Abstract
What actually changes in psychoanalysis, and how? Theodore Fallon has written a short book (a monograph really) offering answers to these questions. Fallon, a child analyst, epidemiologist, and internist, directs the child and adolescent training program at the Psychoanalytic Center of Philadelphia. His thinking clearly comes out of his work with children with significant disturbances. But Fallon does not simply claim that he has found a way to help severely disturbed patients through psychoanalysis. His goal is to advance a theory of therapeutic action that will apply to all development, one that will help us understand the important growth that occurs in psychoanalysis. In this brief book he presents a theory that integrates his psychoanalytic ideas with his reading of the attachment literature, his ideas about affect management, and his understanding of nonlinear dynamic systems theory.
Fallon lays out his argument in his introduction. His contention is that development is forced when an individual faces something new that cannot be accommodated within the mind’s existing organization. He offers a classic example: “Consider the pre-oedipal child who suddenly realizes that in addition to having a relationship with her mother and father, there is also a relationship between her mother and her father that does not include her. Suddenly she recognizes that her pre-oedipal model of the universe is limited” (pp. 1–2). This new realization throws into question the existing model, which until now has provided purpose and direction. A new model will have to be built. It will have to include the old understanding, but also incorporate the new information. Central to Fallon’s argument is his contention that even in a successfully developing individual, for this reorganization to take place the current structure of the mind will have to undergo a transient disorganization. When all goes well, this leads to a new and higher level of organization. As can be seen in this example, Fallon is hoping to show that his way of understanding development and change underlies even well-established psychoanalytic concepts (here the oedipus complex).
Fallon claims that this “moment,” when the old organization no longer holds but a new one is not yet in place, is rife with uncertainty and is inherently dysphoric. Because of this, there is a resistance to being present in the moment (for both the analyst and the patient). Indeed, because of the disorganized nature of the experience, the moment is often not remembered. It may not even be organized into a thought or experience that can be laid down as a memory or put into language.
If the moment cannot be put into language and directly expressed or understood, how are we to identify it? The moment is surrounded by unprocessed affects that may be seen in the analytic setting in feelings of anxiety or experienced as a bodily state. Careful attention to such experiences can help guide the analyst and allow him to recognize subtle experiences of disorganization. This is especially important because these affects can overwhelm the individual. If this leads to an overwhelming of ego capacities by unprocessed affect, a downward spiral can result that leads to getting stuck in a chaotic moment, rather than to growth and a new organization (a “moment” may last for an indefinite period in Fallon’s thinking). Our patients often come to us in one of these stuck moments, where understanding is not available and development is arrested. As the final piece of the puzzle, Fallon believes that it is attachment (in analysis to the analyst) that provides the supportive environment that allows the patient to face these overwhelming affects and move on to develop and reorganize.
Fallon believes that “the perspective of the moment provides new and powerful ways of grasping and assisting maturation . . .” (p. 2). He believes that if analysts have “a clear concept of the moment, and a practiced ability to tolerate the disorganization” (p. 5), they can be present with their patients in these moments, rather than distancing themselves from them, which is the reflexive reaction. By being present in the moment, we can lend our ability to tolerate affect to our patients, and can also lend ego structure, which can help patients reach the next level of organization. Thus, the main thrust of Fallon’s argument is laid out in the introduction; the remainder of the book elaborates and illustrates these concepts.
In chapters 1 and 2 Fallon recounts two case histories, one of a psychotic adolescent (Jay) and one of a boy, almost four, with a pervasive developmental disturbance (Evan). In these cases and others presented later, Fallon demonstrates the work of a thoughtful, creative, and gifted clinician, working successfully to help his patients. He also demonstrates what he means by the “moment,” how this theory informs his clinical work, and how he knows when he and his patients are in a “moment.” The cases do a wonderful job of bringing the theory alive, showing how the author came to his understanding, and how he uses it to manage difficult clinical situations (e.g., a patient whose productions are clearly disorganized and seemingly devoid of any comprehensible meaning, or a patient who refuses to come into his office for weeks). Fallon’s theory helps him manage his own anxiety, something we all need to do, and helps him reach toward an understanding of what is happening in his patients, and between him and his patients. After these in-depth clinical examples, Fallon uses chapter 3 to flesh out his theories in greater depth. His writing is clear, concise, not at all obtuse or difficult. He makes clear what he means by common terms such as affect or attachment.
Chapter 4, “Neurodevelopment and Psychoanalysis: Discussion of Evan and Jay,” is contributed by Susan Sherkow, a training and supervising analyst at the Berkshire Psychoanalytic Institute and Society, and an instructor and supervising analyst at the New York Psychoanalytic Institute and Society. She clearly has an interest in neuroscience. In her chapter she explores the relationship between observable behavior and brain function, and relates this to psychoanalytic ideas about development. She believes that psychological change affects neurobiological patterns inside the brain, a belief not likely to be controversial today, even if hard data supporting it may be limited.
In her discussions of Fallon’s cases, she shows her ability to understand the analyses in familiar psychoanalytic terms. Developmental stages, psychosexual development, managing aggression and affect, empathy, projection, internalization, etc. are all explored. She takes basic psychoanalytic ideas about development, emotions, and cognition, and asserts that understanding them in neurobiological terms is useful. But at this point in time, is it? I’m not fully convinced. Her main interest appears to be in the connections between different parts of the brain. She states that “the neurobiological development of emotions in an infant is, by definition, yet independent of the connection to the cognitive part of the brain, connections that will enable ‘explicit knowledge,’ once myelinization begins to connect emotional and cognitive centers of the brain” (p. 48). If, for example, we know that infants have implicit relational knowledge, and that cognitive ideas about this develop only later, how helpful is it to say that it’s because myelinization has not yet occurred, and the cognitive and emotional parts of the brain cannot yet speak to each other? To me it is a nice correlation between clinical observation and neurodevelopmental observation, which some people will find validating. When she gives her own case example, she shows a lovely piece of work with Anna, who at thirty-three-months presented with some autistic spectrum symptoms. She describes the girl’s growing ability to tolerate her anger and manage negative feelings. Sherkow helps Anna and her mother manage anxiety and internal conflict over triangular relationships. While it is undoubtedly true that this is “a new organization of neurobiological cognitive processes,” it is not immediately clear to me that acknowledging the underlying neurobiology helps a clinician know how to approach such a situation.
What seems more helpful to me is her focus on “developmental unevenness,” a situation in which there are specific areas of deficit, with other areas developing normally. In such situations, there are secondary effects both in the child’s sense of self and the parents’ sense of safety and security (p. 50). Acknowledging this can help us be sympathetic to our patients and their families, as well as keeping us aware that some of the pathology we see may be secondary to other underlying deficits or problems.
As an aside, both Fallon and Sherkow posit inborn deficits or difficulties in their patients. In chapter 2 Evan is described as having an “inborn” hypersensitivity to proximity; when discussing Evan, Sherkow remarks that “hypersensitivity to sensory stimuli reflects an abnormality in brain wiring” (p. 51). And Sherkow’s patient, Anna, is described as having a biologically based extreme auditory hypersensitivity, which interfered with her processing of negative emotions and inhibited her language skills. In the cases of both Evan and Anna, it is only somewhat into the case description that the mother’s difficulties are described. Evan’s mother had serious trauma that interfered with her ability to be close and manage her son’s difficulty with proximity, while Anna’s mother had unconscious anxiety about sharing, which in some ways mirrored her daughter’s difficulties. While it is always dangerous to comment on case material (the authors have so much more information and experience with the patients and their families), the fact that the mothers’ unconscious difficulties so perfectly mirrored the presenting difficulties of their children for me raises questions of causality. We know that even from the earliest days infants read the implicit messages their parents send them about how to relate, and they respond to those messages. My own reading of the cases would be more humble about our ability to know what is inborn and what is reactive to environment. Certainly there was a time when analysts were too quick to “blame the mother” for her baby’s temperment, and it is important to introduce the disposition of the infant into our conversations, but I believe we may need to simply recognize both possibilities and admit our inability to know. When a mother’s difficulties are so complementary to her child’s, it seems that the child could have inherited a disposition toward the problem or could have developed the problem in reaction to the mother’s issues.
In chapter 5 Fallon presents a number of brief clinical examples showing how he uses his ideas about the moment, organization, and close attention to affect. His examples include two patients who had suffered the traumatic loss of their parents, which led to overwhelming affect and an inability to move forward in important domains of life. Also included is a child with a clear neurological deficit (absence of a corpus callosum). Fallon shows how in analysis she developed the ability to express affect and connect to others in the world. Carefully tracking the affect allowed the analyst to connect to the patient and help her develop an internal working model of the world.
Chapter 6 presents a good summary of Fallon’s ideas, an exploration of their implications, and future questions. Here he expands his idea that in the moment the organizational capacity itself is being reorganized. The capacity to organize has its own developmental line and changes at each successfully navigated moment.
Fallon believes that we can recognize that we are in a moment by seeing the unprocessed affect and knowing that the mind may be so disorganized there is no meaning attached to the affect. This can allow us to understand what is happening and “more easily withstand the disorganizing effect of the strong affect” (p. 77). This will allow us as analysts to calmly take stock of the situation and begin the organizing process, allowing our patients to move on in development. We must accept that an attachment is necessary in order to manage the affect, and also as a prerequisite for the analytic task of lending ego structure and organization.
Fallon looks at familiar psychoanalytic ideas from the vantage point of the moment. For example, he sees defenses as compensatory mechanisms for the inability to organize an understanding of the reality the individual is facing. In another example, he notes that during a toddler’s toilet training, sometimes the child’s language abilities momentarily slip. Fallon sees this loss of language ability as a sign of disorganization leading to the loss of a previously established capacity. This exemplifies for him the process of disorganization/reorganization in small incremental steps in normative development. As this example would normally be described in terms of regression, it can be seen how he uses his concept of disorganization to explain from a slightly different vantage point a phenomenon we are all familiar with.
In the historical background Fallon provides, he discusses Freud, Erikson, Mahler, Bion, and Bowlby, among others. Notably absent, to my mind, are British object relations theorists like Winnicott (cited once), Guntrip, and Balint, who like those others worked with psychotic and severely disturbed patients (including children). They thought deeply about the regression inherent in the therapeutic process, and how therapeutic progress depends on the analyst’s tolerating this regression. And of course they emphasized that at times in analysis (especially with more disturbed patients) the object relationship itself is more important than interpretation. These ideas can be seen as a precursor to Fallon’s idea that during times of disorganization the attachment to the analyst is of primary importance. And just as Fallon sees the “moment” as a time of rich possibility when a new level of organization may be achieved, so object relations theorists were hopeful that regression “carries with it the hope of a new opportunity for an unfreezing of the frozen situation” (Winnicott 1955, p. 19). Winnicott took pains to point out that analysts may not want their patients to regress, but that they must be open to regression in the service of growth, just as Fallon hopes to help us be open to the moment, even if it is dysphoric for both analyst and patient.
We should consider whether thinking about “disorganization” rather than “regression” adds anything to our thinking. When (in Fallon’s view) the mind disorganizes, I think that it clearly does not lose all ability to organize an understanding of the world and experience. Rather, it reverts to an earlier, less comprehensive or sophisticated understanding, which, though it does not fully address the issues at hand, has the advantage of providing some framework. (There are times in Fallon’s examples where even this is presented as not possible, the experiences being simply ignored or put out of mind.) Is this different from regression, or just another formulation of the same idea?
Some theorists, such as Loewald, might bridge this gap. In “On the Therapeutic Action of Psycho-Analysis,” Loewald (1960) stated his belief that development happens after “periods of relative ego-disorganization and reorganization, characterized by ego-regression” (p. 17). Clearly Loewald sees disorganization as a central aspect of regression, and his work can be seen as exploring many of the concepts Fallon works with.
Loewald more clearly emphasizes the role of interpretation as the analyst’s way of organizing the patient’s material and helping the patient find a higher level of organization. For Loewald, the new object relationship with the analyst allows this to happen, just as for Fallon attachment creates a space that can contain the affects and allow the “inner push that moves development along” (p. 79) to create a higher level of organization. I think Fallon assumes the importance of interpretation (despite giving few examples of interpretation in his clinical examples) and emphasizes noninterpretive mechanisms because the noninterpretive aspects of his work are not always assumed by psychoanalysts.
Another topic that could be productively explored is the similarities and differences between Fallon’s thinking and that of the Boston Change Process Study Group (BCPSG). Their “Non-Interpretive Mechanisms in Psychoanalytic Therapy: The ‘Something More’ Than Interpretation” (Stern et al. 1998), is listed as the second most popular journal article on PEP. It shows striking similarities to Fallon’s work. The BCPSG too grew out of a developmental perspective, includes serious infant researchers immersed in attachment theory, and uses nonlinear dynamic systems theory to understand development and the psychoanalytic situation. Interestingly, they also use the idea of “the moment” to understand development in psychoanalysis. But while the language is similar, Fallon’s idea of the moment is more focused on a moment in development, whereas the BCPSG’s use of the term is more focused on an actual moment in time in an analysis, a moment that can be identified in close process monitoring. It is not clear if these theorists are talking about the same thing, but it is striking that they both reached for the same phrase—“the moment”—and think about so many of the same issues (nonverbal communication, the use of affect monitoring to help identify the moment, etc.).
Clearly Fallon’s is a rich theory, one that combines ideas about development with ideas about therapeutic action and uses ideas from many schools of thought. While his way of conceptualizing the analytic process may not be for everyone, it is thought-provoking and worth considering. As Sherkow says at the end of her chapter, “Dr. Fallon’s formulation of the moment, thinking in terms of being on the brink of chaos when confronted with disorganizing, unprocessed affect, offers a way to think about the central task of analysis” (pp. 61–62). After reading this book, I did find myself listening to certain patients in a new way. When that happens, I know that a book has been worth reading.