Reframing causality in psychiatry: Massimo Fagioli’s theoretical contribution

Fiamma Rinaldi1, Alice Dell’Erba2, Valentina Mancini2

1Villa Armonia, Psychiatric Clinic, Rome, Italy; 2Department of Mental Health, ASL Roma 1, Rome, Italy.

Summary. This paper explores the concept of causality in Massimo Fagioli’s works, in the context of his ‘Human Birth Theory’, especially with respect to propositions in Western philosophical thought and to the psychiatric debate. In the history of philosophy, the nature of cause-and-effect relationship has taken on three basic meanings: regular succession, rational deductibility and productive power. We propose how these are rethought in Fagioli’s theorisation as follows: as psychic activity (reaction), as dynamic phenomenon in the context of an unconscious relationship, and as human creativity. In particular, Fagioli analyzed how, within sadomasochistic relationships, the subject unconsciously conceives a concept of cause as constant repetition, and how this dynamic is resolved pathologically with the annulment pulsion, through the psychic elimination of the external object. This makes it possible to regard interhuman relationships as irrational, unconscious dynamics. Finally, the concept of cause is reconsidered based on the internal emergence of new psychic contents for the disappearance fantasy – psychic human creativity – originating at birth. Implications for psychopathology, psychodynamics and psychotherapy are then discussed.

Key words. Causality/causation, etiopathogenesis, human birth theory, philosophy, psychiatry, psychodynamics.

Riformulare la causalità in psichiatria: il contributo teorico di Massimo Fagioli.

Riassunto. Questo articolo esplora il concetto di causa nell’opera scritta di Massimo Fagioli, nel contesto della sua “Teoria della nascita umana”, con particolare riferimento alle proposizioni del pensiero filosofico occidentale e al dibattito psichiatrico in merito. Nella storia della filosofia, la natura del nesso causa-effetto ha assunto tre significati fondamentali: successione regolare, deducibilità razionale e forza produttiva. Proponiamo come vengono ripensati da Fagioli: come attività (reazione) psichica, come fenomeno dinamico nel contesto di relazioni non coscienti, e come creatività umana. In particolare, egli ha analizzato come, nell’ambito del rapporto sadomasochistico, il soggetto formuli a livello non cosciente un concetto di causa intesa come ripetizione costante, e come questa dinamica sia risolta patologicamente con la pulsione di annullamento attraverso l’eliminazione psichica dell’oggetto esterno. Ciò conduce a considerare le relazioni interumane come processi dinamici, irrazionali e non coscienti. Infine, il concetto di causa viene riconsiderato sulla base dell’emergenza interna di nuovi contenuti psichici, in virtù della fantasia di sparizione – la creatività psichica umana – che origina alla nascita. Vengono infine discusse quali siano per la ricerca le implicazioni di tutto questo in psicopatologia, psicodinamica e psicoterapia.

Parole chiave. Causalità/causa, eziopatogenesi, teoria della nascita umana, filosofia, psichiatria, psicodinamica.

Introduction

The search for the why, for the cause of things and events, has always engaged human beings. The concept of cause is a matter of commonsense, being used on daily basis spontaneously and mostly unreflectively. Also, reflections on this concept have been shaped into collective, hence, cultural and historical form in science and, previously, in philosophy, in which it has a prominent position1,2. Philosophical issues intertwine with theoretical and practical positions in psychiatry, where comprehending the nature of causal processes appears to be of utmost relevance3.

Italian psychiatrist Massimo Fagioli engaged in a dialogue, both explicit and implicit, with cultural milieus and history of human thought as well as with psychiatric researches4. References to the concept of cause can be found in many significant passages of his theoretical writings.

The aim of this paper is to investigate Fagioli’s elaboration of the concept of cause in the context of his theorization about psychic physiological and pathological processes. Additionally, the paper is intended to highlight innovativeness of Fagioli’s theoretical proposition, especially with respect to thesis about causality in Western philosophical thought, to the psychiatric debate, and its potential relevance for psychopathology, psychodynamics and psychotherapy.

In medicine overall, research on etiopathogenesis has always been a tenet. However, in the domain of psychiatry, this approach has shown many criticalities and animated a long-lasting and articulated debate between reductionists and non-reductionists5. It is worth mentioning how this controversy also revolves around the question about the ontological status of the human mind and body and their interacting6.

In line with scientific commonsense, the bottom-up model considers the existence of an organic alteration – physical impairment or genetic defect – as determinant of mental diseases. On the contrary, other positions emphasize psychological, social and cultural factors in the development of psychiatric illnesses considering top-down causation processes7. Although the Biopsychosocial model can be criticized for its being vague and nonspecific, a pluralistic, integrated paradigm is currently regarded as the most valid and efficacious approach8; however, the relationship between the different levels of factors (or levels of explanation) still poses issues9. Accordingly, and given the need to preserve etiological explanation, hence, the efficacy of realistic preventative and therapeutic efforts, psychiatric epidemiology and nosology are also challenged10,11.

In psychiatry, finding the cause is strictly connected with Jaspers’ definition of “explanation”, meant as identification of a regular and repeated link between phenomena in a lawlike generalization. On the contrary, phenomenological psychiatry comprehends psychic events by “understanding” – an empathy-based process – looking for self-evident meaningful connections. In particular, “genetic understanding” grasps how a psychic event emerges from another in individual consciousness12. The actual status of understanding and explaining, their mutual independence or possible continuity as cognitive processes, are still being discussed13-15.

Fagioli formulated what has been defined as Human Birth Theory in the 1970s16, approaching the physiology of the psyche and the origin of and the dynamics involved in mental diseases in an innovative way. Based on his theorization, psychic life begins at birth with the newborn’s reaction to light – an inanimate, meaning, aggressive stimulus. Fagioli defined this reaction as pulsion – a feature exclusively human – which is a psychic activity that mentally makes the surrounding material reality nonexistent. At birth, pulsion merges with vitality, the latter being the psychic expression of the reality of the body that senses and reacts to the external world. Considering human biology specificity, vitality originates from the transformation of the physical sensation of the contact with amniotic fluid recorded by the fetus during intrauterine life. Simultaneously with the psychic elimination of the external reality, the newborn’s mind creates the first psychic content derived from the mnemic and synesthetic traces of that prior sensation. This process constitutes the first image of the newborn’s self and of the existence of another human reality. This process at birth – namely disappearance fantasy – gives rise to the newborn’s capability of making images. Consequently, at human birth, a complex interaction occurs between the biological organism and the environment, with the break of the homeostatic condition, leading to the emergence of the nonconscious thought – that persists into adult life and is expressed in dreams. Therefore, birth marks a caesura from the fetal condition. Afterwards, in the context of interhuman relationships, the physiological fusion of pulsion with vitality might be altered or lost. When directed against the human reality of the external object, pulsion, bereft of vitality – defined as the annulment pulsion – impairs human beings’ primal healthy psyche and thus can lead to the onset of psychic illness. Regarding nonconscious dynamics as a resultant over time, Fagioli considered that, when the subject’s capability to implement affective relationships with the external object is impaired or flawed, then, a dimension of negation is at work; on the other hand, when this capability is completely absent, one should rather speak of loss of affectivity17-19.

Given the paper’s aim and intent, a brief historical review of the main philosophical and epistemological propositions of the concept of cause is provided, focusing, in particular, on the nature of the cause-and-effect relationship. Then, the use of this concept in Fagioli’s works is expounded with analysis and theoretical contextualization of the most significant occurrences. Finally, Fagioli’s contributions are discussed in relation to philosophical basic conceptualizations and within the context of the psychiatric debate about causality.

A bird’s-eye view of the concept of cause in the history of philosophical thought

Despite its centrality in philosophy and epistemology, the concept of causality is far from being clear and unambiguous given its multiple and varied meanings.

This lack of homogeneity concerns different aspects of this notion, including its objective and ontological/metaphysical value or rather subjective and cognitive/regulative value; its relation to temporality and spatiality; its relation to the concepts of law, predictability, and determinism and to those of necessity, probability, function, and condition; its relation to the ideas of chance and free will; and its validity in different fields of application such as natural, social, and human sciences1,2.

Throughout the history of thought, the very nature of the connection between cause and effect has taken on meanings that are heterogeneous in usage and definition by the various authors. Albeit with some degree of simplification, they can be led back to three fundamental forms:

1. as a regular and constant succession, a repetitive and uniform association;

2. as deductibility, as the logical-rational derivability of the effect from the cause;

3. the idea of cause as an acting, productive and generating force20.

The first position can be referred to as the regularist idea of causality.

Its major representative is commonly identified in Hume. According to this author, what we experience on the basis of sense impressions is never the causal relationship but the constant conjunction of things and events. On the basis of repeated observations, a natural habit of the human mind leads to an induction, that is, to generalize the observed succession and consider it as a permanent association21.

In the regularist position, the repetition of the association between cause and effect is eventually traced back to the existence of universal laws – essentially meaning natural laws – where the predictability of the recurrence of particular events in a certain connection implies conformity to them. The necessitating character of the nexus would thus depend on the non-derogability of the law.

For some scholars, laws may reflect a repetition that is only empirically ascertained and can be at any time disproved by the change of events: this is the case with Hume, who grounds it on a mental custom of expected regularity. Others justify uniformity by subsuming it under laws that find their own force and validity in themselves. We can take as an example Kant’s theorization of the transcendental: regarding the universal validity of scientific knowledge, and in response to Hume’s radical empiricism, he makes the cause-and-effect relationship a condition of thought insofar as it addresses sense-data, that is, an a priori concept through which the intellect can do no more than filter experience22. According to both of these positions, there is nothing in cause or effect that can justify or prove the correlation between them.

In the case of the second and third meanings of causality, philosophical thought has been concerned with the quality of the relationship between the two elements.

The so-called singularist thinkers such as Ducasse and Anscombe argue that the causal relationship can also be found and known at the level of a single succession of particular events, without having to refer to general regularities. Their arguments thus place the emphasis on the nature of the nexus itself, as attested by the presence in ordinary language of a wide variety of terms that imply a spontaneous understanding of causation as derivativeness23-25.

According to his second meaning, the cause is the intelligibility principle, rooted in the very strength of the nexus as a logical/rational connection.

The idea of cause as a logical-rational derivation, as that which constitutes the determining reason for something else, can already be discerned in the school of Democritus, who makes causation, reason and necessity coincide. Aristotle, whose doctrine of cause is eminently pluralistic, makes rigorous knowledge coincide with knowledge of principles and causes26, which assumes both objective and logical/explanatory value. Cause (aitia), which can be understood here as synonymous with reason, is the “middle term”27 capable of connecting two things and thus providing their causal explanation28. Moreover, cause is a principle of intelligibility insofar as it is closely connected to the notion of substance: to understand cause is to understand the internal articulation of substance itself. The connection with substance also gives us an account of the necessary character of Aristotelian causation29.

Among authors with strictly rationalist approaches, we find Descartes and Spinoza, as well as Leibniz and his formulation of the “principle of sufficient reason”, according to which for everything that happens there is a determinant cause or reason that can explain a priori its existence and characters, that is, from which it is demonstrable and deducible.

Partly connected to this second historically and conceptually, the third meaning of causality, that is, understood as production.

Aristotle famously distinguishes four types of causes: material, formal, final and efficient causes29,30. The efficient or agent cause is the meaning that has resonated most in modern and epistemological thought. It is understood as that from which the process of becoming or, in general, change or rest begins, that is, it is cause ‘what makes of what is made and what changes of what is changed’29. An exegetical line of thought31 understands the Aristotelian cause primarily as power: cause would coincide with the causal action that the agent actively imprints on a passive receiver. The idea of cause as productive capacity is found, for example, in the Stoics – who understand cause as that by whose action an effect arises, an active principle coinciding with the reason and form of things – and, in a completely different historical period, in Locke32.

Some scholars define this conception of causality, that is, an originating power, as referring to human-like attributes.

Nietzsche ascribes an anthropomorphic character to the concept of cause, considering it a transposition of the subjective experience of will33.

Russell takes a critical look at causality in philosophy and in common language and particularly highlights the analogy existing between the notion of cause and human volition. Among the maxims that he considers to be expressions of this fallacy is the maxim that causes “operate” and the maxim that “cause and effect must more or less resemble each other”, referring in particular to the idea that the universe must contain something as noble as our nature to have been able to generate the mind34.

On the other hand, the principle recalled by Russell would open up complex and interesting issues concerning the preservation of an invariant between cause and effect. It may be recalled that as early as Descartes takes up the ancient principle that causa aequat effectum, arguing that the cause transmits properties to the effect35. Locke, for his part, distinguishes creation ex novo – a divine operation – from the generation/making of natural or artificial entities, constituted of pre-existing particles32.

The question may be asked whether the connection between cause and effect is explained by various thinkers by virtue of the passage or maintenance of something unchanged between the two terms of the relationship, and whether this element is traced back to the explanation on the one hand, and the production of the effect on the other; to this question is connected another, namely, whether and to what extent philosophers have accounted for the emergence of the new*36.

These three fundamental meanings of the concept of cause, as representative of Western thought, have been explicitly and implicitly adopted by science and psychiatric theorizations. A comparison with Fagioli’s propositions can highlight the innovativeness of his approach.

The concept of cause in Massimo Fagioli’s works

Projective dynamics and the sadomasochistic relationship

Massimo Fagioli first referred to the concept of causality in 1962, in a paper on delusional perception. In this psychotic symptom, the subject adds meanings that are syncretic to perception itself, which Fagioli described as “impressions of immediate causality”. In line with phenomenological tradition, the author defined the psychotic’s experience of being in contact with the human world as unbearable. In order to escape from it, the delusional person removes what is intolerable to him/her from the real world and puts it into the new world being created37. Fagioli pointed out how the new meaning ‘adumbrates the activity of another human being’, as the perception of a ‘psyche acting’ on the subject that tends to alter him/her38.

In his introduction to the 1970 Italian translation of Spitz’s “No and Yes”, Fagioli proposed a psychodynamic interpretation of the “tendency to refer to the term ‘cause’ that appears to be inherent to the human psyche”. He questioned about the search for the etiopathogenesis of psychic suffering. Fagioli, thus, highlighted the risk, for both the subject and the researcher, of attributing the cause of the malaise to the external object following mechanisms of projective identification39.

Fagioli further expounded this issue in his main theoretical work, “Death instinct and knowledge”16, where he associated the concept of cause primarily with projection and the dynamics involved in sadomasochistic relationships. The subject projects his/her own internal libidinal dimensions onto the object – using projection, considered a pathological dynamic in which an internal content is put onto and added to the object. Thus, the relationship is characterized by dependence and ambivalence and, due to projection, by blindness towards the actual reality of the external object. In other terms, the subject does not see, does not get to know the object in its reality but, rather, for what he/she has put onto it; meaning, the subject is partially blind. Therefore, the subject blames the object for his/her own masochism. According to Fagioli, “[…] in the subject’s mind, a projection‐derived unconscious ‘logic’ becomes thought […]. Any such logic is the thought that the subject’s own masochistic condition is caused by the external object. In other words, the subject formulates a concept of cause […]”.

According to Fagioli, the relationship is implemented as a “conflict with no solutions”, meaning, is always reiterated, due to the bond that the subject establishes with the object. Blindness, as lack of libido typical of sadomasochistic dynamics, prevents thereby the evolution of relationship itself.

In the passages above, Fagioli explored the concept of causality – present, although being invisible, in the diseased subject’s thought – from the perspective of the subject. In particular, within the context of unconscious sadomasochistic dynamics, the concept of cause – associated with projection – compels the subject to attribute the responsibility for his/her being bad to the external villain, which makes him/her run in circles wondering why, thus, repeating his/her own past history. Here, the causal relationship is mainly intended as regularist and appears to bind the two partners to repetitive dynamics intended as natural phenomena regulated by constant and invariable laws.

Pulsion as the subject’s psychic activity

Fagioli argued how, based on projection, every action of the external object, and, in particular, its physical absence, is experienced by the subject as an aggression. Following the aggression received – experienced as such due to projection – the subject becomes as aggressive as and more aggressive than the object itself, switching from a passive to an active role: “[…] Making the sadistic object disappear, as it is the ‘cause’ of the subject’s own condition of masochism or castration, is the ensuing ‘logical’ thought […]”. The subject overcomes the masochistic relationship of dependence on the object – experienced as aggressive – by increasing blindness itself, that is, by eliminating the external object with what Fagioli defined as annulment pulsion: the subject makes the object psychically disappear.

One can observe how Fagioli’s theorization is deeply rooted in his daily clinical practice and has a clinical and therapeutic intent. Annulment pulsion was in fact deduced from observation of events such as when returning from holidays, patients accused him of having been psychologically absent: “I understood that he was telling me: ‘You did me harm because you weren’t there’”. Fagioli intended that patients, confronted with a physical absence, responded with an annulment, making the therapist disappear from their mind.

In “A case history” – a section of “Death instinct and knowledge” – where Fagioli described the psychotherapy he conducted with a psychotic patient, he emphasized how, in the patient’s clinical history, every critical passage represented a reaction to a physical parting within significant relationships, experienced as an abandonment – such as the father’s going to war and subsequent death, as well as the therapist’s holidays. Consequently, every annulment had followed an identification relationship based on projection; before the loss of affectivity occurs, an object-relation is implemented, albeit pathological; before the nothing, something exists.

Against a static, absolute, ahistorical view of the diseased person – comparable to causation meant as a repetitive and regular sequence of events dictated by laws – the psychiatrist can instead propose to find the before of the sadomasochistic relationship and the after of the crisis of the loss of affectivity.

Since the external object is the projection of one’s own internal situation, the pulsional reaction of annulment is the cause of the illness, meaning, the loss of the dimension making the relationship possible. With the formulation of annulment pulsion, Fagioli theorized about the etiopathogenesis of mental illnesses on an exclusively psychodynamic level: the cause of mental illnesses are the subject’s internal reactions, his/her diseased psychic activities. Thereby the elaboration of his/her history and reactions to the relationships experienced can be proposed.

Clinical vignette 1

During a session, the patient, a young woman, inquired: “Why am I sick?” In the subsequent session, she answered her question by recalling two dreams. The first involved her entering a new house, accompanied by her father, and searching for a personal space. The second involved the recollection of her grandfather’s death. The interpretative hypothesis proposed was: “Her attempt to seek a personal space within the hospital – intended to facilitate the development of an internal, autonomous dimension – was hindered by her identification with the father. This identification, rooted in a highly conflictual relationship characterized by dynamics of abandonment and devaluation, was projected onto the therapeutic setting”. The patient’s perception of the possibility of change, mediated through projection, appeared to be experienced as an intolerable threat, leading her to react with the disappearance of the affective relationship, which can be conceptualized as a form of “psychic death”. This reaction risked reenacting the dynamics experienced years earlier, notably her father’s abandonment of the family, the death of her beloved maternal grandfather, and the ensuing severe crisis which marked the onset of her condition.

Causality and unconscious interhuman relationships

With the internal onset of pulsion, as investment of death directed against the external human reality, there occurs, in the subject’s mind, an affective detachment, a complete break in the relationship. As seen before, however, investment stems from a relationship with the external object. In other terms, even a condition of isolation, of total lack of relationship, following the psychic elimination of the other, consists in the reaction of the subject being in relation with the other and should always be understood within the relationship itself.

By identifying this dynamic, Fagioli succeeded in delineating the very first onset of pulsion, occurring at birth as a response to the luminous, inanimate and, thus, aggressive stimulus. Here, the internal onset of the death instinct as pulsion takes place as a reaction to the insult: “[…] Even when conceptualizing the death instinct as a non‐relation with the object, still, this non‐relation happens within the context of a relation with the object […]”.

According to Fagioli, human reality is always in relation with; it is, therefore, based on this fundamental statement that psychic reactions, whether healthy or diseased, should be understood. What is it then that determines the onset of pulsion? Does it occur spontaneously and autonomously or is it caused by the subject’s relationship with the object? In this regard, Fagioli wrote: “[…] We do not know and, in a certain sense, we do not want to know. We are not at all interested in the concepts of cause or in the exactness of ‘logic’ […]”. Conceptualization of the death instinct as a reaction moves away from the idea of a linear derivation and to considers a dynamic phenomenon instead.

This concept demands to consider the reality of both partners in the interhuman relationship; this reality, with his/her qualitative features of humanity or inhumanity, is an active constituent of the relationship itself and influences the subject’s reactions. The object’s responsibility consists in his/her capability or inability to respond to the other’s requirements, to satisfy his/her desire.

However, Fagioli argued that object’s psychic absences, the deficiency, or rather the violence, have an effect because of the subject’s internal reality being uncertain or castrated, so, because of the subject’s reaction to the relationship being proposed. In “Una depressione” [“A case of depression”], a 1993 essay that the author devoted to the exposure of a case of depression, the term cause appears again to describe what determines the illness in the patient. The cause is at first found in the invisible, unconscious violence carried out by the patient’s schizoid partner. As the discourse unfolds, however, it becomes evident how the cause of the illness lies in the patient’s psychic blindness, in her own complicity with a negation – an altered nonconscious idea of the self – which determines a deficiency in her self-image, becoming guilt, impossibility, flawed identity: “[…] It is the absence, the lack of knowledge and of certainty that oppresses the internal structure. A ‘non’, a negation is the cause of this strange affection […]”40.

The nexus is indeed there but cannot be grasped with a logical or rational approach. According to Fagioli, mental diseases’ causation is not to be intended as the observable conscious derivation, that is, logical deductibility or rational intelligibility, but, rather, as the nonconscious reality of the human environment and the quality of the relational dynamic implemented at a nonconscious level.

Clinical vignette 2

A patient diagnosed with depression, showing severe alexithymic features, engaged in an anticonservative attempt of pharmacological overdose following a seemingly moderate mood deflection and during a familial dispute. The patient’s personal history was negative for suicidal ideation or suicide attempts and there was no relevant psychiatric family history. Shortly after, the patient’s uncle, who lived in the same housing complex, committed suicide by hanging, with no prior warning signs. It was proposed that the uncle’s unexpressed suicidal project had resulted in a psychic violence on the patient, since she had become attached to him due to her own lack of affectivity, with an idea of impossibility and a profound emptiness. After receiving this interpretation, the patient calmed down and engaged in a better elaboration in a variety of areas.

Human creativity and the rethinking of the concept of cause

In “Teoria della nascita e castrazione umana” [“Human Birth Theory and Castration”], Fagioli focused on the relationship-end of the relationship dynamic. The actuality of valid and fulfilled relationships allows for successful separations and the realization of an evolved and also creative internal condition – separation with fantasy. It is the becoming of human beings that changes and transforms his/her internal reality with disappearance of the previous one. Fagioli identified the causal factor of psychic realizations in the external human reality and in the relationship experienced, including separation41.

This dynamic originates at birth, with what Fagioli defined as the disappearance fantasy16, meaning the disappearance, at the level of the psyche, of that which is – the inanimate external environment – and the rise of the capability of making images. This latter originates from the internal and spontaneous onset of pulsion as a reaction to light and the memory of fetus’s skin being in contact with amniotic fluid. This material reality of being a physical body in relation with merges with pulsion, giving rise to an image. This dynamic involves the creation of that which is absolutely new, meaning, the species-specific human capability of making images.

Can we speak of cause in this context? The answer is far from being obvious. Being the relevant stimulus, light is indeed the cause of the reaction and activation of the brain. However, it does not seem correct to say that it is the cause of pulsion, which has a spontaneous internal origin; nor does it seem appropriate to say that pulsion is in itself the cause of the beginning of psychic life, regardless of the fetus’s skin relation with amniotic fluid and of vitality that emerges thereof and merges with pulsion. Drawing from Fagioli’s theorization, we tried to show how these dimensions are intertwined in a dynamic phenomenon. Moreover, although this dynamic repeats itself at every birth, identical for all human beings, like a law of nature42, it is hard to conceptualize the disappearance fantasy as a cause given its dimension of creativity which makes every birth unrepeatable. For instance, each individual’s sense of him/herself is unique, just as every realization in the course of life is.

Therefore, the traditional idea of causal derivation as generic production proves, here, to be inadequate because it is nonspecific. Fagioli considered creativity as a specific feature of the human psychic reality.

Moreover, with his theorization, Fagioli delineated the psychic dynamic that gives rise and explains creativity, meaning the disappearance fantasy. Human psychic capability of making that which is that which is not, and that which is not that which is, allows the complete separation from the past and the emergence of new internal contents.

Clinical vignette 3

A patient recalled a dream in which he returned to his childhood home and reconnected with his father. The house closely resembled the real one but was larger and more beautiful, featuring a garden with more trees - including those that were dry in reality but appeared luxuriant in the dream. From the terrace, he observed the landscape and glimpsed the old house, experiencing an expanded visual field. It was proposed that the patient was retrieving his own affective possibilities related to the relationship with his father. This dream was interpreted not as a literal retreat into the past, but as a recreation of past relational dynamics, because of increased vitality and fantasy (represented by the trees) corresponding to a more valid identity with an increased possibility of seeing and a wider perspective (represented by the terrace).

Discussion

Based on the study of some of Fagioli’s works, referring to the concept of cause, we tried to argue how there emerges the proposal to rethink this concept in the context of the physiology of the healthy psyche and psychopathology. In particular, deriving some of the basic formulations put forth by the author of Death instinct and knowledge, we proposed that this notion, with its main historical meanings, be reconsidered as follows:

1. the concept of causation, meant as regular and repetitive conjunction, applicable to the material world, and which may refer, in the psychic domain, to pathological dynamics based on projection – typical of sadomasochistic relationships given their repetitive character – gives way, in Fagioli’s theorization, to the idea of psychic activity as a reaction;

2. causality as logical-rational deductibility of the effect from the cause is replaced by the proposition of a dynamic phenomenon in the context of nonconscious interhuman relationships;

3. and, finally, a generic idea of power or productive capability is reconsidered by theorizing about human creativity based on the disappearance fantasy.

It has been shown how Fagioli regarded the search for the why in psychiatry as etiopathogenetic investigation. He identified the cause of the mental diseases in the subject’s nonconscious psychic activity as reactions to the defective or violent external object – valorising internal psychic processes, which are not directly observable, yet are linked to the individual’s subjective history and the lived relationships. These processes are not prompted by external factors, in an automatic predictable manner, rather it is the subject who internally reacts within a non-rational relational dynamic with others. Causality, in this framework, is not understood as a linear or deterministic mechanism.

Cognitivism and social psychology, particularly research on attributional styles, examine the subjective patterns through which individuals explain the causes of events. For example, a fundamental dimension concerns who or what is considered responsible for the event, whether responsibility is attributed internally (to something unique about the person) or externally (to the situation)43. These psychological attitudes show some analogy, on a conscience descriptive level, with Fagioli’s psychodynamic reflection about projection, which involves analyzing the subject’s point of view.

As previously discussed, the relational status of psychic processes is a fundamental aspect of Fagioli’s proposal. Additionally, phenomenological research has explored intersubjectivity, though the nonconscious interhuman dimension is not always explicitly addressed. For instance, Fuchs emphasizes the inherently relational nature of affects, highlighting the mutual influence exerted through lived bodies, their affectability and resonance. This process entails the creation of a shared space characterized by circular intertwining44.

Reframing psychic causality as a nonconscious reaction within the context of a specific relational dynamics has significant implications for psychopathology and psychotherapy. According to this perspective, psychic illnesses originate from the alterations or losses in the subject’s self-image and his/her capability to establish affective relationships, at a nonconscious level. Achieving the cure is possible for the disappearance fantasy addressed towards one’s own diseased internal condition. The disappearance fantasy, originating at birth, is conceptualized as the initial creation of the self-image. Recreating the birth dynamic within psychotherapy allows the transformation of internal images, promoting the recovery of the primal internal image and its subsequent development. The disappearance fantasy, directed against the current self, enables the elimination of pathological dynamics, specifically the process of separating from the past, recovering what has been lost and fostering the development of new internal contents.

Such process requires current relationships with a valid external object, that is, it can be stimulated via new interhuman relationships the patient establishes with the psychotherapist’s healthy human reality17,45. The patient’s response in this context is not primarily a process of constructing meaning but a nonconscious reaction to an existing reality that the patient must concretely relate to, this differs from a narrative-hermeneutic approach46.

From a phenomenological perspective, it has been proposed that images – meaning fragments derived from the patient’s lived experience, arising within the clinical encounter – could be interconnected within a pathos-resonant constellation. The emergent links and meanings should be intended as a space for new thoughts, functioning as a “figurative cause” – a process whereby the nexus of images retroactively transforms each individual image. This dynamic process offers an alternative to linear explanatory models based solely on motivation or causality47,48. A comparative analysis can be drawn between this phenomenological approach and Fagioli’s proposal, although the latter is primarily characterized as a psychodynamic exploration of internal images and the transformative role of human fantasy, as previously outlined.

According to Fagioli’s theorization, psychic reality is qualitatively different from material reality and its own causation4. Fagioli’s approach might be regarded as reductionist, as it excludes a non-psychic cause in mental illnesses. As already supported in the research of which Jaspers is an eminent representative, the knowledge of human beings’ reality cannot be gained with approaches belonging to the science of the material world. Fagioli, however, distanced himself from the phenomenological approach highlighting the inadequacy of a descriptive and rational methodology and considering going beyond consciousness as the requisite for understanding psychic contents.

On the other hand, based on Human Birth Theory, psychic reality emerges from and is fused with the biology of the human body. Consequently, in Fagioli’s perspective, comprehending human beings demands to consider the wholeness of human reality, in all of its facets and dimensions; this consists in a non-reductionist approach since different levels of understanding merge with one another.

Conclusions and limitations

Referring to Massimo Fagioli’s work, three fundamental conceptualizations of “cause” have been identified within the psychic and psychopathological domains: (1) as psychic activity (reaction); (2) as a dynamic phenomenon operating within the context of an unconscious relationship; (3) as human creativity.

Etiopathogenesis is intended as the subject’s nonconscious acting in response to the external object, a non-rational dynamic phenomenon within interhuman relationships. On the other hand, the pulsional reaction physiologically merges with vitality, a uniquely human dynamic – meaning, disappearance fantasy. This is the basis of human creativity, defined as the capability of making images. The mental creation/transformation of actual lived relationships serves as a process through which new internal contents are produced. This gives rise to – “causes” – images that structure and enrich the subjective psychic reality.

Revolving around Fagioli’s theorization, we have chosen a very specific perspective. Following are some limitations of this paper:

1. the present work needs further examination of the use of the concept of cause in psychodynamic literature and of the differences with Fagioli’s conceptualization;

2- the actual meaning of Jaspers’ idea of understanding by empathy is discussed. An analysis of the differences between Fagioli’s views and the concept of empathy itself, in particular with regard to the idea of projection and identification, is advisable49,50;

3. the relationship between the unconscious as theorized by Fagioli and the phenomenological investigation of implicit pre-reflective structures of conscious experience should also be explored. In particular, additional reflections about intersubjectivity, the relational nature of psychopathological phenomena and the related proposed epistemic models in phenomenological psychopathology and psychotherapy might enrich our work 51-53;

4. we mentioned that studies about the theory of mind and attributional styles struggle with the concept of causality43. Further investigations into how this research compares to Fagioli’s work on this topic may be considered.

Conflict of interests: the authors have no conflict of interests to declare.

Author contributions: Fiamma Rinaldi and Valentina Mancini developed the paper’s concept and structure. Fiamma Rinaldi reviewed the literature on the topic and wrote the paper. Alice Dell’Erba participated in the analysis and interpretation of data and, together with Valentina Mancini, reviewed all sections. The authors agree to be accountable for all aspects of the work; they all contributed to the article and approved the submitted version.

Acknowledgements: the authors wish to thank Mrs. Aila Mohoroff and Dr. Ilaria Rocchi for English editing; and Dr. Fernando Panzera for the revision of the article and his thoughtful suggestions.

Note

*Bergson proposed a debate on the topic with the intent to give a philosophical shape to the specificity of consciousness. Drawing from sciences and commonsense, he believed that causality takes from mathematics a model of inference, whereby the effect is somehow already determined by its cause. According to Bergson, this conception flattens psychological time, which is qualitatively heterogeneous – the concept of Duration. A proper understanding of this author’s position goes beyond the scope of this paper36.

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