aspects of emo-tional experience are highlighted because they arerelevant to emotional awareness and are supported bythe current neuroimaging literature.

As described above, implicit aspects of emotioninclude those sensory and motor aspects of emotionalresponses that precede the emergence of an emotionalfeeling state. Background feelings are emotional stateson the periphery of awareness that color consciousexperience but are not noticed as such unless attendedto. Focal attention to feelings refers to the condition inwhich one’s own subjective emotional state is theobject of directed attention. Reflective awareness in-volves thinking about the contents of conscious emo-tional experience, typically after it has been the objectof focal attention. Thus, there is a progression in thedegree of conscious processing involved. We will con-sider the neural substrates of each of these categoriesin turn.

A. Implicit aspects of emotion

The distinction between implicit and explicit processesis well established in cognitive neuroscience becausethe neural substrates of implicit and explicit cognitiveprocesses are dissociable. For example, explicitmemory for facts and events requires participation ofmedial temporal-lobe structures (such as the hippo-campus) and diencephalon, whereas implicit memoryrequires structures such as the striatum (skills andhabits), neocortex (priming), amygdala and cerebel-

lum (classical conditioning), and reflex pathways(nonassociative learning). Implicit processes have alsobeen demonstrated in a variety of other cognitive do-mains, including attention, perception, problem solv-ing, etc. (Gazzaniga, Ivry, & Mangun, 2002). Thisbody of research has led to a growing recognition thatconsciousness is the tip of the cognitive iceberg, in thesense that most cognitive processing occurs outside ofconscious awareness. Given the evidence presentedabove that the implicit–explicit distinction applies toemotion, it follows from this general principle that theneural substrates of implicit and explicit emotionalprocesses are dissociable. What might these neuralsubstrates be?

One clue may be derived from the concept of modu-lar processing. Ladavas Cimatti, del Pesce, and Tuozzi(1993) have shown that the presence or absence ofemotional content can be accurately detected in sub-liminally presented pictures. Drawing on Fodor’s(1983) concept of modularity, these researchers sug-gest that these and other findings support a criticaldistinction between modular and nonmodular emotion-information processing. Modules are domain-specificcomputational devices for functions such as languageor vision that are cognitively impenetrable and gener-ate shallow output. Cognitive penetrability (or infor-mational encapsulation) refers to the degree to whichinformation processing can be influenced by priorknowledge, expectations, beliefs, or other cognitiveinput. Ladavas et al. (1993) argue, based on their ownwork and that of others, that the automatic, uncon-scious process of emotion generation is cognitivelyimpenetrable. The output of this module is crude anddiffuse but becomes the substrate for further cognitiveelaboration, which is highly cognitively penetrable.

Such a module seems logical when considering theevolutionary significance of emotional responses—when faced with an unpredictable, dangerous environ-ment, our evolutionary ancestors relied on an auto-matic and accurate system of identifying maleficentand beneficent elements of the environment andquickly forming appropriate actions in response. In areview by Öhman and Mineka (2001), an evolution-arily defined fear module is proposed, citing evidencethat the fear response is elicited by stimuli of evolu-tionary significance (e.g. a snake), that these responsesare elicited automatically, that they are free from theinfluence of cognitive expectancy or instruction, andthat they find a neuroanatomical substrate in the amy-gdala (Öhman & Mineka, 2001).

There is evidence from brain-imaging studies inrecent years that amygdala activation can occur inresponse to emotional stimuli in the absence of con-


scious awareness of the stimulus. This is consistentwith the notion that the amygdala performs its func-tions implicitly and plays a key role in establishingwhether exteroceptive stimuli have an emotionalmeaning. The concept of cognitive penetrability fitswell here also. Certain autonomic responses that areknown to be modulated by the amygdala, such as theskin-conductance response (Mangina & Beuzeron-Mangina, 1996), are unaffected by information thatbrings the possibility of shock associated with negativestimuli to zero. In other words, conditioned responsesto negative stimuli persist despite full access to theknowledge that the contingency has been dissolved(Hugdahl & Öhman, 1977).

LeDoux has written widely about the thalamo-amyg-dala pathway for processing exteroceptive stimuli rap-idly and crudely in the absence of conscious awareness(LeDoux, 1996). In contrast, the amygdalo-neocorticalpathway provides more precise and differentiated iden-tification of the stimulus, requiring an additional 12msec of processing time. Evidence for similar subcorti-cal processing in humans comes from neuroimagingstudies utilizing backward masking of emotionalstimuli that disrupt cortical processing and obscure theexplicit knowledge of the stimuli. The subjective expe-rience of these stimuli is simply that the maskingstimulus (usually neutral) has been displayed, but theamygdala responds to emotional stimuli such as fearful(Whalen et al., 1998) and angry (Morris, Öhman, &Dolan, 1998) faces.

The amygdala may indeed be a domain-specificcomputational device specific to emotion that operatesin a modular fashion. If so, the output of the amygdalashould be crude and diffuse but can be the substrate forfurther processing. LeDoux (1996) has hypothesizedthat the output of the amygdala attains consciousnessonly when it is relayed to working-memory areas in theprefrontal cortex. This idea can be traced back toWalter Cannon who, in 1928, hypothesized that theconscious experience of emotion occurs when subcor-tical emotion information is relayed to the cortex.

As noted above, MacLean (1990) and Panksepp(1998), who have each made enormous contributionsto the study of brain and emotion through their study oflaboratory animals, hold that subcortical activation issufficient—and cortical participation is not neces-sary—for conscious emotional experience to occur.Why do we hold otherwise? There are several reasons.

1. MacLean (1990) maintained that the limbic system(a term he coined) consisted of structures that werehighly interconnected and whose functional activitywas self-contained. For example, a partial (non-

generalized) seizure associated with the experienceof fear was assumed to occur with limbic activationonly. Recent neuroimaging studies, however, showthat during ictal fear, cortical structures such as theanterior cingulate cortex and prefrontal cortex areactivated in addition to the amygdala, whereaswhen amygdala activation alone was observed dur-ing seizures using depth electrodes the experienceof fear did not occur (Biraben et al., 2001).

2. If the amygdala were a sufficient substrate for theexperience of fear, one might expect that amygdalalesions would be associated with altered emotionalexperiences. However, studies of the subjectiveexperience of emotion in patients with unilateraland bilateral amygdala lesions show that emotionalexperience is not appreciably altered (Anderson &Phelps, 2002).

3. Changes in the subjective experience of emotionwere examined in subjects who had undergonesurgical lesions of various subregions of the medialprefrontal cortex. Results showed that changes inthe subjective experience of emotion (typically in-volving exaggerated intensity) were most pro-nounced in those subjects who had lesions thatinvolved dorsomedial prefrontal cortex (BA9) andanterior cingulate cortex compared to those who didnot (Hornak et al., 2003).

4. Deep-brain stimulation is the treatment of choicefor patients with medically refractory Parkinson’sdisease, and a number of clinician-investigatorshave observed the induction of depressed mood incertain patients when the subthalamic nucleus iselectrically stimulated. A recent case report involv-ing functional neuroimaging demonstrated wide-spread cortical changes during the inadvertentinduction of depressed mood with electrical stimu-lation of the right subthalamic nucleus. Depressedmood did not occur during electrical stimulation inthe left subthalamic nucleus, and a different, morecircumscribed, pattern of brain activity was de-tected with neuroimaging (Stefurak et al., 2003).

5. The phenomenon of blindsight has been enor-mously important in the exploration of the neuralsubstrates of conscious experience. Patients withstrokes in visual cortex report that they are blind andyet they demonstrate behaviorally the ability toperceive visual stimuli. Since the strokes are typi-cally unilateral, it is possible to test each sideseparately and use each patient as his or herown control. Presentation of visual stimuli to ablindsight patient in conjunction with functional


magnetic resonance imaging (fMRI) revealed thatin the aware mode there was a shift to neocorticalactivity, whereas in the unaware mode there was ashift to subcortical structures (Sahraie et al., 1997).

6. Numerous functional neuroimaging studies of emo-tional states described below expand upon thesecase reports and small case series by providingabundant evidence of correlations between self-reported experience and participation of corticalstructures.

7. Although laboratory animals or household pets ap-pear to be experiencing emotion by virtue of theirmotor behavior, it is necessary to have a commen-tary channel in order to verify the nature of subjec-tive experience (Weiskrantz, 2000). In fact, newdiscoveries regarding the neuroanatomical basis ofinteroception reveal differences between primatesand nonprimates and between human and non-human primates. Craig (2003) concludes that inte-roceptive inputs are “encephalized” in humans andthat the anterior cingulate cortex and insula play anessential role in subjective experience. The discov-ery that spindle cells in the anterior cingulate cortexare present only in humans and higher primates andappear to play a role in higher-level integration(Nimchinsky et al., 1999) are consistent with thisview.

Together these findings support the view that, in hu-mans, cortical participation is necessary for emotionalexperience. This does not rule out the possibility thatin animals with less developed cortices, subjectiveexperience of emotion may exist and may have adifferent neuroanatomical substrate.

B. Background feelings

Background feelings (Damasio, 2003) are emotionalstates that color conscious experience but are not no-ticed as such unless attended to. They are generated byinternal regulatory functions as well as external stimuliand provide information about one’s current state ofwell-being. They are akin to what Farthing (1992)refers to as peripheral awareness—those mental con-tents that are on the periphery of focal awareness. Theyinclude stimuli that are being processed automaticallywhile focal attention is directed elsewhere, as well asevents that have been in focal awareness recently. It isour intention to include in this concept both undiffer-entiated (e.g. feeling lousy) and differentiated (e.g.feeling sad) emotional states that are situated on theperiphery of focal awareness, are part of conscious

experience, and are easily attended to if necessary. Ouruse of the term “background feelings” differs from thatof Damasio (2003), who views background feelings asa continuous readout of bodily state, whereas we viewbackground feelings as occurring only when an emo-tional response is activated.

A category of background feelings familiar to psy-choanalysts is Stern’s vitality affects. Vitality affectsare the feelings elicited by changes in motivationalstates, appetites, and tensions and are inferred fromtheir kinetic properties. They have what Stern (1985)calls an “activation contour” such as surgings, fadings,explodings, collapsings, slowings down, drawing out,or drifting. The psychoanalytic clinician expresses vi-tality affects all the time, from the “uh huh” to the“mmmm” and the myriad other sounds, noises, simpleutterances, and “body language” that characterize theebb and flow of communication (Garfield, 2001).

In a study that is described in more detail below, wepresented emotion-inducing pictures to subjects andasked them to indicate on a keypad whether eachpicture induced a pleasant, unpleasant, or neutral feel-ing. We performed an “event-related analysis” inwhich brain images associated with one type of keypadresponse are aggregated and compared to brain imagesassociated with another type of keypad response. Thecomparison involves a subtraction analysis, whicheliminates that which is common between the twotypes of conditions and reveals that which is different.In this case we were interested in the pleasant-minus-neutral and the unpleasant-minus-neutral comparisonsto reveal what was specific for pleasant and unpleasantemotion relative to neutral.

Both subtractions yielded activation of a region thatincluded ventromedial prefrontal cortex and ventralanterior cingulate cortex. For all of the conditions(pleasant, unpleasant, and neutral), the subjects wereattending to how they felt and labeling the feeling (orits absence) with a keypad label. As such these ele-ments canceled one another out in the subtractionanalysis. What remains from this subtraction is theconscious experience of emotion that is not attended toor labeled—background feelings.

We speculate that a number of paralimbic and neo-cortical areas participate in background feelings of thistype. The ventral anterior cingulate cortex is an areaknown to participate in visceral regulation. Bechara,Damasio, Tranel, and Damasio (1997) have shown thatthe nearby ventromedial prefrontal cortex biasesbehavior and decision-making without consciousawareness of an emotional state necessarily occurring,although the gut feelings associated with this structurethat are central to the somatic-marker hypothesis


(Damasio, 1994) clearly implicate it in some type ofconscious bodily experience. The so-called affectivedivision of the anterior cingulate cortex has denseinputs from the amygdala and other subcortical struc-tures and may well participate in background feelings.This interpretation is consistent with the findings ofBush and colleagues (1998) involving the EmotionalCounting Stroop, in which the pregenual anteriorcingulate cortex was activated during a foregroundcognitive task while background emotional stimuliserved as distractors. Similarly, Blakemore, Wolpert,and Frith (1998) showed that this region was activatedby the greater ticklish sensation induced by someoneelse compared to that induced by oneself—again, thepleasant feeling of being tickled is revealed by a sub-traction that removes attention to the feeling. In a studyby Lévesque and colleagues (2003) in which subjectsviewed sad film clips, self-reported sadness correlatedwith activity in bilateral ventrolateral prefrontal cor-tex, the affective division of the anterior cingulatecortex, and the left insula. In that study, imaging wasperformed during the viewing of the film clips,whereas ratings of sadness were made after imagingwas completed. Thus, the sadness that subjects re-ported may have been in the background of theirconscious awareness during imaging.

The insula is another paralimbic structure that isthought to contribute to the representation of one’sown bodily state (Augustine, 1996; Craig, 2003;Critchley, Wiens, Rotshtein, Öhman, & Dolan, 2004).The insula contains a topographic representation ofinputs from visceral, olfactory, gustatory, visual, audi-tory, and somatosensory areas and is proposed to inte-grate representations of external sensory experienceand internal somatic state (Mesulam & Mufson, 1982).The insula has been found to be activated in a numberof studies of emotional processing (Phillips et al.,1997), especially those involving emotion that is in-duced by imagery or recall (Reiman et al., 1997), andemotional tasks that have a concurrent cognitive de-mand (Phan, Wager, Taylor, & Liberzon, 2002). Con-sistent with a role in background emotion, the insulawas recently found to be more engaged when emo-tional stimuli were passively viewed than when atten-tion was directed at one’s own emotional state (Hariri,Mattay, Tessitore, Fera, & Weinberger, 2003).

The right parietal cortex is known to be activated byemotional arousal (Tranel, 2000). It has also beenimplicated broadly while subjects engage in a task thatinvolves emotional stimuli that are not the focus ofattention, such as a gender-decision task (Iidaka et al.,2001). Somatosensory cortex plays a major role in themapping of bodily sensations and thus contributes to

background feelings as well (Damasio, 1994, 2003).Thus, the ventromedial prefrontal cortex, ventral andpregenual anterior cingulate cortex, insula, somatosen-sory cortex, and right parietal lobe are all likely partici-pants in the neural basis of background feelings.

C. Focal attention to feelings

The LEAS was administered to participants in a posi-tron emission tomography (PET) study of emotion(Lane et al., 1998). They included 12 right-handedfemale volunteers who were free of medical, neuro-logical, or psychiatric abnormalities. The LEAS andother psychometric instruments were completed priorto PET imaging. Happiness, sadness, disgust, and threeneutral control conditions were induced by film andrecall of personal experiences (12 conditions). TwelvePET images of blood flow were obtained in eachperson using the ECAT 951/31 scanner (Siemens,Knoxville, TN), 40-mCi intravenous bolus injectionsof 15O water, a 15-sec uptake period, 60-sec scans, andan interscan interval of 10 min.

The recall paradigm imposed constraints thatemphasized the attention component of the stimulusconditions. Specifically, recalled experiences of happi-ness, sadness, and disgust were prepared in advance byasking subjects to select a memory of each type and tofocus on an aspect of the memory in which the targetemotion was particularly intense. At the time ofimaging, we asked subjects to focus on feeling thetarget emotion as they recalled the scene in question. Inorder to make the film and recall conditions similar,prior to each film clip we told the subjects whatemotion was being targeted by the film clip and askedthem to concentrate on feeling that emotion. As aresult, the subjects were intentionally focusing theirattention on the experience of each emotion in both therecall and the film conditions.

To examine neural activity attributable to emotiongenerally, rather than to specific emotions, one cansubtract the three neutral conditions from the threeemotion conditions in a given stimulus modality (filmor recall). This clustering of conditions was under-taken to ensure adequate statistical power due to therelatively small number of subjects and scans persubject. This “emotion-minus-neutral” difference,which can be calculated separately for the six film andsix recall conditions, identifies regions of the brainwhere blood-flow changes occur that are specificallyattributable to emotion. These blood-flow changes,which indicate neural activity in that region, can thenbe correlated with the LEAS scores to identify regions


of the brain that are associated with emotional aware-ness during emotional arousal.

Findings from this covariate analysis revealed onecluster for film-induced emotion with a maximumlocated in the right mid-cingulate cortex. For recall-induced emotion, the most statistically significant clus-ter was located in the right anterior cingulate cortex.An analysis was then performed to identify areas ofsignificant overlap between the two covariance analy-ses. Based on an a priori statistical threshold, a singlecluster was observed in the right anterior cingulatecortex (BA 24) maximal at [14,6,30] (Lane et al.,1998).

Traditionally the anterior cingulate cortex has beenthought to have a primarily affective function (Papez,1937; Vogt, Finch, & Olson, 1992). However, in addi-tion to emotion, it is now recognized to play importantroles in attention, pain, response selection, maternalbehavior, vocalization, skeletomotor function, and au-tonomic control (Vogt & Gabriel, 1993). The multiplefunctions of the anterior cingulate cortex no doubtcontribute to the significant changes in activation thathave been observed in a variety of studies. How canthese different functions be reconciled with the presentfindings involving emotional awareness?

One answer might be that these various functions ofthe anterior cingulate cortex may reflect its super-ordinate role in executive control of attention andmotor responses (Lane et al., 1998) in a way that isconsistent with Freud’s signal theory of anxiety. Ac-cording to this view, emotion, pain, or other salientexteroceptive or interoceptive stimuli provide mo-ment-to-moment guidance regarding the most suitableallocation of attentional resources for the purpose ofoptimizing motor responses in interaction with theenvironment. Awareness of a feeling could occur con-comitantly and automatically as attention gets redi-rected by emotion. As such, a role for the anteriorcingulate cortex in the conscious experience of emo-tion fits well with its other functions but suggests thatthis role is not exclusive to emotion.

It may be that this set of operations, which sit at thecusp between conscious and unconscious experience,is crucial to emotional development. To the extent thatpeople who are more emotionally aware attend more tointernal and external emotion cues, the cognitiveprocessing of this information can contribute to ongo-ing emotional development. This is so because atten-tion to an emotional experience necessarily precedesand facilitates the description of that experience usinglanguage or other representation mode. This in turnwill contribute to the further elaboration and refine-ment of the schemata used for future processing of

emotional information from the internal world or theexternal world.

The dorsal anterior cingulate cortex may have beenactivated because attention was intentionally focusedon the experience of the feeling in question. An almostidentical area of the anterior cingulate cortex wasimplicated in emotional experience in a study byRainville, Duncan, Price, Carrier, and Bushnell(1997). The study involved manipulating the unpleas-antness of a painful stimulus by hypnotic suggestion.As a result of the hypnotic suggestion, the subjectsfocused conscious attention on the unpleasantness ofthe painful stimulus. As such, these studies togetherindicate that this area of anterior cingulate cortex maybe involved in that aspect of phenomenal awarenessinvolved in focused attention on emotional experience.We emphasize, however, that the function of this re-gion is specific not to emotion but, rather, to attention.

D. Reflective awareness of feelings

Within the field of consciousness research, a distinc-tion is made between phenomenal and reflectiveawareness. Phenomenal awareness refers to the actualcontent of consciousness (focal attention to feelingsand background feelings), whereas reflective aware-ness involves attending to or performing a cognitiveoperation upon the contents of conscious experience(Farthing, 1992). Reflective awareness, or metacog-nition, requires the creation of a representation ofexperience, and this representation will affect howfuture emotional information is interpreted and experi-enced. Reflective awareness is a fundamental skillrequired for successful psychoanalysis and is a keygoal of treatment in patients with more primitive per-sonality organizations (Fonagy, Gergely, Jurist, & Tar-get, 2002).

In another PET study we examined the pattern ofneural activation associated with attending to one’sown emotional experience (Lane, Fink, Chua, &Dolan, 1997). To confirm that subjects were allocatingtheir attention as we instructed, we had them indicateon a keypad how each emotion-evoking picture madethem feel. In essence, we were examining an aspect ofconscious experience involving commentary on thatexperience (Weiskrantz, 2000). By having subjects inthis study attend to and label their experience, we wereexamining reflective awareness.

We studied 10 healthy men as they viewed 12picture sets, each consisting of pleasant, unpleasant,and neutral pictures from the International AffectivePicture System (Lang, Bradley, & Cuthbert, 1995).


Pictures were presented for 500 msec every 3.0 sec.Twelve PET-derived measures of cerebral blood flowwere obtained in each subject, one for each picture set.During half the scans, subjects attended to their emo-tional experience (indicating on a keypad whether thepicture evoked a pleasant, unpleasant, or neutral feel-ing); during the other half, they attended to spatiallocation (indicating whether the scene depicted wasindoors, outdoors, or indeterminate). Across subjects,picture sets were counterbalanced across the two atten-tion conditions. Unlike the event-related analysis de-scribed above (in the introduction to the section onbackground feelings), this analysis focused on compar-ing scans during attention to emotional experience toscans during attention to spatial location.

During attention to subjective emotional responses,increased neural activity was elicited in rostral anteriorcingulate cortex (BA 32) and medial prefrontal cortex(coordinates: 0,50,16), right temporal pole, insula, andventral cingulate cortex. Under the same stimulus con-ditions, when subjects attended to spatial aspects of thepicture sets, activation was observed in parieto-occipi-tal cortex bilaterally, a region known to participate inthe evaluation of spatial relationships.

In that PET study, all of the scan conditions in-cluded pleasant, unpleasant, and neutral pictures(“mixed” picture sets). We sought to replicate thosefindings in the fMRI environment and determine therelative influence of pleasant, unpleasant, and neutralstimuli on the observed activations. Subjects included10 healthy men and women. Relative to the mixedexternal-attention condition, dorsal medial prefrontal-cortex activation was observed during the mixed,pleasant, and neutral internal-attention conditions; at-tention to unpleasant pictures revealed activity thatwas slightly more posterior in anterior cingulate cor-tex. In addition, posterior parieto-occipital cortex wasactivated bilaterally during the external relative to theinternal focus conditions. Findings from our previousPET study were therefore replicated and extended inthis fMRI paradigm. Indeed, these same fMRI find-ings—activation of dorsomedial prefrontal cortex dur-ing attention to and labeling of emotional experienceand activation of parieto-occipital areas during theevaluation of spatial relationships—have been repli-cated in another independent laboratory (Gusnard,Akbudak, Shulman, & Raichle, 2001).

Frith and Frith (1999) hypothesize that the ability tomentalize evolved from the action system for the pur-pose of identifying the intentions of others and antici-pating their future actions. We know that emotionalstates may fundamentally consist of action tendencies(Frijda, 1986), which can be construed as equivalent to

the intentions of the self. This dovetails beautifullywith the Piagetian perspective on cognitive develop-ment in that all mental representations at the concep-tual level are fundamentally derived from actionschemes. It is therefore reasonable to consider, as afirst approximation, that the paracingulate sulcus,which includes the dorsomedial prefrontal cortex, is asubstructure within the prefrontal cortex that partici-pates in establishing the representations of mentalstates (including emotional states) of both self andother. As such, another aspect of emotional aware-ness—the ability to reflect upon one’s own emotionalstate—requires participation of a structure that servesa more general function (mentalizing) that is not spe-cific to emotion.

This conclusion is supported by several recent find-ings. Sterling Johnson and colleagues (2002) demon-strated activation of this region during self-reflectivethought (considering whether statements or attributespertain to the self). Vogeley and associates (2001)have observed activation of this region during theprocess of evaluating what someone else is thinking(theory of mind), as have others previously (e.g. Happéet al., 1996)

Recently, investigators have attempted to isolate theeffects of attention to one’s own emotional state thatare necessary to rate one’s emotional reaction to astimulus. Passive viewing of emotional stimuli hasbeen found to activate the amygdala, hippocampus,putamen, cerebellum, and lingual gyrus (Lange,Bradley, & Cuthbert, 2003) whereas an emotional-rating task did not activate the amygdala or hippocam-pus and, in addition, activated the left ventral frontalgyrus. Another study found activation of anteriorcingulate, dorsomedial prefrontal cortex, and cerebel-lum when subjects were asked to rate emotional im-ages but found greater activity in the right amygdala,bilateral insula, and other areas during passive viewing(Taylor, Phan, Decker, & Liberzon, 2003). These find-ings are consistent with evidence that amygdala activ-ity is modulated by cognitive tasks such as labelingstimuli (Hariri, Mattay, Tessitore, Fera, & Weinberger,2003). These findings are of great importance to psy-choanalysis as they reveal that automatic emotionalresponses can be modulated by reflective awareness,which is part and parcel of the insight process.

The imaging research just reviewed, which focuseson the conscious experience of emotion, highlightedactivity in paralimbic and neocortical structures thatare not unique to emotion. Rather, these structuresperform domain-general functions such as executivecontrol of attention (in the case of dorsal anteriorcingulate) and mentalizing (in the case of dorsomedial


prefrontal cortex). These findings suggest that thestructures that preferentially participate in the con-scious awareness of emotional experience are notunique to emotion but, rather, are domain-general. Tothe extent that this is true, it provides powerful supportfor a cognitive neuroscientific approach to emotionalawareness. The domain-general function of these areasmeans that emotions compete with other inputs forconscious processing. This may help to explain whythere are such vast individual differences in the extentto which people attend to and use emotional infor-mation, whether that information (generated by theexpression of emotion) originates externally or inter-nally. A key question for future research is how thesestructures negotiate between and give priority to thesediffering inputs to determine what the contents ofconscious experience will be. This neuroscientific re-search may well provide important information aboutthe neural mechanisms of unconscious defense mecha-nisms, choice of symptom, and neurotic style (Shapiro,1999).

From these considerations, two general principlescan be derived that are consistent with the psychologi-cal model presented above: (1) The structures that areuniquely responsible for emotion generation set im-plicit functions in motion. (2) The brain structuresneeded for conscious awareness of emotional experi-ences emerged more recently during phylogenesiscompared to those required for implicit processes.

A neural model of implicit and explicit emotionalprocessing

A rudimentary neuroanatomical model of emotionalawareness that distinguishes between implicit and ex-plicit processes can now be formulated (Lane, 2000).Parallels between the corresponding neuroanatomicaland psychological models are schematically depictedin Figure 1.

Both models are hierarchical and show a similararchitecture of concentric shells. A remarkably similarconception of the neuroanatomical basis of emotionhas been independently developed by Fellous (1999).The concentric architecture means that each new levelsubsumes and modulates that of previous levels. Al-though both the psychological and the neuroanatom-ical models designate five levels, we do not intend tosuggest a direct correspondence between a given levelin one model and that of the other model. In general,implicit functions at Levels 1 and 2 in the psychologi-cal model correspond to Levels 1–3 in the neuro-anatomical model, and explicit functions at Levels 3–5

in the psychological model correspond to Levels 4 and5 in the neuroanatomical model.

Following Ladavas et al. (1993), Levels 1 and 2 inthe psychological model involve implicit processesthat are automatic, modular, and cognitively im-penetrable. It would appear that subcortical structuresparticipate in the automatic generation of emotionalresponses associated with absent or diffusely undiffer-entiated awareness. It may be speculated that the neu-ral substrates of Level 1 in the psychological modelinclude the thalamus and hypothalamus (dien-cephalon) and brainstem. At Level 2 in the psychologi-cal model, the sensorimotor enactive level, crudedistinctions between globally positive and globallynegative states can be made. Given that decorticatecats can demonstrate fear and pleasure reactions (Bard& Rioch, 1937), it is likely that the thalamus partici-pates at this level. The amygdala appears to be prefer-entially activated in association with aversive stimuli(Zald, 2003), and the ventral striatum, including thenucleus accumbens, is preferentially activated by ap-petitive or reward stimuli (Koob & Goeders, 1989).The outputs from this stage of processing are wide-spread. Emotions at this level are represented in ac-tions such as gestures and other movements that havean either/or quality. Much evidence suggests that thebasal ganglia participate in the automatic behavioraldisplays of emotional gestures and expression (Gray,1995; Rolls, 1990). They likely participate in mediat-ing the emotional procedures discussed at some lengthin this paper. A key tenet of this model is that struc-tures at this level, such as the amygdala (Cahill &

Figure 1.Figure 1.Figure 1.Figure 1.Figure 1. Parallels in the hierarchical organization of emotionalexperience and its neural substrates. The shell structure is intended toconvey that each succeeding level adds to and modulates lower levelsbut does not replace them. Although each model contains five levels, aone-to-one correspondence between each level in the psychological andneuroanatomical models is not intended. Lower levels with whitebackgrounds correspond to implicit processes. Higher levels with graybackgrounds correspond to explicit processes.


McGaugh, 1998; LeDoux, 1996), are essential for im-plicit processing and contribute to but are not suffi-cient for the explicit experience of discrete emotions orcombinations thereof (i.e. Levels 3–5 in the psycho-logical model).

Levels 3–5 in the psychological model involve ex-plicit processes that are influenced by higher cognitiveprocesses, including prior explicit knowledge. Theonline experience of Levels 3–5 constitutes phenom-enal awareness, which is mediated by the addition ofparalimbic structures to the network of structures thatmediate implicit aspects of emotion. Paralimbic struc-tures include the anterior cingulate cortex, insula, tem-poral pole and orbitofrontal cortex. Orbitofrontalcortex activity appears to be associated with the per-ception of somatic sensations in context, biasingbehavior either toward or away from a stimulus(Damasio, 1994), overriding automatic processes inthe amygdala, and participating in extinction, amongother functions (Emery & Amaral, 2000).

Phenomenal awareness can be differentiated intobackground feelings and feelings that are the focus ofattention. When focal attention is directed to the expe-rience of emotion, the dorsal anterior cingulate isactivated and interacts with the other structures at thislevel and below. In the absence of focal attention,participation of paralimbic structures, ventromedialprefrontal cortex, somatosensory cortex, and right pa-rietal cortex are associated with background emotions.These structures may well be sufficient to mediateexperience at Levels 3–5 at the psychological level.

The highest level of the neuroanatomical model isprefrontal cortex. The paracingulate region of medialprefrontal cortex is necessary for reflective awareness.The paracingulate region includes rostral anteriorcingulate cortex and medial prefrontal cortex per se.The critical importance of representations in creatingknowledge and their pivotal role in emotional aware-ness was discussed above.

The anatomical relationship between key structuresin the model is depicted in Figure 2. As noted, threetypes of conscious emotional experience are ad-dressed: (1) background feelings, (2) focal attention tofeelings, and (3) reflective awareness of feelings.Background feelings are subserved by a variety ofstructures in the ventral medial frontal lobe (labeled“1”) including orbitofrontal cortex, ventromedial pre-frontal cortex, and ventral and pregenual anteriorcingulate cortex, as well as insula, temporal pole, andright parietal-lobe structures involved in mapping ofsomatic states (the structures not in the frontal lobe arenot visible on the medial surface of the brain). Focalattention to feelings is subserved by dorsal anterior

cingulate cortex (labeled “2”) and the structures towhich it is connected. The establishment of a represen-tation of mental state that can be used for purposes ofreflection and future planning is subserved by theparacingulate region of the dorsomedial prefrontal cor-tex (labeled “3”). The function of all of these structuresin mediating different aspects of conscious experienceis dependent upon the generation of emotional re-sponses in limbic, diencephalic, and brainstem struc-tures.

Speculation on self-regulation

The focus up to this point has been on bottom-upphenomena—the transition from subcortical-implicitto cortical-explicit processing. The neuronal pathwaysin question are bidirectional, indicating that top-downprocesses must be considered as well. To the extentthat we are dealing with conscious processing, thequestion may be asked how conscious processing ofemotional information alters the functioning of subcor-tical structures, and how top-down and bottom-up pro-cesses equilibrate. This is an area in which relativelylittle work has been done, and the discussion thatfollows is decidedly speculative.

One approach is to consider cortical influences onautonomic regulation. The dorsal anterior cingulatecortex and dorsomedial prefrontal cortex have auto-nomic regulatory functions that are mediated by directneural connections with subcortical visceromotorcenters such as the lateral hypothalamus (Price,Carmichael, & Drevets, 1996). Drevets (1999) hasobserved in PET research that blood flow in medialprefrontal cortex is inversely related to heart rate

Figure 2.Figure 2.Figure 2.Figure 2.Figure 2. Structures on the medial surface of the frontal lobe thatparticipate in (1) background feelings, (2) attention to feelings, and (3)reflective awareness of feelings.


(Drevets, 1999). Stimulation of the medial prefrontalcortex is also known to produce decreases in heart rateand blood pressure in rabbits (Buchanan, Valentine, &Powell, 1985). Critchley and colleagues (2003) ob-served in an fMRI study of physical and mental stressthat the sympathetic component of heart rate variabil-ity (HRV) correlated positively with activity in thedorsal anterior cingulate cortex. Gianaros, Van DerVeen, and Jennings (2004) observed a positive correla-tion between the high-frequency, vagal component ofHRV and activity in ventromedial prefrontal cortex,insula, and the amygdala–hippocampal complex dur-ing a working-memory task. We have similarly ob-served a positive correlation between the high-fre-quency, vagal component of HRV and activity in amore superior area of medial prefrontal cortex (BA10)during emotional states (Lane, Reiman, Ahern, &Thayer, 2001). Thus, these latter centers, when acti-vated in conjunction with conscious emotional experi-ence, appear to have a tonic inhibitory effect mediatedthrough the vagus nerve.

The positive correlation between medial prefrontalactivity and vagal tone is interesting in two respects.First, one aspect of the correlation is that higher levelsof vagal tone are associated with greater activity inmedial prefrontal cortex. Based on the findings re-viewed above, it would appear that a greater degree ofconscious processing of emotion is associated withgreater vagal tone. This can be understood in terms ofparallel levels of complexity in the experience of emo-tion and the associated autonomic substrate for thatexperience (Thayer & Lane, 2000). Greater HRV con-stitutes greater variation and complexity in thepatterning of autonomic responses. Greater emotionalawareness is associated with greater differentiationand complexity of experience. Support for the associa-tion between the two comes from studies of anxietydisorders, in which less differentiated emotional expe-rience is associated with lower levels of vagal tone(Thayer & Lane, 2000). An important clinical implica-tion is that awareness can be expanded through inhibi-tory processes; inhibition does not simply consist ofpreventing behavior or experience from occurring.

Second, in the case of lower levels of vagal tone, thepositive correlation means that when vagal tone is low,activity in the medial prefrontal cortex is diminished.One way of understanding this is that in a state ofemergency associated with high arousal (and reducedvagal tone), the more evolutionarily advanced frontal-lobe mechanisms exert less influence (i.e. their activitybecomes attenuated), leaving behavioral control tomore automatic, evolutionarily more primitive, neuralcenters. The decrease in frontal-lobe function during

arousal, probably triggered by the amygdala and medi-ated by dopaminergic and noradrenergic mechanisms,has been well established in a series of studies byArnsten (2002). Put in another way, in an emergencysituation implicit processes become ascendant as ex-plicit, deliberative mechanisms recede in importance.This may be an automatic mechanism that ensures thatin a life-threatening crisis, mechanisms perfected dur-ing the course of evolution take over.

The ventromedial and orbitofrontal cortex are wellestablished as structures that have an inhibitory effecton the amygdala. Recent evidence (Milad & Quirk,2002) shows that the process of extinction of amyg-dala-mediated conditioned fear in rats does not involvesimply unlearning the conditioned response. Rather,extinction involves new learning mediated by ventro-medial prefrontal cortex. Changing old patterns doesnot eliminate the patterns—it involves adding to thoseold patterns and modulating them. Importantly, recentfindings (Maroun & Richter-Levin, 2003; Radley etal., 2004) reveal that chronic or acute stress compro-mises the ability of medial prefrontal cortex to extin-guish conditioned fear. This suggests that previouslylearned fear associations may be uncovered.

Extrapolating to the human condition, one mayspeculate that in certain circumstances, such as majorlife stress, a person who has been “successfullyanalyzed” may manifest regression. This may be un-derstood in the following neurobiological terms. Me-dial prefrontal activity may become attenuated in thecontext of high arousal. Based on the hierarchicalorganization of brain function following Jackson(1864), Yakovlev (1948), and others, phylogeneticallyolder structures take over to handle an emergencyusing automatic routines that have been perfectedthrough the course of evolution. This can be under-stood as an uncovering of the latent procedures thatwere modified through top-down mechanisms in thecourse of the analysis. As long as cortical structurescan exert their top-down influence, the hard-won gainsof analysis will be evident. Yet, the phenomenon ofregression illustrates that the old procedures have beenadded to but not eliminated.

It therefore appears that when emotional experienceis consciously attended to and reflected upon, a feed-back process occurs whereby vagal tone is facilitatedand emotional arousal is modulated. In contrast to ageneralized state of arousal, in which a diffuse networkof neural structures is mobilized to process sensoryinformation, attention is selective for certain inputsand not others and involves selecting certain actions asothers are inhibited (Paus, 2000; Thayer & Lane,2000).


Recent neuroimaging evidence has shown that whenindividuals are instructed to regulate their emotionalresponse, a conscious effort to do so can modulateamygdala activation. Decreased amygdala activationto emotional stimuli can result from the use of acognitive reappraisal strategy (Ochsner et al., 2002),and amygdala activation can be enhanced by an in-struction to maintain one’s emotional state (Schaefer etal., 2002). The anterior cingulate cortex is often acti-vated to a greater extent during the emotion-regulationconditions than during the unregulated processing ofemotional stimuli. This is consistent with the role ofthe anterior cingulate cortex in allocating attention asdescribed above. Beauregard, Lévesque, and Bour-gouin (2001) observed that free viewing of erotic filmexcerpts was associated with activation of right amyg-dala, right anterior temporal pole, and hypothalamus,whereas attempted inhibition of sexual arousal bythese male subjects was associated with activation ofthe right anterior cingulate cortex and right dorsola-teral prefrontal cortex and the absence of subcorticalactivation. The contribution of the anterior cingulatecortex to successful relaxation using biofeedback(Critchley, Melmed, Featherstone, Mathias, & Dolan,2001) implicates it in accurate monitoring and modula-tion of somatic state. As noted above (Lange et al.,2003; Taylor et al., 2003), rating one’s emotionalresponses is associated with decreased activity of theamygdala compared to passive viewing of emotionalstimuli.

Thus, through a process of equilibration of bottom-up and top-down interactions, bodily state is altered asdiffuse arousal mechanisms become modulated anddifferentiated. One implication of this model is thatbecoming consciously aware of one’s own emotionalresponses in itself has a physiological effect that isself-regulatory. It is entirely consistent with the clini-cal notion that to get through an episode of emotionaldistress, one must first allow oneself to experience thedistress fully, as this will then lead to a process ofrecovery (Greenberg, 2002).

Implications for psychoanalysis

The cognitive neuroscientific approach to emotion isuseful in several respects: (1) it makes it evident why acognitive-developmental approach, typically appliedto “cognitive” functions, can be applied to emotionalexperience; (2) the distinction between implicit andexplicit processes, well established for cognitive func-tions, also applies to emotion in that the neural

substrates of implicit and explicit emotional processesare dissociable; (3) the brain structures responsible forthe conscious awareness of emotion are not unique toemotion and therefore share this functional space withother cognitive functions. Each of these principles hasimportant implications for psychoanalysis.

The nature of change associated withinsight and the potential for regression

As noted at the start of the paper, the importance of thedistinction between implicit and explicit emotionalprocesses for psychoanalysis has been discussed byClyman (1991), from the perspective of the “proce-dural organization of emotion.” Emotional procedures,as indicated above, include facial, gestural, andbehavioral expressions of emotion that occur duringemotional arousal. Emotional procedures develop im-plicitly and are expressed automatically, and they canserve an emotion regulatory function such as avoid-ance of embarrassment or shame. Clyman points outthat during development, emotional procedures areexpressed in different contexts, and families selectwhich procedures are permissible and which are not byresponding to some and ignoring or punishing others.Over time these procedures are repeatedly rehearsedand eventually become resistant to change. Proceduresdefine our fundamental ways of interacting with oth-ers. Clyman argues that transference may be conceptu-alized as a set of emotional procedures in the sense thattransference is a way of interacting with the analystthat is based on automatic repertoires established inprevious important relationships. Of course, these en-coded emotional “ways of relating and responding”have been described in the analytic literature by termssuch as “model scenes” (Lichtenberg, 1989) or “repre-sentations of interactions generalized” (RIGS: Stern,1985) and serve as a key component of transference tothe analyst. Here, traditional concepts of transference,including the perceptual and meaning aspects of objectrepresentations, are inextricably linked to establishedimplicit emotional repertoires.

Patients who come for therapy or analysis typicallyhave maladaptive patterns of behavior that they wantor need to change. Not uncommonly these in-volve emotional procedures (ways of relating and re-sponding) of which they are not consciously aware.Changing these procedures through insight involvesinterrupting the automatic behavioral enactment, con-sciously experiencing the associated “underlying”emotions, consciously extracting the information in-herent in the emotional response, reappraising the situ-


ation and pattern, altering behavior, and establishingnew procedures until they become automatic (i.e.working through). Thus, the therapeutic process in-volves transforming implicit-emotion patterns intoexplicit representations—a cognitive-developmentalprocess. The consciously processed information cansecondarily be used to alter behavior. The term “sec-ondarily” is used to indicate that a good therapeuticoutcome consists of keeping the implicit, automaticbehaviors in check sufficiently so that they do notinterfere with adaptation any longer. Developing thecapacity for conscious regulation of one’s emotionalresponses can have enormous benefits in social adapta-tion. It follows from this model that completely elimi-nating the old procedures rarely if ever occurs.

The model that we have presented emphasizes thetransition from implicit to explicit processing ofemotion as the core process associated with clinicalchange. Based on our model, in neurobiological termsthis means that cortical structures communicate withsubcortical structures in the mediation of explicitprocessing. The cortical structures have a modulatoryeffect on action tendencies that were established earlyin childhood. The end result, in the case of a goodtherapeutic outcome, is that old procedures are notautomatically recruited and expressed when the stimu-lus conditions exist that would have elicited these oldprocedures in the past. Instead, as a result of consciousprocessing, the patient can make different choices.

Case illustrations—the transition from implicit to explicitaspects of emotion

As noted above, implicit aspects of emotion consist ofthe physiological activation and action tendency ex-pressions of emotion. They are implicit in that thefeeling state (e.g. happy, sad, angry) is not consciouslyexperienced. Psychoanalysts are extremely familiarwith the practice of identifying nonverbal indices ofaffective states such as facial expressions and gesturesand helping to bring these emotional states into con-scious awareness. While it is sometimes assumed thatthe nonverbal expressions of emotion and the feelingstates that they are paired with are inextricably related,the transition from implicit to explicit processing in-volves a transformation of information. The labeling ofaffective states is a creative process and is not neces-sarily predetermined at the implicit level.

The neuroscientific literature has helped us to dis-tinguish between three different types of consciousexperience. In the following examples, we illustrate

how these three types of conscious experience are usedby the analyst and analysand to promote insight.

Ms. X. is a 27-year-old woman who entered analysiswith a desire to be more successful in her job and tobe less of a “dishrag” with her boyfriends. She hadnot been able to have a good long-term relationshipwith a man, had not been able to move forward inher career, and wanted these issues “fixed.” A pleas-ant, “allocentric,” bright, and astute person, Ms. X.readily established a good working relationship withthe analyst. It became clear that, in most of herrelationships, she sacrificed her own point of view,autonomy, and self-worth to the altar of preservingthe relationship. She rarely got angry. She couldalways see the other person’s point of view, and,although she was frequently hurt and disappointed,her intellectualization kept her anger out of aware-ness. Ms. X. talked a good deal and rarely left spacefor quiet during her session. Her speech was impres-sionistic, and she could use long sentences. Thus,another characteristic defense against unbearableaffect was her heightened activity level, which wasalso evident in her day-to-day personal and worklife.After about six months of treatment, Ms. X. wasdescribing how her boyfriend, “Tom,” had not calledher back and that when she had called him later in theevening she thought she heard someone in the back-ground. He immediately hung up the phone. Sheconsidered and dismissed the idea that he might beseeing someone else, focusing more on his rudebehavior. She became quiet for about 15 or 20seconds. She then went on talking about how impo-lite and inconsiderate Tom was in his manner. Whenthe analyst asked her what she made of the sounds inthe background, she became quiet again for about 10seconds. She no longer had an animated look on herface. It is also important to note that she did not havea “sad” look or an “angry” look either. She had aslightly “anxious” look. When the analyst asked herwhat was going on at that moment, Ms. X. assertedin a clear, succinct, and angry tone, “Tom is a selfishand deceitful jerk and I don’t know why I am wastingmy time with his crap.”When this type of quiet ensued again, the analystasked Ms. X. to describe what she was experienc-ing. She struggled for a bit to focus on her experi-ence and then was able to put words to it: “I simplystopped. There is an upheaval or churning in mystomach. I get quiet, also very anxious.” Whenasked if she thought this was anger, Ms. X. said


“Absolutely.” Much discussion ensued about notonly her bodily experience of anger (Garfield, 1995;McDougall, 1989), but how clear she gets when sheis angry and how less frantic she is when she experi-ences her anger.

This case illustrates several important points thatcan be incorporated into the framework developedabove: (1) The nonverbal indices were clues to back-ground feeling states that the patient was not attendingto. (2) The analyst’s intervention enabled the patient tofocus on the bodily state, an implicit aspect of emotion.Notice that the feeling state is not yet present inconscious awareness. (3) The appropriate label for theemotional state required careful consideration of themotor behavior as well as the context in which themotor behavior occurred. (4) Attending to the con-scious experience of anger made it possible to reflectupon her anger. This led her to reappraise the situation,alter her behavior, and begin working on creating anew behavior pattern.

Another example of the centrality of emotion com-ing into awareness is illustrated by the case of Mrs. Y.

This middle-aged mother of two school-age chil-dren found herself in the contemporary dilemma ofparenting her elderly parents as well as her own 8-year-old daughter and 3-year-old son. She was com-petent at her job as a paralegal, and before movingto the United States with her husband 10 yearsearlier had worked as a barrister in England. Shefound herself tearful with her brother, who was herclosest confidant, and she was completely at a lossas to why. She entered treatment to determine whyshe was “losing her grip.”

Mrs. Y. detailed a fairly stable upper-middle-classupbringing in London, where her father was a busyand successful businessman. Her mother was left toraise the four children: her two oldest sisters, her 1-year-older brother, and herself. Mrs. Y. describesher family of origin as being very close, and shearranged, with her husband, for numerous businessleads and opportunities that allowed for her siblingsall to move to the same city in the United States. Herparents also retired and moved nearby. It seemedthat everyone consulted her about everything. Afterjust a few weeks of treatment, shortly after begin-ning a session, Mrs. Y. would be talking yet have anextremely sad look in her eyes. When the analystcalled her attention to the look, she became tearyand on occasion would cry for a minute and then beembarrassed because she had no idea why she was

sad. She had so many blessings, and, busy thoughher life was, she felt she had little to complain about.

The analyst followed traditional technique insofaras he carefully listened to associations that precededand followed the sad looks and tearful spells. After afew instances of calling her attention to these epi-sodes with little new material emerging, the analystasked her to stay with the newly attended-to emo-tion as it came into awareness. In what ways did sheexperience this sadness in the here-and-now? Mrs.Y. reported that there was an emptiness in herstomach, and the sadness moved up into her chestand then into her eyes, which would well up withtears. She was then able to describe how embar-rassed she felt about reporting these experiences.They were able to discuss her experience of embar-rassment as well, which was more mentalized andless phenomenal. In between sessions, Mrs. Y. wasable to engage her substantial cognitive capacity toreflect upon these experiences and begin to associ-ate to her fears of becoming a pessimistic and lonelywoman like her mother had been. Mrs. Y. began toexperience frustration with her husband traveling somuch when she was left by herself with so muchresponsibility for the family.

This case illustrates the value of focusing on thebodily experience of emotion, even when an appar-ently appropriate label for the affective state (sadness)has been identified. The case illustrates how attendingto background feelings can lead to a more intense andauthentic phenomenal experience of emotion than sim-ply labeling a feeling state. The new information pro-vided by the emotional experience and its meaningthen served as a springboard for changing a long-standing maladaptive procedure.

This approach to the focus on bodily states in psy-chotherapy as a source of new emotional informationwas developed by Eugene Gendlin (1978) and has beenelaborated by others, including Greenberg (2002).Similarly, the Boston analyst Elvin Semrad (Semrad &Van Buskirk, 1969; see also Garfield, 1995) detailedan affect-centered approach to analysis that laid out asimilar kind of roadmap, from perception of the bodilyexperience to a reflective putting of words to affectstates, that parallels the process we are describinghere. Bolstered by the striking correspondence to theneuroanatomical evidence supporting three differenttypes of conscious emotional experiences, we are sug-gesting that analytic attention to the process by whichemotion comes into awareness may be much morecentral to the analytic task of investigating and eventu-


ally reworking the unbearable affects that bring pa-tients into treatment than has been previously recog-nized.

Change without insight

Many psychoanalytic clinicians and researchers be-lieve that significant clinical change in the absence ofinsight does occur (Bruschweiler-Stern et al., 2002;Clyman, 1991; Kohut, 1984; Stolorow, Brandchaft, &Atwood, 1987; Winnicott, 1965). As the analyst be-haves in a manner that continually disconfirms thepreexisting transference patterns, the patient is allowedto have an ongoing “new” experience, and the analystis experienced as a new kind of object who does not setoff the old automatic emotional-control procedures.With enough time, new emotional procedures can takehold. To a certain extent, with an emphasis on the“leading edge” (Tolpin, 2002) and empathic attune-ment, certain patients expand a previously circum-scribed negatively biased emotional repertoire. Gestaltapproaches (Fagan & Shepherd, 1970) have histori-cally aimed at this kind of mobilization of affect,with an eye to a new kind of experiencing. Morerecently, the Boston Change Process Study Group(Bruschweiler-Stern et al., 2002) has detailed themicrocommunications that occur during psychoanaly-sis and posit that change takes place when there is anoptimal “fitting” between the current transference-ex-pectancy set of the patient and the nonthreateningresponse from the analyst that allows for an expansionof the patient’s emotional and interactional repertoire.There is no interpretive technique that facilitateschange in this model; rather, change takes place due toa kind of learning that is “beyond interpretation”(Gedo, 1979).

It is notable that clinical change without insight orconscious awareness can be understood within thesame model that has been presented above. Simply put,this phenomenon may be understood as one set ofemotional procedures being replaced by another set ofemotional procedures, as described by Clyman. Thenthe output of this new implicit procedure becomesconscious—the patient feels better and doesn’t knowwhy. In this scenario, the change comes first and theinsight comes second. We would submit, however, thatthere is significant potential value in the insight thatcomes later. Without new emotional responses cominginto awareness, the patient is left vulnerable to notknowing what to do when the vicissitudes of lifechallenge the limitations of the relatively undifferenti-ated, newly established emotional procedures. Regres-

sive activation of the old procedural patterns can takeplace, and the patient is left in a quandary. To mini-mize the likelihood of this occurring, in this situationanalysts should help their patients to experience thenew feelings fully so that they can be used as rawmaterial for the conscious, insight-oriented approachto change described above. According to our proposedmodel, this engages a “top-down” solidification ofnewly established “bottom-up” patterns.

Individual differences: alexithymia and the limitsof analyzability

Analyzability refers to the patient’s ability to undergopsychoanalysis. There are a variety of characteristicsthat are thought to be prerequisite, including the abilityto form attachments and engage in a trusting relation-ship, the capacity to commit to the work and attendsessions faithfully, the ability to tolerate distress with-out self-destructive acting out, the ability to describeone’s experiences, and the capacity to engage in fan-tasy. Less commonly considered is the ability to have arange of affective experiences and describe them inwords. The levels-of-emotional-awareness constructprovides a framework for evaluating the emotionalcomplexity of the prospective patient that may beuseful in predicting therapeutic success. Although apatient may be out of touch with his or her emotions inan area of conflict, the lack of emotional awarenessshould not be pervasive. We would predict that thehigher the level of emotional awareness of the prospec-tive patient, the greater the likelihood of a successfulanalysis.

Conversely, patients who are low in emotionalawareness are typically quite difficult to analyze.Alexithymia is a condition that means “lacking wordsfor emotion.” Rather than having difficulty accessingemotions due to defensive processes, the condition canbe understood as a deficit in the capacity to con-sciously experience emotion, and the literature indi-cates that such patients are very difficult to treat(Krystal, 1979). This difficulty is due to several fac-tors. Alexithymia frequently arises in the context of adevelopmental history of physical or emotional abuse.Thus, a fundamental limitation is the extent to whichthe patient can engage in a trusting relationship. An-other key issue is the ability to tolerate the affects thatare activated. Although an approach that does notinvolve insight could be considered, simply replacingone set of implicit procedures with another takes agreat deal of time and patience and, as noted above,may not be that resilient to environmental challenges.


The patient must be helped to overcome the deficit insome way.

Consistent with a cognitive-developmental perspec-tive, one must meet patients at their level, whateverthat might be (Lane & Schwartz, 1992). In the case ofalexithymic individuals, that means the implicit levelof somatic experience and action tendencies. Thus,nontraditional techniques are required. Gedo (1979)and McDougal (1989) have been two of the more vocalpsychoanalytic writers espousing this approach. Wehave discussed how focusing on bodily states will behelpful with all analytic patients in general, as theytypically have a broad array of affective experiences todraw upon in understanding what the bodily experi-ence means. In alexithymia, while it is especially im-portant to focus on bodily sensation, the emotionalrepertoire must be created largely from scratch, and theanalyst must be especially active in labeling and inter-preting what the bodily sensations mean.

One of us has discussed alexithymia as analogous toblindsight (Lane, Kaszniak, Ahern, & Schwartz,1997). As noted above, blindsight is a condition inwhich patients have had strokes involving the visualcortex, claim that they are blind, yet successfully trackvisual stimuli despite subjective blindness. Alexi-thymia may be analogous to blindsight in the area ofemotion, because the implicit manifestations of emo-tion may be present (comparable to successful visualtracking) without the associated explicit experiences(comparable to blindness). Indeed, Bucci (1997) viewsalexithymia as resulting from a failure in “referentialactivity” that “makes sense” of the psychophysiologi-cal activation by linking sensory input with differentmemory and symbolizing systems.

Blindsight has been divided into two types. Type 1involves no subjective experience of any kind duringvisual stimulation, whereas Type 2 involves vaguebodily sensations or other nonvisual subjective experi-ences during visual stimulation (Weiskrantz, 2000).One might hypothesize that in order to treat alexi-thymia successfully, the patient must have some back-ground feelings that can potentially be attended to,experienced, and then reflected upon.

The absence of such experiences, or the inability orunwillingness to process them, will substantially re-duce the likelihood of improving the condition throughpsychological or behavioral means. Indeed, a failure toattend to background feelings and understand theirsignificance may have contributed to the developmentof alexithymia in the first place. In such contexts,analysts are familiar with the use of behavioral tech-niques, such as massage, dance, or movement therapy,as adjuncts to verbal techniques. Perhaps their effi-

cacy, when it occurs, may result from heightening theintensity and salience of background feelings in a waythat facilitates the transition from implicit to explicitaspects of emotion.

Conclusion

The neuroscientific understanding of emotion andemotional experience is advancing at a rapid rate, andit is now possible to establish correspondences be-tween the neuroscience of affect and psychoanalysis ina way that is clinically useful. Although many of theanalytic concepts presented above have been reviewedelsewhere in the analytic literature, what is new is theselection and integration of particular aspects of psy-choanalytic theory, and the correspondence of theseclinical concepts to current neuroscientific understand-ing.

In closing, we highlight the following points ofoverlap between neuroscience and psychoanalysis:

1. The neural basis of emotion generation is modular.We cannot avoid having modules activated, evenafter a successful analysis. However, their activitycan be modulated either through conscious meansor by substitute procedures. The persistent exist-ence of these early behavior patterns is evidentunder certain circumstances, such as the regressionthat may accompany severe stress.

2. Functional-imaging studies suggest that differentneural mechanisms are responsible for implicit as-pects of emotion and three different kinds of ex-plicit emotional experiences, including backgroundfeelings, focal attention to experience, and reflec-tive awareness (reflection upon the contents ofconscious emotional experience).

3. The neural bases of attending to and reflecting uponemotional experience are not unique to emotion;there is a competition for limited conscious process-ing resources, which may be the origin of individualdifferences in emotional awareness.

4. There is physiological benefit to the process ofbecoming emotionally aware, such that the struc-tures involved in generating an emotional state aremodulated by those involved in emotional experi-ence. This may contribute to the physiological un-derpinning of emotional development.

5. The neural substrates of the different levels ofemotional awareness are not yet known. However,certain broad parallels can be identified between thehierarchical organization of the psychological


manifestations and neuroanatomical underpinningsof implicit and explicit aspects of emotion.

6. Psychoanalysis may be the treatment of choice forconditions requiring a change in emotional proce-dures. The length of time that the patient spends incontact with the analyst in the various phases ofbecoming aware of emotion may be necessary forthe creation of new implicit emotional proceduresand the establishment of reliable modifications toold implicit patterning. Most frequently, this occursthrough the analysis of the transference and duringthe “working-through” process.

7. As knowledge advances, it is conceivable that in thefuture functional neuroimaging may be useful inselecting patients for treatment and documentingthe effects of successful intervention. We wouldsubmit that the neural basis of emotion, emotionalexperience, and emotional regulation will be aparticularly fruitful way of documenting how pro-cesses fundamental to psychoanalysis are instanti-ated in the brain.

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