Keywords

Psychiatry has long been divided by two opposed views: that of those who, although admitting that mental disorders may have brain representation, emphasize that in a substantial number of cases this representation may be irrelevant to their definition, meaning, generation, and treatment and that of those who contend that all causes of mental disorders are to be found in brain dysfunctions, whether they are mental symptoms or mere epiphenomena of them. The former does not deny organic accounts of mental disorders; it simply holds that such accounts may sometimes be incomplete. The latter does not deny the use of mental or social variables or descriptions; it simply urges psychiatrists, if possible, to reduce them to low-level (neural) descriptions, even when, by doing it, crucial and causally related semantic elements may be disposed of.

The subject of debate is, therefore, whether mental disorders may be the result of complex, interactive, semantically pregnant actions and, thus, psychogenetically caused. A corollary question is how this can be conceptualized. This psychogenesis debate has ontological and epistemological consequences but also clinical and organizational derivatives. Since the early nineteenth century, the dichotomy ‘organic-psychogenic’ has been built into the definition of psychiatry. That is why the possibility of psychogenesis can be considered the fundamental question in psychiatry, from which all other questions follow (Berrios 2003).

Psychogenesis and Its Convergences

Two main convergences of a term, a concept and a cluster of behavioural referents, can be identified in the history of psychogenesis (Berrios 2018a). On the one hand, since before the nineteenth century, psychogenesis had referred to the process whereby the soul (later the mind and personality) was constructed. This convergence, ontological in nature but with epistemological consequences, explains its etymological origin and is still being used, coexisting during the nineteenth and twentieth centuries with the second convergence in such diverse fields as philosophy (Baldwin 1902), sociology (Elias 2000), pedagogy (Pruzzo 2017), psychology (Preyer and Talbot 1881; Hill 1892; Morgan 1892; Andriezen 1894; Piaget and Garcia 1983; Wallon 2007), and also psychiatry (Dide 1926).

On the other hand, during the nineteenth century, psychogenesis started to refer to the mechanism whereby the mind can generate mental disorder. First used in psychiatry and mainly epistemological in its origin but with ontological consequences, this second convergence stems from the old notion of moral causation of insanity, present in the first half of the nineteenth century in the works of, among others, Esquirol (1845) and already anticipated in seventeenth century authors such as Cullen (1789).

The second convergence is said to be created by Robert Sommer in his book Diagnostik der Geisteskrankheiten, in which he uses the words Psychogenie and Psychogene to name the process through which hysteria is explained (Sommer 1894, pp. 125–127). Later on, he again uses the term to refer to “psychogenic neuroses” (psychogener neuroses) (Sommer 1906, p. 51). In both cases, Sommer attributes to them a causal sense: they refer to pathological states (Krankheitszustände) induced or influenced by ideas (Vorstellungen). Over the next decades, psychogenesis appears with slightly different meanings in the work of many authors (Savill 1909; Glueck 1912; Wimmer 2003; Jung 1919; Prince 1920; Birnbaum 1918, 1928; Braun 1928) and contributes to the explanation of obscure psychological phenomena such as dissociation and hypnotism and of various mental disorders (Berrios 2018a). Two main meanings can be distinguished (Faergeman 1963). On the one hand, from the Anglo-Saxon tradition, there is the notion of psychogenesis as something produced and developed in mental space; on the other hand, the continental view that psychogenesis is something produced by environmental (including relational) factors on the mind. Although for this reason some authors have advised to provide a ‘decent burial’ to the concept (Lewis 1972), the fact that psychogenesis has a variety of meanings does not seem to warrant getting rid of it (Berrios 2003).

Psychogenesis: Epistemological Context

Berrios (2018a) proposed a number of contextual epistemological factors or structures that already begin to appear in the eighteenth century and contribute to the conceptual development of psychogenesis from the nineteenth century to this day:

  1. (a)

    Kant’s epistemology and his view of mind as active in the knowing process and the structuring and forming of experiences arrived at by applying his categories of understanding (Hartnack 1977)

  2. (b)

    The evolutionary theories of Spencer and Darwin, which held that, in the course of evolution, new properties and behaviours emerge (like life, mind, and reflective thought) that cannot be predicted from the already existing entities they emerged from (Morgan 1927)

  3. (c)

    The gradual development of the ontological concept of self, initiated by Luther in the sixteenth century, which gained a more active role with Fichte in the nineteenth century (Berrios and Marková 2003a)

  4. (d)

    Changes in the concept of meaning and the relationship between language and reality, which emerge from the linguistic debates at the end of the eighteenth century (from Herder, Rousseau to Humboldt) and posit that language, with its semantic space full of symbols, creates reality and influences human behaviour (Formigari 2004)

  5. (e)

    The questioning of dualist models, in particular the Cartesian one, which do not protect res cogitans, making this one dependent on changes in res extensa (Berrios 2018b)

  6. (f)

    The notion of inner sense, a sort of inward experience different from outward (sense) impressions, and its role as an important source and basis of knowledge, which influenced the individualist French spiritualism of the nineteenth century (De Biran 2016)

  7. (g)

    The concept of reaction, introduced as ‘irritability’ in medicine by Glisson in the seventeenth century, and its application to psychology as a response to external stimuli (Starobinski 1974)

These epistemological changes favoured the notion of psychogenesis and made it acceptable and understandable in the nineteenth century culture, either as description or explanation.Footnote 1 As the latter, it gained stability when opposed to the concept of somatogenesis.

In contrast to psychogenesis, somatogenesis is the view that holds that mental disorders are caused by specific modification of the body. Accordingly, the presence of a specific somatic lesion is necessary and sufficient to account for the mental disorder. The notion of lesion in psychiatry changed during the nineteenth century. While up to the 1820s it was conceptualized in anatomical or structural terms, from then up to the 1880s physiological lesions were hypothesized as causes of mental pathology (Moreau de Tours 1845; Griesinger 1845). Only in the transition from the nineteenth to the twentieth century could a psychological mechanism be entertained and, generally, only when a somatic one could not be found (Cossa 1969; Berrios 2018a).

In the eighteenth century, Frank Mesmer (1779) proposed a new modulating cause of human behaviour, an external, magnetic fluid ontologically different from the somatic changes accepted until then. In contrast, Faria (1906) denied the existence of this fluid and proposed that the sommeil lucide (hypnosis) is caused by a mechanism inherent to the individual himself (in his imaginationFootnote 2) that can be manipulated through suggestion. With Freud, Janet, and others, this internal force became more subtle and psychological. At the turn of the century, the adjective psychogenic was used in conditions that could be cured (or improved for long periods of time) by hypnosis, suggestion, analytic work, or some sort of ‘moral’ or persuasive treatment (Ellenberger 1976).Footnote 3

Throughout the twentieth century, psychogenesis is used to describe (a) how the body generates mental events; (b) how it generates personality; (c) how these mental events take part in the development of the latter; (d) how they cause mental disorders, directly or through personality, such as psychogenic psychoses, hysteria, folie à deux, dissociation, post-traumatic stress disorder, etc.; (e) how mental events influence the body and take part in the origin of physical disorders (which led to psychosomatic medicine); or (f) how mental events generate unexplained somatic symptoms (somatization disorders and hypochondriasis) (Berrios 2018a).

The Methodenstreit

The use of the notion of psychogenesis in psychiatry is embedded in another important debate (known as the Methodenstreit or ‘methodological debate’) that was happening at that time: the debate over the nature or status of the human sciences and whether their methods are the same as those of the natural sciences (Fulford et al. 2006). This debate, launched in the middle of the eighteenth century by John Stuart Mill (1974), had a considerable influence on Jaspers through the views of authors such as Dilthey, Weber, or Rickert, who sought to counter Mills’ claims that there were no substantive differences between the methods and aims of the human and natural sciences. The debate ran into the first decade of the twentieth century and re-emerged several decades later triggered by the logical positivist idea of a unified conception of science (Oppenheim and Putnam 1958; Hempel 1962).

Proponents of a distinctive method for both sciences distinguished between understanding (giving an account that concerns the meaning of an action or event) and explanation (giving a causal account). Understanding is the process of grasping a meaningful connection between events, while explaining is the way of identifying a logical connection.

Psychogenesis in Freud

Although the term psychogenesis appears several times in Freud’s works and is included in the title of one of his famous clinical cases,Footnote 4 the concept has a problematic integration (Meléndez 2004). This may be the reason why Jung initially felt uncomfortable in dealing with this subject (Jung 1960, p. 211). Freud considered psychoanalysis a natural science and, thus, sidestepped the Methodenstreit and the distinction between explanation and understanding. Freudian interpretation is a modality of explanation as long as it searches for a causal account from the effects but assumes the latter are overdetermined and therefore there is not a linear connection between causes and effects. Freud, unlike Jaspers, does not take a point of synthesis such as personality as the basis of the understandable or meaningful connections of an individual. Rather, he establishes as a starting point a structural division of the individual so that a primary or original scene can be identified, through analytical work, as the base upon which symbolic construction is built.

Psychogenesis in Jaspers

It is stated that Jaspers’ main contribution to psychiatry was the introduction of Dilthey’s psychology and the notion of understanding (Tellenbach 1969, p. 14). The fact is that Jaspers’ view on the distinction between understanding and explanation is not clear enough (Fulford et al. 2006, p. 219). While in the first section of his 1913 paper on the topic (Jaspers 1913/1974, pp. 82–3) he seems to follow Dilthey’s view that understanding and explanation are two ways of apprehending two separate realms of reality, in another part of the same paper (p. 86), he seems to endorse Weber and Rickert’s view that they are two different methods to approach the same reality, either mental or physical.

Jaspers suggests that in psychopathology, apart from causal links between sensory data coming from our sense organs that natural explanation (erklären) can account for, there are meaningful connections that can be grasped by psychological understanding (verstehen) or empathic representation of psychic data.Footnote 5 Accordingly, Jaspers distinguishes between process and development. Process is the alien factor that makes empathic, genetic understanding impossible, and, thus, building a Weltanschauung or global meaning is not allowed. Processes are all the pathological phenomena that produce a permanent change in the meaningful connections of personality.Footnote 6

For Jaspers, this dialectical notion (Lantéri-Laura 1962), opposed to that of development and reaction, and parasitic upon the notion of the non-understandable ((un)verständlich), is central to psychiatry and makes the aetiological question (whether the ultimate cause of mental disorder is a metabolic dysfunction or an unconscious dynamism) secondary. Thus, the aim of psychiatry is the search for process symptoms (primary or fundamental, as opposed to secondary ones) and their pathogenic mechanisms (Jaspers 1910/1977). However, the fuzzy boundaries of the concept of psychological understanding, its excessive flexibility to extend beyond them, and the overvaluation of the position of the observer were correctly criticized as leading to the idea that all pathological manifestations of mental disorders may have a psychogenic origin (Pichot 1984, p. 82; Castilla del Pino 1980).

Psychogenesis in Wimmer

Wimmer, in his 1916 book on psychogenic psychoses (Wimmer 2003), defines psychogenesis according to four criteria: (a) predisposition, (b) psychological causes determining the course (onset, evolution, and end) of the disorder, (c) psychological causes shaping its form and content, and (d) marked tendency to recovery.

Although it has been claimed (Faergeman 1963; Garrabé and Cousin 2001) that Wimmer’s criteria draw on Jaspers’s reactive psychoses, he might have been much influenced by his own clinical observations (included in his 1902 doctoral dissertation) and the views of Magnan, Legrain, or Reiss (Schioldann 2003). Be that as it may, Schneider’s reformulation of the concept of psychosis,Footnote 7 with the impossibility of a non-organic aetiology, and Swiss psychiatry’s (Bleuler, Jung) extension of understanding to a wide variety of mental disorders which made superfluous the delimitation of a specific group of reactive psychoses (Gabriel 1987) contributed to the disappearance of psychogenic psychosis after the Second World War, at least in German psychiatry (Strömgrem 1974, 1986, 1989).

Psychogenesis in Lacan

Lacan’s views on psychogenesis can be analysed in three different periods. In his 1932 doctoral thesis, Lacan considers psychogenicFootnote 8 a symptom (either physical or mental) whose causes are expressed through complex mechanisms of personality, whose manifestations reflect them, and whose treatment may depend upon them (Lacan 1987, p. 41). He affirms that a psychogenic symptom still rests upon an organic basis, generally pathological, sometimes identified as a lesion (p. 42), and distinguishes between organic (either functional or lesion) and psychogenic causality of a disorder, both being mutually compatible.

The notion of psychogeny of this first Lacan differs from Jaspers’ view (Lantéri-Laura 1984b). As mentioned above, Jaspers empathic understanding (verstehen) differentiated between normal and pathological (or process), whereas Lacan considers that even process can be understood in its psychogenic meaning (i.e. by psychoanalytic theory) (Casarotti 2018).Footnote 9 He draws on Jaspers’ concept of psychic process (as opposed, on the one hand, to development and, on the other, to organic process), which, by introducing a new and heterogeneous element in personality, conforms again to meaningful connections and understanding (Lacan 1932/1987, pp. 128–131).Footnote 10

In his contribution to the third Bonneval colloquium in 1946, Lacan (1975) changes his views. In his paper ‘Propos sur la causalité psychique’ (Observations on Psychic Causality), he opposes his view to Ey’s organo-dynamism, which he considers to be a variety of mechanistic organicism (p. 147). He no longer draws on Freudian theory to find, in a basically epistemological stance, psychogenic mechanisms that differentiate some delusional disorders from some other organically determined. Rather, in an ontological turn, he centres on man as the root of mental alienation and affirms that madness, from its origin, is entirely experienced in the register of meaning, in what makes human experience specific, that is, language (pp. 165–166).

In his seminar on psychoses in 1955, psychogenesis is finally excluded from psychoanalysis with his much quoted sentence: ‘…if this [understanding in Jaspersian sense] is psychogenesis, then the great secret of psychoanalysis is that there is no psychogenesis’ (Lacan 1984, p. 17). By rejecting understanding as a method of identification of the psychogenic, and relying on his symbolic, imaginary, and real triad presented a few years earlier, Lacan proposed to overcome dualism and the distinction between psychogenesis and organogenesis, thereby questioning the very etiological enterprise in psychiatry.Footnote 11

Psychogenesis in Ey

Probably the most important and conceptually profound debate on psychogenesis during the twentieth century was that of the Third Bonneval Colloquium organized by Henry Ey in 1946 (Bonnafé et al. 1950). Following the topic of the second colloquium held in 1943 (dedicated to the inferior limits of psychiatry, i.e. its relationship with neurology), Ey (1950) proposed as the theme for the third edition the superior limits of psychiatry; that is, what differentiates mental pathology from normal mental life. He contributed to the debate with a paper called ‘The limits of psychiatry: the problem of psychogenesis’, which generated replies by Lacan (see above), Rouart, and Bonnafé and Follin. Rouart’s contribution (Rouart 2004) is interesting from an epistemological point of view, as he criticizes the subordination of psychic causes of mental disorders to physical ones and proposes a three-part causality (sociological, psychological, and biological) with a different contribution of each cause in every case, concluding that all mental disorders have a psychic origin but in different degrees (Berrios 2018a).

In his paper, Ey seems to use the term psychogenesis in its two meanings, as the development of mental functions and as psychic causation of mental disorders. He criticized, as he had done in an earlier paper (Ey 1932), the notion of constitution as a necessary condition to the development of mental pathology and followed Jaspers’ concept of process as the pathology criterion. Drawing on Jaspers’ notion of psychic process, he defended his doctrine of organo-dynamism against Lacan and herewith repudiated psychic causality of mental disorders. On the other hand, he emphasizes the processes of normal psychogenesis, which lead to a synthetic organization of adaptive functions, and claims that mental disorder is both the process of unstructuring or dissolution of psychic structure (into an inferior level of psychic organization) and the expression of this dissolution in every form of mental pathology (Casarotti 2018). In a later paper, Ey (1974) criticizes the notion of reactive mental pathology by affirming that what is pathological is reactivity itself, expressed through a disorganization of psychic life.

The Notion of Reaction

This concept, probably introduced in the thirteenth century, had acquired both vitalistic and mechanistic meanings by the seventeenth century, which have run in parallel ever since (Starobinski 1974, 1977, 1999; Berrios 2003).

The ontological space in which reactions take place has changed from matter (from Glisson’s notion of irritability to Newton’s mechanistic view or Boyle’s reaction to reagents) to mind (in Breuer and Freud’s notion of abreaction or in Jaspers’ meaningful genuine reactions). When taking place in the latter, reactivity and psychogenesis overlap.

Adolf Meyer introduced reactivity into twentieth-century psychiatry, and since then it has been applied to many categories. However, it remains unclear whether the term means the same in all of them and how all these are connected to the notion of psychogenesis. It is also unclear what the relationship is between reaction and its trigger, whether reaction acts as a reason or a cause (Berrios 2003).

Psychogenesis in Symptom Formation

The modelling of descriptive psychopathology on semiology, its development during the nineteenth century trying to link specific signs and symptoms with brain lesions, and its later exclusive dependence on correlational accounts neglected the possibility that non-lesion factors (social, semantic) could play a crucial role in the construction of mental symptoms. Mental symptoms may arise from complex interactions between brain signals and semantic information. There can be two types of symptoms according to its brain representation (Berrios and Marková 2003b). On the one hand, there are those that originate in a putative, more or less specific brain signal, which penetrate awareness and are first experienced in a formless, prelinguistic experience, which is later formatted through a configurative process into verbal or behavioural tokens. On the other hand, there are those that originate from a reconfiguration process of the former. This reformatting activity occurs in a semantic (linguistic, symbolic) space in which personal, relational, and social clues are crucial. It also has a brain representation, but this is not necessarily specific nor sufficient to fully account for it. Symptoms resulting from this reformatting process may be similar to the first type and constitute behavioural phenocopies (Berrios and Marková 2002, 2003b) and lead to medically and psychologically unexplained symptoms.

Mental disorders built upon this second type of symptom constitute veritable ‘pathologies of meaning’ and should be formulated in terms of reasons rather than causes.

How Does Psychogenesis Exert Its Causal Power?

Three positions can be adopted regarding the causality of mental events: (a) mental events do not cause; they are just folk descriptions of the real causal processes to which they can be reduced. This is the view supported by all reductionist accounts of action explanation, including those of philosophers of mind such as Gilbert Ryle (1963) or AI Melden (1961) for whom reasons can never be causes; (b) mental events do cause; reasons (at least some of them) can be causes, assuming a nomological account of causation; (c) mental events do cause, and reasons can be causes but assuming a non-nomological account of causation.

The most influential example of the b) position is Donald Davidson’s Anomalous Monism (Davidson 1980). Davidson states that mental concepts cannot be structured in natural laws, but mental events to which they apply are part of the causal fabric of the world. An action is an event that may have different descriptions depending on their relational properties. Action explanation is a method of fitting one action into a broader pattern, and reasons are an appropriate way of rationalizing them, making sense of them through contextualization. But, reason explanation is, to Davidson, also a form of causal explanation. Although reasons and causes structure reality in different ways, this does not imply that what is being structured is not the same in both. Davidson, however, does not provide an answer to the question of how mental properties play a part in causal explanation of action, as he assumes that properties that are invoked in the nomological account of the causal efficacy of mental events are exclusively physical (Tanney 1995; Fulford et al. 2006, p. 728).

But what if the nomological, Hempelian, Newtonian notion of cause is insufficient? This notion excludes important aspects of human behaviour such as time and context. If human beings and their behaviour are complex adaptive phenomena, their actions are unpredictable, making covering-law models clearly inadequate to explain these processes. This is the view held, for example, by Juarrero (1999) for whom the causal mechanism at work between levels of hierarchical organization can best be understood as the operations of context-sensitive constraints. High levels of self-organization of the human brain and nervous system can access different states with different properties than less complex and uncorrelated neuronal processes can. These include meaning, intentionality, purposiveness, and the like. Thus, higher level’s self-organization is the change of probability of the lower-level events. Top-down causes cause by changing the prior probability of the component’s behaviour. What follows is a non-reductive model of explanation, one which includes historical narratives (Juarrero, pp. 131–150).

Conclusion

Psychogenesis may be an out-of-fashion concept (Lewis 1972), but there are important reasons not to reject it, as part of contemporary neuroscience does (Berrios 2018a). On the one hand, the rejection of psychogenesis contradicts the results of clinical, historical, and epistemological analyses of mental disorders, assuming a very narrow notion of them. Moreover, the study of psychogenesis may offer an important key to the understanding and effective handling of many mental disorders. On the other hand, the epistemological caveats that have been shown regarding the causality of mental events dissolve when the proper notion of causality departs from the linear cause-effect, covering-law model, and the excessive dependence on correlations (with brain activity) as the only confirmed evidence of the existence of a causal link between mental events. The issue here is not whether a known disease of the brain can ‘cause’ people to behave in strange ways; it is whether every time a person behaves in a strange way the claim can be made that something is wrong with his/her brain. If that is not the case, psychiatry must have the tools to distinguish those mental disorders in which brain representation is causal and primary, and the target for treatment, from those in which it is secondary and non-causal, and hence the treatment target lies on the semantic and symbolic network at the origin of that mental disorder (Berrios 2018b).