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RESEARCHARTICLESAND COMMENTS Politics, Power and Psychiatry: A Review of L’Ordre Psychiutrique: LYge d’Or de 1%&isme by Robert Caste1 Harvey Mitchell* I Robert Castel’s study of the establishment of what he terms the “golden age of alienism,” or what may be identified with some greater degree of felicity as the golden age of the psychiatric asylum in France, follows from his earlier and longer treatment of psychoanalysis, first published in 1973 but reissued three years later’ so that the two books made a dual appearance in France in the same year. Both are inspired and informed by the major influences of Michel Foucault, who understands knowledge and power as existing in an interlocked relationship; by Pierre Bourdieu and JeanClaude Passeron who plot through their concept of “symbolic violence” the processes by which interpretations of the world, say, in the educative realm, assume an unquestioned autonomy serving alleged objective systems of thought but actually constituting apparatuses of power affirming and legitimizing the hegemony of dominant classes;2 and by Franc0 Basaglia who tantalizingly but not unequivocally suggests to Caste1 alternatives to psychiatric thought and practice. With so formidable an intellectual armature, Caste1 was bound to command attention, but he has produced more than a respectable book. His efforts have yielded a rather extraordinary one whose significance owes as much to his own brilliant powers as to his mentors’ and colleagues’ attempts to deal comprehensively with the transformation of systems of knowledge into instruments of power and politics. Caste1 sets out to deal with the development of mental medicine within the setting of the asylum not as a discrete domain possessing inviolate epistemological foundations, but as a discourse in intimate relationship with other areas of human endeavour, not the least of which were the exceedingly complex, vexing, and more often than not concealed, environmental conditions expressive of social constraints. economic pressures, and political uncertainties. Whatever autonomous claims the principal actors made for themselves as they developed medical and non-medical theories and strategies to deal with the mentally deranged, Caste1 demonstrates how each of them rested heavily on the other, and that both moved towards the achievement of similar if not always identical *Professor of History, University of British Columbia, 1R. Castel, Le Psychanalysme: L’ordre psychanalytique ‘P. Bourdieu, Cultural Studies,
Symbolic 1977).
Power
(trans.
Vancouver, British Columbia, Canada, et le pouvoir (2nd. ed. 1976).
R. Nice, Occasional
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goals. Sometimes indeed they insisted that their motivations were separate and distinct. but quite often they revealed how close their affiliations were, thus quite unconsciously providing us, as their distant heirs, with an accurate model of what was really transpiring between men of knowledge and men of action, neither of whom of course thought and acted in such well-defined spaces. Caste1 does not deny, however, the existence of what his protagonists thought constituted scientific knowledge, or more precisely in the present case, medical knowledge. Implicitly, like Foucault, he maintains that the knowledge of a given time is like a grid of social and intellectual conditions, a total system permitting the creation of new knowledge, thus enlarging its boundaries. What is not clear is the extent to which Castel, like Foucault, is prepared to discuss power and its technologies as breaking free, being released from, and ultimately not owing their reality to, historically determined entities. It would seem, though, that Caste1 has not followed Foucault so far as to carry out an “ ‘anafrom a certain representation of lytics’ of power . . . [freed] . . . completely power that [ Foucault] would term . . . ‘juridicodiscursive,’ ” liberated in other words from the notion of law as theoretically formulated and actually applied under the French monarchy, or as it was thought the law should be reformed to establish an exact congruence between it and power in a new and enlightened political regime.3 Knowledge is not in Castel’s view, as it is not in Foucault’s, apolitical; neither of them is the victim of such an illusion. For both it becomes a weapon of disciplinary action and power. But Caste& it should be made as clear as possible - at any rate on the basis of the present study - is not saying that the reality of power lies inevitably, essentially, and ultimately within ourselves, engaging us all in its exercise, so that to grasp its authentic nature, we must reach out beyond any analysis of power as the exclusive possession of successive dominant classes at different points in history.4 II. Caste1 is thus engaged in a fascinating, but exceedingly difficult, endeavour. He states at once that he will be concerned not only with the linkages between knowledge and power, some straightfonnrard, others elusive, but with two levels of change in the theory and practice of psychiatry, the first constituting the shifts and adjustments - what he calls serial changes - within a prevailing explanatory system, which he distinguishes from a total systemic transformation. The reliance on Foucault’s notion of epistemic change is apparent. The first sort may shake convicitons, but fail to alter the system’s framework, since “M. Foucault, The History of Sexuality I: An Introduction at 82.88 (trans. R. Hurley 1978) (originally published as Histoire de la sexual&e I: La Volonte de Savoir 1976). 4Cf: D. Lecourt, Dissidence ou revolution (1978). Besides discussing Foucault’s relationship to Marx and Marxism, Lecourt notes that Foucault’s major interest lies in the charting of densities and diffusions of power, rather than in its particular and temporal political manifestations. For Lecourt, quite unjustifiably I would suggest, Foucault’s position brings him within the orbit of Andre Glucksmann’s critique of the Enlightenement and the Revolution in his Les maitres penseurs (1977). For a friendlier, yet critical review of Foucault’s Discipline and Punish (1978) (originally published as Naissance de la prison, 1975), see Seem, Book Review, 29 Telos 245 (1976). A very perceptive and fair assessment of Foucault comes from Guedon, Michel Foucault: The Knowledge of Power and the Power of Knowledge, 5 1 Bull. History Medicine 245 (1977).
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crises within it can force compromises and even stimulate fresh departures, both at the theoretical and practical levels. By contrast, a systemic transformation is a total metamorphosis, marked by a movement or a passage from one to another coherent and global perception which is accomplished in every aspect of social as well as intellectual life. In the case of psychiatry, such a metamorphosis would have to encompass procedures in treating the insane, which were conceptually and socially innovative and pervasive, creating, as it were, a new unity, a new totality, a new grid, a new episteme. Caste1 is concerned with both forms of change. His study in fact is bounded by two metamorphoses. the first eventuating in the 1838 law which confirmed the outlines of a total system that was to endure until 1968 when a second total transformation of psychiatric processes obliterated the former. The asylum. as the psychiatric and social paradigm, was displaced in the 1960’s by “sectorization,” the creation of complete psychiatric services for each unit of population of 70,000; and there is the further prospect of a “capillary” penetration of society at large, by which Caste1 means a preventive, prophylactic psychiatry as part of the state’s judicial, welfare, and educational structures. Clues for the establishment of the second such transformation are to be found throughout his study, and more may be found more systematically treated in his book on psychoanalysis, but we must await the second volume of the present study to ascertain how successful he has been in finding symmetries at either end of these metamorphoses separated by more than a century and a half. For the moment, we are presented with rich and abundant documentation of the problems which, from roughly the midpoint of the eighteenth century, disturbed knowledge seekers and policy makers both, since existing orthodoxies appeared to compound rather than solve problems. A good part of Castel’s book is devoted to a patient but constantly interesting reconstruction of these failures and the shaping of the new structures that would, it was expected, ensure success. What Caste1 guides us through is nothing less than the growing awareness of and dismay at what was perceived as an unprecedented and dangerous excess within the population of undesirable elements, the deviants of all sorts, the indigent, the delinquent, the criminal. the sick, the abandoned. the insane, the people who have become familiar to us in Foucault’s books and in a growing number of others.’ ‘What may be said to have started it all nearly twenty years ago was Foucault’s Histoire de la folie a l’agc classique (‘1961). An abbreviated translation by R. Howard was published as Madness and Civilization (1965). Among Foucault’s other works on these questions see La naissance de la clinique (1963), translated as The Birth of the Clinic (1973). His interview with Michelle Perrot 09 prisons is included in J, Bentham. Le panoptique (trans. M. Sissung 1977). Other studies of particular importance are E. Goffman. Asylums (1961): D. Rothman. The Discovery of the Asylum (1971); G. Rosen. Madness in Society: Chapters in the Historical Sociology of Mental Illness (1968): 0. Hufton. The Poor of Eighteenth-Century France 1750-1789 (1974): M. Ignatieff. A Just Measure of Pain: The Penitentiary in the Industrial Revolution 1750-1850 (1978): two unpublished doctoral dissertations, one by, M. Alexander on the insane asylum in nineteenth-century Paris (Johns Hopkins tiniversity), and the other by M. Donnelly on the development of medical psychology in nineteenth-century Britain (Birkbeck College, University of London). See also Deviants and the Abandoned in French Society (trans. E. Forster and P. Ranum, R. Forster and 0. Ranum eds. 1978). Other works bearing on the hospital on the eve of its transformation at the end of the old regime and of the movement towards public hygiene and the new perceptions of public space are inspired by a collection of essays edited by Foucault, Les machines i guerir: Aux origines de l’hopital moderne (1976), and another edited by B. Fortier, La politique de l’espace parisien a la fin de l’ancien regime (1975). 1. Illich. Medical Nemesis (1975) is not without pertinence, though he is not sensitive enough to the links between medical theory and practice and their social context.
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What was at stake in the impending transformation that found its medical and institutional forms logically and precisely laid out in the 1838 law? Nothing less than the transformation of society itself; its “rationalization,” its becoming a fact of pohtical economy. The bureaucrats, physiocrats, scientists. medical men, and other professionals accepted the fact, but did not explain it. They came to embrace the premises and goals of political economy as natural and true. They gave credence and conviction to it because it provided a solution to an overwhelming problem that took on the dimensions of an obscene blemish which threatened to spread and infect the totality of society the longer and less effectively the administrative, juridical and domestic institutions of the old regime were ‘permitted to deal with it. Working and thinking within and against the constraints of a traditional society, the state, the judicial organs and the family could not elaborate legitimating principles for the treatment of the most refractory sections of the population until they were given the opportunity to elevate the market economy as a theoretical and practical model for the deployment of the larger working population. This did not come to pass suddenly, largely because there was no full agreement on the causes and nature of unemployment, the kinds of assistance and welfare which would or should be available, and the various categories of the population entitled to either of the above or to other kinds of social efforts altogether. The legislation of the revolutionary period did not establish consistent policies either of repression or assistance: but if it did not, it helped to sanction, especially once it withdrew from its radical stages, the supremacy of the market model of society. But not even in England, as Karl Pofanyi’s great book tells us, was the labour market fully free for more than a brief period after 1834.6 Caste15 analysis leans heavily on the mutual needs and isomorphic perceptions of two groups of people who in fact did not, he would insist, present arguments for their policies or invent “scientific” theories from to tally distinct vantage points in society. Political economy, predicating the free circulation of goods, also required the free circulation of labour if it was to liberate society from its customary restraints. The intervention of the state was justified to remove all impediments to the fullest operation of such an economy. In such an optique, it proved, Caste1 argues, much easier to deal with one section of an unmanageable population than the others, precisely because the mad escaped the criteria for rational participation in an exchange society on the grounds of their incapacity to assume responsibility for themselves, while most other categories of deviance and delinquency were not deprived of reason, and hence were ultimately responsible for themselves. Varying degrees of social responsibility were nevertheless recognized for the old, the sick, and those afflicted with some of the more dramatic diseases, but the discussions surrounding the establishment of a new structure of assistance, combining specialized hospital care on the one hand and general domiciliary care on the other, singled out the insane almost from the beginning. The point is that a policy of sequestration, of social isolation, of specialized treatment was seen as being more appropriate for them than for any other part of the deviant population, with the exception of the criminal. No clear cut case could be made for the others, if only because the ideolo’ K. Polanyi,
The Great Transformation:
The Political
and Economic
Origins
of Our Time (1944).
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of the market prevented total state aid for people who should ideally look after themselves. Castel’s tight analytical structure threatens to collapse at one point, when he appears to give much more substance to the debate on hospital and domiciliary care than it warrants. He is disposed to think, more seriously than the actual situation warranted, that for a moment the future of welfare and medical policies teetered between total incarceration, which was the “totalitarian” model of the old regime, and the treatment of deviance, including insanity, at the pIace of its origin - within the family or the neighborhood. Fortunately he leaves this bit of speculation behind him. He cannot really sustain a convincing historical argument for either alternative model. At the time, in fact, many of the advocates of hospital care, who predicted that medical advances were possible only within its clinical teaching sector, did not permit questions related to the style of traditional forms of authority to inhibit them from viewing the hospital in a specifically technoscientific or techno-medical way. Caste1 is on much stronger ground in drawing our attention to that important constellation of figures mutually attracted to one another by their work in welfare, hygiene, medicine and philanthropy - Cabanis, Thouret, Lavoisier, Condorcet, Pastoret, Fourcroy, Delecloy. They approached the enormous problems of a society caught between the old and new legitimations, as technologists working within the sociology of organization avant la lettre (p. 83), and in the belief that people were not being subdued and crushed under systems of power, but suffered because of improper procedures, bad management, and irrational and archaic structures. Such a view appears to adhere more closely to historical realities, and is not unlike one which I have been urging.’ I would emphasize much more the important qualification that this technologization of power had far less to do with the emergence of a bourgeois society than with the conviction that, once the possession of expert knowledge became the principal source of power legitimation, the previous justification and manifestations of power would be revealed in all their nakedness as survivals of primitive forms of political behavior. The political economists contributed, to be sure, to the strengthening of this new attitude to politics and power because they could claim that the laws of the market economy were analagous in every way with the laws of the natural sciences. If left to themselves, the laws of the market could be counted on to ensure the designs of nature, so it was said, just as reason was surely divulging the laws of the physical universe. This must underlie, I would suggest, Castel’s perception, rather allusively presented, that in a sense he idea of a contractual society, based on market exchange is mythical (p. 2 4 1). Specialized knowledge in all areas of social endeavour? it can be further proposed, gave new life to another notion of politics which had its roots in the administrative practices of the old regime, even if representative political institutions were devised and fresh legal force was given to the exercise of power. The true repositories of power would exist henceforth at the level of expert knowledge and technology, but this development would be concealed by the establishment of new legally constituted bodies wherein duly elected representatives gy
’ In a paper entitled, Politics in the Service of Knowledge: fare and Medicine in Late 18thCentury France (unpublished
The Debate 1977).
over the Administration
of Wel-
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claimed to be debating real issues. It seemed as if the full implications of what can only be cbncelved of as a revolutionary notion of’ power, that is. power not requiring a juridical basis, could and would not be grasped by the rnoulders of the non-absolutist politics of Revolutionary and nineteenth-century France. The true meaning of the liberal bourgeois political regime is found behind its facade of legality in the power relationships shaped by purveyors and recipients of knowledge. Partial confirmation for the approach I am taking can be found in Foucault who, in his most recent study of sexuality, writes, “ . . . we should not be deceived by all the Constitutions framed throughout the world since the French Revolution, the Codes written and revised, a whole continual and clamorous legislative activity: these were the forms that made an essentially normalizing power acceptable.“8 Such a view, I believe. gives additional rather than less weight to the exercise of that power by dominanr groups in society. Although Caste1 might, of course, insist on the totally determining and monocausal impact of the market, a fully-operating exchange economy, as he recognizes, was hardly in evidence, even though political economists were doing their best to refine a theoretical model for it. Foucault erases the importance of legal-political forms and, as I read him, achieves nearly the same effect in his analysis of a virtually classless exercise of power. My own response to his archeology. of power is therefore mixed. On the one hand, his insistence on the instrumental rather than substantive importance of political constitutions and codes confirms my own conclusions reached by another path, namely, that the most important goal of experts, both before and after the Revolution, was to locate “the rational principles that would ensure the taming of [the state’s] power,” entitling them “to assert that they could purge politics of it.“” My interpretation of how politics came in this way to be devalued or at least confirmed within the well-established administrative applications of power reveals how the principal actors in its technologization perceived its political forms, aithough they denied that they were involved in its deployment.‘0 On the other hand, when Foucault seems at times to reject the notion that individuals and classes matter, it is difficult to follow him without being painfully conscious that the capacity of man to perceive the world differently and to alter its direction is almost totally diminished.”
*M. Foucault, The History of Sexuality, supru note 3, at 144. 9 H. Mitchell, supra note 7. “Herbert Marcuse is referring to late developments in capitalism when he writes: “Today, domination perpetuates and extends itself not only through technology, but ns technology, and the latter provides the great legitimation of the expanding political power, which absorbs all spheres of culture.” One Dimensional Man 158 (1964). But the movement towards the technologization of society provided fresh foundations for political power before capitalism reached its mature phase. ‘I Cf. J. Habermas, Toward A Rational Society (trans. J. Shapiro 1970). Habermas, in revising Marcuse’s revision of Weber, is attracted but not beguiled by Marcuse’s critique, since he claims that it ultimately accepts the standard of rationality, even while asserting the need to change values. Habermas. himself, comes under scrutiny in Stockman, Habermas, Marcuse and the .4ufhebung of’ Science and Technology, 8, Phil. of Sot. Sciences 15 (1978). Stockman, looking for clues in Joseph Needham’s and Edgar Zilsel’s work, disputes Habermas’s “assertion of the universality of certain fundamental features of man’s relationship to nature,” because of its historical connection “with an alienated form of the division of labour ” id. at 35.
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III The asylum as the model of total confinement for the insane was rescued from its earlier reputation as a pestiferous institution, because it was presented as an expertly managed rational instrument by the psychiatric profession, the first specialists in social medicine. They thus overcame the hindrances caused by arbitrary confinement, dubious legal sanctions, and the powerlessness of families to control their mad relatives. An important step was taken in the development of innovative forms of social discipline and control. Pinel’s exercise of nearly supreme power in a total institution, established the paradigm of madness for the ensuing century and a half (p. 93). This was his historic role. But the Pinelian model had its precursors within general medicine itself. Caste1 is not unaware of this, but perhaps he might have located Pine1 more fully within a growing medical consensus which urged isolation of the patient from his domestic environment as the precondition of successful treatment. There is little to distinguish Pinel’s prescriptive right to intervene in the lives of-the mad from the plea by his contemporary, Dr. Nicholas Chambon de Montaux (121, who practised for a time at the Salpetribre hospital, to remove patients from the baneful influence of their families, except that the sufferings of the first and the impotence of their relatives to alter the states of madness made the establishment of the asylum much more imperative. Why, Caste1 asks, were the pseudo-scientific arguments for the asylum triumphant, while isolation and confinement in the hospital, workhouse, and even the prison, were only partially and intermittently applied? Why, in short, were the plenitude and omniscience of power duplicated nowhere else? In the minds and expectations of many associated with each of these institutions, such a model appeard to suggest the only way to deal with the sick, the poor and the criminal. The two major branches of medicine, clinical and hygienic, were after all making enormous claims to transform society, alter morals, and ensure something like mastery of both. But the public health movement could not capture full support from the state before Pasteur: it lacked the technological resources to make good its global claims at so early a date. The same was true for clinical medicine: it, too, was far from having achieved technical mastery, as Cabanis, the most impressive doctor-philosopher of the period, was painfully aware: besides it remained locked for some considerable time into a somatic and individual mode of treatment. As for the unemployed, the poor, the various superfluous elements in the working force, only the most egregious deviants within the proletariat would, it was concluded, be confined, while other farms of discipline would accomplish social control within the factory, home and school, supplemented by philanthropic interventions.13 Not even the prison fully duplicated the paradigm of the asylum. In the first place; the criminal was considered to be rational and held responsible for his acts, at least until the alarming appearance of crimes which were said to be “On Chambon. see H. Mitchell, supru note 7 and History Medicine 397 (1977). 13For what some of this meant, see the studies by cile: L’Cdification de la famille. 28 Recherches (1977): isme, No. 3 Critiqncs de I’konomie politique 3 (1978):
Gelfand.
A Clinical Ideal: Paris I789
51 Bulletin
Joseph, Fritsch and Battegay, Disciplines i domithe article Travail domesfique et jam& du capitaland J. Donzelot. La police des families (1977).
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against nature broke down some of the distinctions between the insane and the criminally insane. The proponents of total isolation in the prison. especially the mental specialists, Esquirol and his colleagues, would later claim that it would not harm the mental state of prisoners. And’both the prison and the asylum could be seen as achieving resocialization, at least theoretically, within a discrete space purified of all disturbing influences (p. 1501. The chief reason for the reticence to go all the way must lie in the notion that the criminal rationally, voluntarily, and violently imposed his private and particular will against the general interest, and must thus expect the more direct sanction of the law exercised by its traditional interpreters, the judges, expert in the law. Caste1 makes it/abundantly clear that neither the scientific claims. which were slender, nor the numbers of the insane, which were hardly overwhelming, established the hegemony of the psychiatrists operating within their preferred therapeutic spaces. The fact that their scientific theory was weak and the proportion of the population affected relatively miniscule, was infinitely less important than the existence of a body of expert opinion which would have been difficult to ignore when the time came to devise a comprehensive apparatus for treating the insane. This is not the usual way to look at the problem nor the usual kind of paradox. What can be seen is not the adoption of policies based on the apprehension of scientific truth, but a mutual adjustment occurring among conflicting sources of power dealing with social and economic problems. The experts in insanity had all the advantages of linking medical and administrative practices in their work. What is important, Caste1 reminds us, is not so much what mental medicine was supposed to be doing at the level of practice as what it was actually doing when masking or covering up the contradictions between its therapeutic and its social and custodial objectives (p. 163). Pine1 and his successors carried the theory and practice of total confinement much further then was at first thought possible. Indeed they determined the substance of the 1938 legislation which gave them power over admissions to the extent of eliminating the courts from a direct role in the asylum’s selective procedures, and of imposing the fullest measure of tutelage over the persons, property, and civil rights of the inmates. Compromises, permitting private establishments and departmental and communal, rather than centralized, financing, did not deflect from the fact that the public asylum was promoted as the preferred form of medical treatment and social discipline, especially for the indigent. Medical power had achieved a singular victory, even if it had to share it in other domains of social life with administrative and judicial experts, as well as those other future experts, most notably the social scientists. All required solutions, but not of the same order or magnitude. The medicalization of insanity served the aims of the state and the goals of psychiatrists. Both were as fully conscious of what they were about as it was possible to be. For the state, the medicalization of the problem of the insane poor masked its social and political configurations; for mental medicine, the state provided a laboratory. For the first, public order was preserved; for the second, the insane were guaranteed rational, humane, and it was hoped, effective, treatment. The only confusion, one so deeply-rooted that it continues to reappear in the same or in slightly altered guises, was the professionals’ illusion that their concepts and their work were achieved outside a political context.
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Moral treatment within the asylum was intended to restore to the mad their reason, through the mediation of the mental physician who incarnated rationality. But the therapy, which was supposed to work only and through an institution of total confinement, came to isolate itself from the mainstream of general medical advances. Psychiatrists locked themselves away, so to speak, with their patients. What is startling is the suppleness with which psychiatry adjusted itself, the strength it continued to command. Again Foucault can be called upon to dramatize and clarify what was happening. Just as students of sexuality who compulsively assembled an extraordinary wealth of psychological and sociological data irrationally withdrew from a full acceptance of its profounder meanings, psychiatrists elaborated tortuous manoeuvres to accommodate yet not surrender to the growing evidence that moral treatment could not be fully reconciled with theories and therapies that were commanding acceptance in general medicine. Moral treatment was, after all, embedded in a philosophic tradition that reduced ideas and knowledge to composites of sensations, and diagnosed madness as an incapacity to deal with socially disturbing conditions. Working class failure to lead disciplined lives was the source of both social and mental pathology. One is reminded of Adam Smith’s analysis of the psychological processes which permit man to anticipate sympathetic understanding from his fellows: “He must flatten, if I may be allowed to say so, the sharpness of [the passion’s] natural tone, in order to reduce it to harmony and concord with the emotions of those who are about him.“14 The more effectively this is done, the more rationally would self-love come into harmony with fellow-feeling. Failure to act rationally, Smith later said, stemmed from lack of ability to exercise self-discipline which he and most of his contemporaries believed had deliberately to be imposed on the poor. ” Psychiatry concentrated similarly on the symptoms of madness and obscured the objective dimensions of the social conditions producing it by seeking to shift the source of the derangement from the material conditions of life to the life of the individual himself. But then it concluded that since the madness of the poor had few if any specific etiologies, uniform rather than individualized treatment was called for. When general medicine began to examine the organization of the tissues and organs, to seek to establish in their pathology the underlying causes of illness, the mad doctors responded politely, acknowledged the need at times to carry out brain dissections, but carried on with the essentials of moral treatment. On their side, they could argue that organicist theories put an end to the possibility of any meliorative treatment, since organic lesions were ineradicable and untreatable. By contrast, moral treatment predicted that man could alter/his environment if properly guided. What was happening across the Channel at the same time was not an exact duplication of developments in France, but the results were the same. Andrew Scull’s workI on the professionalization of the treatment of madness in Britain “Adam Smith, The Theory of Moral Sentiments 67 (Liberty Classics edition 1969). ‘*Adam Smith. The Wealth of Nations 740, 747-748 (Random House edition 1937). 16Two articles by Scull: From Madness to Mental Illness: Medical Men as Moral Entrepreneurs and Mad-Doctors and Magistrates: English Psychiatry’s Struggle for Professional Autonomy in the Nineteenth Century. appeared in 16-17 European Archives of Sociology 218-251, 279-305 (1975-76).
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tells us how medical men wrested control of the asylums from laymen, principally from the founder of moral treatment, William Tuke and his supporters. Tuke and Pine1 travelled the same trajectory in their advocacy of moral treatment, but there was no lay movement in France to set down the foundations for it as there was in Britain: the medical men in France had a headstart. British doctors caught up, however, in a very instructive way. In France, the organicists did not effectively challenge the Pinelian-Esquirolian synthesis, since they could hardly offer any distinctive advantages, while on the contrary could be realistically seen as casting a demoralizing pall on the work of moral therapists. While moral .treatment in the British asylums may have been more oriented towards individuahzed treatment than in France, there seems to be no doubt that in both countries the available alternatives were not seen as superior. How then did the medical men in Britain come to achieve their power over the madhouses, even when as in France their armoury of physical treatments proved to be futile when administered as a substitute for moral treatment. rather than supplementing or complementing it. When, to gain confidence in their interventions, they devised an organicist view which they felt established the. somatic foundations for insanity by ingeniously but unconvincingly locating derangement in the brain rather than in the mind, the seat of the soul, they could not even then pretend that they had been scientifically vindicated, since no empirical evidence showing physical lesions in the brain, in most cases of madness, was available. This did not. however, deter the psychiatrists from predicting that future advances in medical technology would reveal them, whether in their early functional or later structural forms. So clever a rationale for and defence of the somatic analysis of insanity was not forthcoming in France, but in both societies the crucial aspects of the development of psychiatry had very little to do with its cognitive strength or its arguments for the custodianship of the insane. Capitulation to the psychiatrists occurred at virtually the same time in Britain, between 1828 and 1845, as in France. And in Britain, too, the jealousy with which the psychiatrists guarded their prerogatives and justified their activities as constituting a branch of medicine, kept pace with the general profession’s mounting contempt for them. But they would not have been able to sustain their self-image or their monopoly without the conscious transfer to them by society of substantial power to act “as caretakers of custodial dumping institutions . . . for its deviants and misfits.“” The scientific validity of competing etiologies was clearly not at issue. Neither could command full assent in any case. The structure of asylum treatment was maintained not because it conformed to “objective” scientific canons, but because it could not escape from the conviction that it met the moral needs of the asylum’s patients and the imperative of social order. The interlacing nature and consequences of these double demands was powerful enough to permit the profession in France to meet a series of challenges to its central postulates. There were several. The organicist interpretation was followed by the dilemma caused by a series of homicides which could not easily be dealt with, since they were seen as spectacular crimes against nature, usually involving murder within the family, thought to be the first and most natural of “Id. at 303-304. “For a discussion of the unnatural crimes and the dilemmas they created for the legal and psychiatric professions, see M. Foucault, About the Concept of the “Dangerous Individual” in 19rh-Centur.v Legal
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social organizations. I8 To the diagnosis of mania. seen as originating in the dipturbance of mental capacity in a disorder of the understanding which produced a disequilibrium effect on the passions, was added the new disturbance of monomania arising from a disorder of the passions which acted on the understanding. This distinction was developed to help overcome problems affecting both the administration of justice and the control of the insane. Before the problems came to engage specialized attention, the criminal act was assumed to be inseparable, as we saw, from its rationality and its responsibility. Because of the difficulty of establishing proof of irresponsibility in crimes against nature, the etiology of monomania was invented to help dissolve psychiatric perplexity over acts without d&e, without a major loss of understanding. The legal profession had to deal with acts which could not be called insane, but which resulted from the perpetrator’s failure to extinguish the impulse to commit them. Hence the idea of monomania, which Esquirol described as a partial kind of delirium, was introduced to cover up the gap in the law. Legists and psychiatrists confronted one another, asserting mutual respect for one another’s domain of expertise. The first worked for the legitimation of and the rationalization for the right to punish: the second pathologized newly-discovered aspects of human behaviour. The long range importance of this strategy was that the courts would increasingly turn to psychiatry to assist them with difficult cases. not only, however, the extraordinary cases: but those arising from the mundane infractions committed in the family or neighbourhood setting, acts connected with alcoholism and eventually with drugs. Simultaneously, psychiatrists increased the range of their concerns and began. under the multiple stresses of industrialization and the fears aroused by their own latent uneasiness over available treatments, to question the finality of cures, to pathologize more and more areas of life, and to acknowledge that the asylum was not the place to discriminate among several and various cases of behaviour deemed to depart from “normal” behaviour. The asylum lost its universal goals in the face of men and women whose behaviour was thought to be unpredictable, impulsive, perverse. and the result of de-. generescence, djsorders caused by congenital and hereditary defects. People could no longer easily be divided into sane and insane. Long before the fuller, but not the fullest, implications of this mutual professional and moral reinforcement came to disturb the dreams of the experts, the asylum was clearly showing signs of disease. It could not take in all the newer cases, because its facilities would suffer financial and physical strain. On the other hand, psychiatrists argued that the failure to give ‘them complete autonomy, both in their administration of the asylum and finances to run it, was forcing them to maintain generalized, instead of freeing them to introduce individualized. treatment. “If only . . . ” they kept saying in defence of their position, with the result that in this important instance, they could continue to advocate the 1838 legislation as a proper model for all states and societies at all times and to find nothing in that prescription to contradict their tolerance of private asylums where paying patients received individualized therapy. That there were psychiatrists working dually in public and private capacities is one Psychiatry. Int. J. Law. Psychiatry 1 (1978). The earlier essays in Moi. Pierre Rivikre 04. Foucault ed. 1973, translated by F. Jellinek as 1. Pierre Riviere . (1975)). contains Castel’s essay, The Physicians and the Judges.
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of the more interesting phenomena in this period of mental medicine. Their intellectual gymnastics in reconciling (assuming that this was always necessary) the therapies in each of the two settings do not require any extra effort of the imagination. Only the bourgeoisie could seek private treatment, or in time avail themselves of psychoanalysis through the university. The rest of the population was offered the psychiatry of the asylum: there existed a psychiatry for the poor, but it was also poor psychiatry (p. 258). The attention given paying clients might have passed as psychiatry, but the attention given the poor in the asylum was hardly that. It became identified unmistakably with rigid forms of guardianship and ,@telage and owed its continuing power, despite its internal bankruptcy, to the symbolic power it exerted on delinquent sections of the population who knew the costs of transgressing the prevailing standards of normality and the permanent stigmata attached to internment in the asylum. In the century preceding the total breakdown of the originai metamorphosis which culminated in the emergence of the present system, the critiques of the first grew and came from the legal profession which began to seek equal power with the psychiatrists to determine selection procedures: from others who became aware of institutionalized care different from the asylum, for example, in the agricultural colony of Gheel in Belgium which treated its inmates in conditions of semi-freedom; from early antipsychiatric individuals who, like Jean Tissot (Brother Hilarion) inveighed against professionalism. gave a mystical interpretation of madness, and even spoke of a kind of group therapy, or like Garsonnet who summed up his position by questioning the “science” of psychiatry and observed that the meaning of the laws governing the insane could be understood by judging the therapist; as well as from the widening of theory to encompass, as we saw, the hidden causes of mental disturbance. In consequence, psychiatry began what Caste1 calls a process of recomposition which assumed two main directions: specificity of treatment within discrete spaces for the senile, criminally insane, the chronically ill, alcoholics, epileptics, and the indigent as well as “free services” within psychiatric hospitals: and policies of prevention - seeking out the causes of mental disturbance in the family, school, army, and very soon, modifying the environment by hygienic measures. The divergence of the response within psychiatric circles was responsible, Caste1 remarks, for the delays in the creation of a new metamorphosis. But, of course, such an explanation for the transformation, which Caste1 will presumably deal with in greater detail in his next volume, is necessarily partial, for it would rest on a totally unrealistic intemalist analysis of psychiatric theory. Instead, the interconnectedness of internal and external, the dynamics of doubly reflecting systems of power, and the proliferation of new areas of specialized fields of knowledge are producing new areas of professionalism, pathologizations of behaviour, and technologies of power which have become part of the present social and intellectual landscape. The movement deinstitutionalizing the mentally ill lacks convincing scientific basis, since the effectiveness of the psychoactive drugs is highly overrated, and the policy of early discharge was in fact initiated before the pharmacological attack was launched. The argument that the mental institution was itself a serious fact in reinforcing irrationality (“infantilism”) and was an independent source of mental disturbance, has perhaps more validity. But serious students of the phenomenon of decarcer-
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have concluded that the enormous social investment in welfare programpossessing strategies that are making custodial treatment superfluous as as contributing strain on treasuries, must carry the burden of the explanafor the latest metamorphosis.” hundred and eighty years ago, Pine1 wrote: In general it is pleasant for a sick person to be in the bosom of his family, receiving from it the cares and consolations of tender and compassionate love, that I must painfully state a sad truth but one established by the most regular experiences, the absolute need to entrust the mad to the hands of strangers, and to isolate them from their relatives.20
By the mid-point
of the present
century,
a profound
change had occurred:
After all. considering what current research had shown, surely “the worst home is better than the best mental hospital . . . so that in the long run the abandonment of the state hospitals might be one of the greatest humanitarian reforms and the greatest financial economy ever achieved. . . .“21
I9 A. Scull. Decarceration: Community Treatment and the Individual. A Radical View (1976). 2”Quotcd in Caste1 at 93. x E. and J. Cumming. Closed Ranks 55 (1957) and I. Belknap. Human Problems of a State Mental Hospital 212 (1956) quoted in Scull, The Decarceratiort o.f the Mentally Ill: A Critical View. 6 Politics and Society 184 (1976).
Journal
in the U.S.A.
of Law All
andPsychratry, Vol.
rights
2, pp. 249-261.
0160.2527/79/020249-13$02.Q0/Q
1979
Copyright
reserved.
0
1979
Pergamon
Press Ltd
RESEARCHARTICLESAND COMMENTS Politics, Power and Psychiatry: A Review of L’Ordre Psychiutrique: LYge d’Or de 1%&isme by Robert Caste1 Harvey Mitchell* I Robert Castel’s study of the establishment of what he terms the “golden age of alienism,” or what may be identified with some greater degree of felicity as the golden age of the psychiatric asylum in France, follows from his earlier and longer treatment of psychoanalysis, first published in 1973 but reissued three years later’ so that the two books made a dual appearance in France in the same year. Both are inspired and informed by the major influences of Michel Foucault, who understands knowledge and power as existing in an interlocked relationship; by Pierre Bourdieu and JeanClaude Passeron who plot through their concept of “symbolic violence” the processes by which interpretations of the world, say, in the educative realm, assume an unquestioned autonomy serving alleged objective systems of thought but actually constituting apparatuses of power affirming and legitimizing the hegemony of dominant classes;2 and by Franc0 Basaglia who tantalizingly but not unequivocally suggests to Caste1 alternatives to psychiatric thought and practice. With so formidable an intellectual armature, Caste1 was bound to command attention, but he has produced more than a respectable book. His efforts have yielded a rather extraordinary one whose significance owes as much to his own brilliant powers as to his mentors’ and colleagues’ attempts to deal comprehensively with the transformation of systems of knowledge into instruments of power and politics. Caste1 sets out to deal with the development of mental medicine within the setting of the asylum not as a discrete domain possessing inviolate epistemological foundations, but as a discourse in intimate relationship with other areas of human endeavour, not the least of which were the exceedingly complex, vexing, and more often than not concealed, environmental conditions expressive of social constraints. economic pressures, and political uncertainties. Whatever autonomous claims the principal actors made for themselves as they developed medical and non-medical theories and strategies to deal with the mentally deranged, Caste1 demonstrates how each of them rested heavily on the other, and that both moved towards the achievement of similar if not always identical *Professor of History, University of British Columbia, 1R. Castel, Le Psychanalysme: L’ordre psychanalytique ‘P. Bourdieu, Cultural Studies,
Symbolic 1977).
Power
(trans.
Vancouver, British Columbia, Canada, et le pouvoir (2nd. ed. 1976).
R. Nice, Occasional
249
Paper
No. 46, Center
V6T 1u’S.
for Contemporary
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goals. Sometimes indeed they insisted that their motivations were separate and distinct. but quite often they revealed how close their affiliations were, thus quite unconsciously providing us, as their distant heirs, with an accurate model of what was really transpiring between men of knowledge and men of action, neither of whom of course thought and acted in such well-defined spaces. Caste1 does not deny, however, the existence of what his protagonists thought constituted scientific knowledge, or more precisely in the present case, medical knowledge. Implicitly, like Foucault, he maintains that the knowledge of a given time is like a grid of social and intellectual conditions, a total system permitting the creation of new knowledge, thus enlarging its boundaries. What is not clear is the extent to which Castel, like Foucault, is prepared to discuss power and its technologies as breaking free, being released from, and ultimately not owing their reality to, historically determined entities. It would seem, though, that Caste1 has not followed Foucault so far as to carry out an “ ‘anafrom a certain representation of lytics’ of power . . . [freed] . . . completely power that [ Foucault] would term . . . ‘juridicodiscursive,’ ” liberated in other words from the notion of law as theoretically formulated and actually applied under the French monarchy, or as it was thought the law should be reformed to establish an exact congruence between it and power in a new and enlightened political regime.3 Knowledge is not in Castel’s view, as it is not in Foucault’s, apolitical; neither of them is the victim of such an illusion. For both it becomes a weapon of disciplinary action and power. But Caste& it should be made as clear as possible - at any rate on the basis of the present study - is not saying that the reality of power lies inevitably, essentially, and ultimately within ourselves, engaging us all in its exercise, so that to grasp its authentic nature, we must reach out beyond any analysis of power as the exclusive possession of successive dominant classes at different points in history.4 II. Caste1 is thus engaged in a fascinating, but exceedingly difficult, endeavour. He states at once that he will be concerned not only with the linkages between knowledge and power, some straightfonnrard, others elusive, but with two levels of change in the theory and practice of psychiatry, the first constituting the shifts and adjustments - what he calls serial changes - within a prevailing explanatory system, which he distinguishes from a total systemic transformation. The reliance on Foucault’s notion of epistemic change is apparent. The first sort may shake convicitons, but fail to alter the system’s framework, since “M. Foucault, The History of Sexuality I: An Introduction at 82.88 (trans. R. Hurley 1978) (originally published as Histoire de la sexual&e I: La Volonte de Savoir 1976). 4Cf: D. Lecourt, Dissidence ou revolution (1978). Besides discussing Foucault’s relationship to Marx and Marxism, Lecourt notes that Foucault’s major interest lies in the charting of densities and diffusions of power, rather than in its particular and temporal political manifestations. For Lecourt, quite unjustifiably I would suggest, Foucault’s position brings him within the orbit of Andre Glucksmann’s critique of the Enlightenement and the Revolution in his Les maitres penseurs (1977). For a friendlier, yet critical review of Foucault’s Discipline and Punish (1978) (originally published as Naissance de la prison, 1975), see Seem, Book Review, 29 Telos 245 (1976). A very perceptive and fair assessment of Foucault comes from Guedon, Michel Foucault: The Knowledge of Power and the Power of Knowledge, 5 1 Bull. History Medicine 245 (1977).
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crises within it can force compromises and even stimulate fresh departures, both at the theoretical and practical levels. By contrast, a systemic transformation is a total metamorphosis, marked by a movement or a passage from one to another coherent and global perception which is accomplished in every aspect of social as well as intellectual life. In the case of psychiatry, such a metamorphosis would have to encompass procedures in treating the insane, which were conceptually and socially innovative and pervasive, creating, as it were, a new unity, a new totality, a new grid, a new episteme. Caste1 is concerned with both forms of change. His study in fact is bounded by two metamorphoses. the first eventuating in the 1838 law which confirmed the outlines of a total system that was to endure until 1968 when a second total transformation of psychiatric processes obliterated the former. The asylum. as the psychiatric and social paradigm, was displaced in the 1960’s by “sectorization,” the creation of complete psychiatric services for each unit of population of 70,000; and there is the further prospect of a “capillary” penetration of society at large, by which Caste1 means a preventive, prophylactic psychiatry as part of the state’s judicial, welfare, and educational structures. Clues for the establishment of the second such transformation are to be found throughout his study, and more may be found more systematically treated in his book on psychoanalysis, but we must await the second volume of the present study to ascertain how successful he has been in finding symmetries at either end of these metamorphoses separated by more than a century and a half. For the moment, we are presented with rich and abundant documentation of the problems which, from roughly the midpoint of the eighteenth century, disturbed knowledge seekers and policy makers both, since existing orthodoxies appeared to compound rather than solve problems. A good part of Castel’s book is devoted to a patient but constantly interesting reconstruction of these failures and the shaping of the new structures that would, it was expected, ensure success. What Caste1 guides us through is nothing less than the growing awareness of and dismay at what was perceived as an unprecedented and dangerous excess within the population of undesirable elements, the deviants of all sorts, the indigent, the delinquent, the criminal. the sick, the abandoned. the insane, the people who have become familiar to us in Foucault’s books and in a growing number of others.’ ‘What may be said to have started it all nearly twenty years ago was Foucault’s Histoire de la folie a l’agc classique (‘1961). An abbreviated translation by R. Howard was published as Madness and Civilization (1965). Among Foucault’s other works on these questions see La naissance de la clinique (1963), translated as The Birth of the Clinic (1973). His interview with Michelle Perrot 09 prisons is included in J, Bentham. Le panoptique (trans. M. Sissung 1977). Other studies of particular importance are E. Goffman. Asylums (1961): D. Rothman. The Discovery of the Asylum (1971); G. Rosen. Madness in Society: Chapters in the Historical Sociology of Mental Illness (1968): 0. Hufton. The Poor of Eighteenth-Century France 1750-1789 (1974): M. Ignatieff. A Just Measure of Pain: The Penitentiary in the Industrial Revolution 1750-1850 (1978): two unpublished doctoral dissertations, one by, M. Alexander on the insane asylum in nineteenth-century Paris (Johns Hopkins tiniversity), and the other by M. Donnelly on the development of medical psychology in nineteenth-century Britain (Birkbeck College, University of London). See also Deviants and the Abandoned in French Society (trans. E. Forster and P. Ranum, R. Forster and 0. Ranum eds. 1978). Other works bearing on the hospital on the eve of its transformation at the end of the old regime and of the movement towards public hygiene and the new perceptions of public space are inspired by a collection of essays edited by Foucault, Les machines i guerir: Aux origines de l’hopital moderne (1976), and another edited by B. Fortier, La politique de l’espace parisien a la fin de l’ancien regime (1975). 1. Illich. Medical Nemesis (1975) is not without pertinence, though he is not sensitive enough to the links between medical theory and practice and their social context.
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What was at stake in the impending transformation that found its medical and institutional forms logically and precisely laid out in the 1838 law? Nothing less than the transformation of society itself; its “rationalization,” its becoming a fact of pohtical economy. The bureaucrats, physiocrats, scientists. medical men, and other professionals accepted the fact, but did not explain it. They came to embrace the premises and goals of political economy as natural and true. They gave credence and conviction to it because it provided a solution to an overwhelming problem that took on the dimensions of an obscene blemish which threatened to spread and infect the totality of society the longer and less effectively the administrative, juridical and domestic institutions of the old regime were ‘permitted to deal with it. Working and thinking within and against the constraints of a traditional society, the state, the judicial organs and the family could not elaborate legitimating principles for the treatment of the most refractory sections of the population until they were given the opportunity to elevate the market economy as a theoretical and practical model for the deployment of the larger working population. This did not come to pass suddenly, largely because there was no full agreement on the causes and nature of unemployment, the kinds of assistance and welfare which would or should be available, and the various categories of the population entitled to either of the above or to other kinds of social efforts altogether. The legislation of the revolutionary period did not establish consistent policies either of repression or assistance: but if it did not, it helped to sanction, especially once it withdrew from its radical stages, the supremacy of the market model of society. But not even in England, as Karl Pofanyi’s great book tells us, was the labour market fully free for more than a brief period after 1834.6 Caste15 analysis leans heavily on the mutual needs and isomorphic perceptions of two groups of people who in fact did not, he would insist, present arguments for their policies or invent “scientific” theories from to tally distinct vantage points in society. Political economy, predicating the free circulation of goods, also required the free circulation of labour if it was to liberate society from its customary restraints. The intervention of the state was justified to remove all impediments to the fullest operation of such an economy. In such an optique, it proved, Caste1 argues, much easier to deal with one section of an unmanageable population than the others, precisely because the mad escaped the criteria for rational participation in an exchange society on the grounds of their incapacity to assume responsibility for themselves, while most other categories of deviance and delinquency were not deprived of reason, and hence were ultimately responsible for themselves. Varying degrees of social responsibility were nevertheless recognized for the old, the sick, and those afflicted with some of the more dramatic diseases, but the discussions surrounding the establishment of a new structure of assistance, combining specialized hospital care on the one hand and general domiciliary care on the other, singled out the insane almost from the beginning. The point is that a policy of sequestration, of social isolation, of specialized treatment was seen as being more appropriate for them than for any other part of the deviant population, with the exception of the criminal. No clear cut case could be made for the others, if only because the ideolo’ K. Polanyi,
The Great Transformation:
The Political
and Economic
Origins
of Our Time (1944).
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of the market prevented total state aid for people who should ideally look after themselves. Castel’s tight analytical structure threatens to collapse at one point, when he appears to give much more substance to the debate on hospital and domiciliary care than it warrants. He is disposed to think, more seriously than the actual situation warranted, that for a moment the future of welfare and medical policies teetered between total incarceration, which was the “totalitarian” model of the old regime, and the treatment of deviance, including insanity, at the pIace of its origin - within the family or the neighborhood. Fortunately he leaves this bit of speculation behind him. He cannot really sustain a convincing historical argument for either alternative model. At the time, in fact, many of the advocates of hospital care, who predicted that medical advances were possible only within its clinical teaching sector, did not permit questions related to the style of traditional forms of authority to inhibit them from viewing the hospital in a specifically technoscientific or techno-medical way. Caste1 is on much stronger ground in drawing our attention to that important constellation of figures mutually attracted to one another by their work in welfare, hygiene, medicine and philanthropy - Cabanis, Thouret, Lavoisier, Condorcet, Pastoret, Fourcroy, Delecloy. They approached the enormous problems of a society caught between the old and new legitimations, as technologists working within the sociology of organization avant la lettre (p. 83), and in the belief that people were not being subdued and crushed under systems of power, but suffered because of improper procedures, bad management, and irrational and archaic structures. Such a view appears to adhere more closely to historical realities, and is not unlike one which I have been urging.’ I would emphasize much more the important qualification that this technologization of power had far less to do with the emergence of a bourgeois society than with the conviction that, once the possession of expert knowledge became the principal source of power legitimation, the previous justification and manifestations of power would be revealed in all their nakedness as survivals of primitive forms of political behavior. The political economists contributed, to be sure, to the strengthening of this new attitude to politics and power because they could claim that the laws of the market economy were analagous in every way with the laws of the natural sciences. If left to themselves, the laws of the market could be counted on to ensure the designs of nature, so it was said, just as reason was surely divulging the laws of the physical universe. This must underlie, I would suggest, Castel’s perception, rather allusively presented, that in a sense he idea of a contractual society, based on market exchange is mythical (p. 2 4 1). Specialized knowledge in all areas of social endeavour? it can be further proposed, gave new life to another notion of politics which had its roots in the administrative practices of the old regime, even if representative political institutions were devised and fresh legal force was given to the exercise of power. The true repositories of power would exist henceforth at the level of expert knowledge and technology, but this development would be concealed by the establishment of new legally constituted bodies wherein duly elected representatives gy
’ In a paper entitled, Politics in the Service of Knowledge: fare and Medicine in Late 18thCentury France (unpublished
The Debate 1977).
over the Administration
of Wel-
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claimed to be debating real issues. It seemed as if the full implications of what can only be cbncelved of as a revolutionary notion of’ power, that is. power not requiring a juridical basis, could and would not be grasped by the rnoulders of the non-absolutist politics of Revolutionary and nineteenth-century France. The true meaning of the liberal bourgeois political regime is found behind its facade of legality in the power relationships shaped by purveyors and recipients of knowledge. Partial confirmation for the approach I am taking can be found in Foucault who, in his most recent study of sexuality, writes, “ . . . we should not be deceived by all the Constitutions framed throughout the world since the French Revolution, the Codes written and revised, a whole continual and clamorous legislative activity: these were the forms that made an essentially normalizing power acceptable.“8 Such a view, I believe. gives additional rather than less weight to the exercise of that power by dominanr groups in society. Although Caste1 might, of course, insist on the totally determining and monocausal impact of the market, a fully-operating exchange economy, as he recognizes, was hardly in evidence, even though political economists were doing their best to refine a theoretical model for it. Foucault erases the importance of legal-political forms and, as I read him, achieves nearly the same effect in his analysis of a virtually classless exercise of power. My own response to his archeology. of power is therefore mixed. On the one hand, his insistence on the instrumental rather than substantive importance of political constitutions and codes confirms my own conclusions reached by another path, namely, that the most important goal of experts, both before and after the Revolution, was to locate “the rational principles that would ensure the taming of [the state’s] power,” entitling them “to assert that they could purge politics of it.“” My interpretation of how politics came in this way to be devalued or at least confirmed within the well-established administrative applications of power reveals how the principal actors in its technologization perceived its political forms, aithough they denied that they were involved in its deployment.‘0 On the other hand, when Foucault seems at times to reject the notion that individuals and classes matter, it is difficult to follow him without being painfully conscious that the capacity of man to perceive the world differently and to alter its direction is almost totally diminished.”
*M. Foucault, The History of Sexuality, supru note 3, at 144. 9 H. Mitchell, supra note 7. “Herbert Marcuse is referring to late developments in capitalism when he writes: “Today, domination perpetuates and extends itself not only through technology, but ns technology, and the latter provides the great legitimation of the expanding political power, which absorbs all spheres of culture.” One Dimensional Man 158 (1964). But the movement towards the technologization of society provided fresh foundations for political power before capitalism reached its mature phase. ‘I Cf. J. Habermas, Toward A Rational Society (trans. J. Shapiro 1970). Habermas, in revising Marcuse’s revision of Weber, is attracted but not beguiled by Marcuse’s critique, since he claims that it ultimately accepts the standard of rationality, even while asserting the need to change values. Habermas. himself, comes under scrutiny in Stockman, Habermas, Marcuse and the .4ufhebung of’ Science and Technology, 8, Phil. of Sot. Sciences 15 (1978). Stockman, looking for clues in Joseph Needham’s and Edgar Zilsel’s work, disputes Habermas’s “assertion of the universality of certain fundamental features of man’s relationship to nature,” because of its historical connection “with an alienated form of the division of labour ” id. at 35.
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III The asylum as the model of total confinement for the insane was rescued from its earlier reputation as a pestiferous institution, because it was presented as an expertly managed rational instrument by the psychiatric profession, the first specialists in social medicine. They thus overcame the hindrances caused by arbitrary confinement, dubious legal sanctions, and the powerlessness of families to control their mad relatives. An important step was taken in the development of innovative forms of social discipline and control. Pinel’s exercise of nearly supreme power in a total institution, established the paradigm of madness for the ensuing century and a half (p. 93). This was his historic role. But the Pinelian model had its precursors within general medicine itself. Caste1 is not unaware of this, but perhaps he might have located Pine1 more fully within a growing medical consensus which urged isolation of the patient from his domestic environment as the precondition of successful treatment. There is little to distinguish Pinel’s prescriptive right to intervene in the lives of-the mad from the plea by his contemporary, Dr. Nicholas Chambon de Montaux (121, who practised for a time at the Salpetribre hospital, to remove patients from the baneful influence of their families, except that the sufferings of the first and the impotence of their relatives to alter the states of madness made the establishment of the asylum much more imperative. Why, Caste1 asks, were the pseudo-scientific arguments for the asylum triumphant, while isolation and confinement in the hospital, workhouse, and even the prison, were only partially and intermittently applied? Why, in short, were the plenitude and omniscience of power duplicated nowhere else? In the minds and expectations of many associated with each of these institutions, such a model appeard to suggest the only way to deal with the sick, the poor and the criminal. The two major branches of medicine, clinical and hygienic, were after all making enormous claims to transform society, alter morals, and ensure something like mastery of both. But the public health movement could not capture full support from the state before Pasteur: it lacked the technological resources to make good its global claims at so early a date. The same was true for clinical medicine: it, too, was far from having achieved technical mastery, as Cabanis, the most impressive doctor-philosopher of the period, was painfully aware: besides it remained locked for some considerable time into a somatic and individual mode of treatment. As for the unemployed, the poor, the various superfluous elements in the working force, only the most egregious deviants within the proletariat would, it was concluded, be confined, while other farms of discipline would accomplish social control within the factory, home and school, supplemented by philanthropic interventions.13 Not even the prison fully duplicated the paradigm of the asylum. In the first place; the criminal was considered to be rational and held responsible for his acts, at least until the alarming appearance of crimes which were said to be “On Chambon. see H. Mitchell, supru note 7 and History Medicine 397 (1977). 13For what some of this meant, see the studies by cile: L’Cdification de la famille. 28 Recherches (1977): isme, No. 3 Critiqncs de I’konomie politique 3 (1978):
Gelfand.
A Clinical Ideal: Paris I789
51 Bulletin
Joseph, Fritsch and Battegay, Disciplines i domithe article Travail domesfique et jam& du capitaland J. Donzelot. La police des families (1977).
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against nature broke down some of the distinctions between the insane and the criminally insane. The proponents of total isolation in the prison. especially the mental specialists, Esquirol and his colleagues, would later claim that it would not harm the mental state of prisoners. And’both the prison and the asylum could be seen as achieving resocialization, at least theoretically, within a discrete space purified of all disturbing influences (p. 1501. The chief reason for the reticence to go all the way must lie in the notion that the criminal rationally, voluntarily, and violently imposed his private and particular will against the general interest, and must thus expect the more direct sanction of the law exercised by its traditional interpreters, the judges, expert in the law. Caste1 makes it/abundantly clear that neither the scientific claims. which were slender, nor the numbers of the insane, which were hardly overwhelming, established the hegemony of the psychiatrists operating within their preferred therapeutic spaces. The fact that their scientific theory was weak and the proportion of the population affected relatively miniscule, was infinitely less important than the existence of a body of expert opinion which would have been difficult to ignore when the time came to devise a comprehensive apparatus for treating the insane. This is not the usual way to look at the problem nor the usual kind of paradox. What can be seen is not the adoption of policies based on the apprehension of scientific truth, but a mutual adjustment occurring among conflicting sources of power dealing with social and economic problems. The experts in insanity had all the advantages of linking medical and administrative practices in their work. What is important, Caste1 reminds us, is not so much what mental medicine was supposed to be doing at the level of practice as what it was actually doing when masking or covering up the contradictions between its therapeutic and its social and custodial objectives (p. 163). Pine1 and his successors carried the theory and practice of total confinement much further then was at first thought possible. Indeed they determined the substance of the 1938 legislation which gave them power over admissions to the extent of eliminating the courts from a direct role in the asylum’s selective procedures, and of imposing the fullest measure of tutelage over the persons, property, and civil rights of the inmates. Compromises, permitting private establishments and departmental and communal, rather than centralized, financing, did not deflect from the fact that the public asylum was promoted as the preferred form of medical treatment and social discipline, especially for the indigent. Medical power had achieved a singular victory, even if it had to share it in other domains of social life with administrative and judicial experts, as well as those other future experts, most notably the social scientists. All required solutions, but not of the same order or magnitude. The medicalization of insanity served the aims of the state and the goals of psychiatrists. Both were as fully conscious of what they were about as it was possible to be. For the state, the medicalization of the problem of the insane poor masked its social and political configurations; for mental medicine, the state provided a laboratory. For the first, public order was preserved; for the second, the insane were guaranteed rational, humane, and it was hoped, effective, treatment. The only confusion, one so deeply-rooted that it continues to reappear in the same or in slightly altered guises, was the professionals’ illusion that their concepts and their work were achieved outside a political context.
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Moral treatment within the asylum was intended to restore to the mad their reason, through the mediation of the mental physician who incarnated rationality. But the therapy, which was supposed to work only and through an institution of total confinement, came to isolate itself from the mainstream of general medical advances. Psychiatrists locked themselves away, so to speak, with their patients. What is startling is the suppleness with which psychiatry adjusted itself, the strength it continued to command. Again Foucault can be called upon to dramatize and clarify what was happening. Just as students of sexuality who compulsively assembled an extraordinary wealth of psychological and sociological data irrationally withdrew from a full acceptance of its profounder meanings, psychiatrists elaborated tortuous manoeuvres to accommodate yet not surrender to the growing evidence that moral treatment could not be fully reconciled with theories and therapies that were commanding acceptance in general medicine. Moral treatment was, after all, embedded in a philosophic tradition that reduced ideas and knowledge to composites of sensations, and diagnosed madness as an incapacity to deal with socially disturbing conditions. Working class failure to lead disciplined lives was the source of both social and mental pathology. One is reminded of Adam Smith’s analysis of the psychological processes which permit man to anticipate sympathetic understanding from his fellows: “He must flatten, if I may be allowed to say so, the sharpness of [the passion’s] natural tone, in order to reduce it to harmony and concord with the emotions of those who are about him.“14 The more effectively this is done, the more rationally would self-love come into harmony with fellow-feeling. Failure to act rationally, Smith later said, stemmed from lack of ability to exercise self-discipline which he and most of his contemporaries believed had deliberately to be imposed on the poor. ” Psychiatry concentrated similarly on the symptoms of madness and obscured the objective dimensions of the social conditions producing it by seeking to shift the source of the derangement from the material conditions of life to the life of the individual himself. But then it concluded that since the madness of the poor had few if any specific etiologies, uniform rather than individualized treatment was called for. When general medicine began to examine the organization of the tissues and organs, to seek to establish in their pathology the underlying causes of illness, the mad doctors responded politely, acknowledged the need at times to carry out brain dissections, but carried on with the essentials of moral treatment. On their side, they could argue that organicist theories put an end to the possibility of any meliorative treatment, since organic lesions were ineradicable and untreatable. By contrast, moral treatment predicted that man could alter/his environment if properly guided. What was happening across the Channel at the same time was not an exact duplication of developments in France, but the results were the same. Andrew Scull’s workI on the professionalization of the treatment of madness in Britain “Adam Smith, The Theory of Moral Sentiments 67 (Liberty Classics edition 1969). ‘*Adam Smith. The Wealth of Nations 740, 747-748 (Random House edition 1937). 16Two articles by Scull: From Madness to Mental Illness: Medical Men as Moral Entrepreneurs and Mad-Doctors and Magistrates: English Psychiatry’s Struggle for Professional Autonomy in the Nineteenth Century. appeared in 16-17 European Archives of Sociology 218-251, 279-305 (1975-76).
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tells us how medical men wrested control of the asylums from laymen, principally from the founder of moral treatment, William Tuke and his supporters. Tuke and Pine1 travelled the same trajectory in their advocacy of moral treatment, but there was no lay movement in France to set down the foundations for it as there was in Britain: the medical men in France had a headstart. British doctors caught up, however, in a very instructive way. In France, the organicists did not effectively challenge the Pinelian-Esquirolian synthesis, since they could hardly offer any distinctive advantages, while on the contrary could be realistically seen as casting a demoralizing pall on the work of moral therapists. While moral .treatment in the British asylums may have been more oriented towards individuahzed treatment than in France, there seems to be no doubt that in both countries the available alternatives were not seen as superior. How then did the medical men in Britain come to achieve their power over the madhouses, even when as in France their armoury of physical treatments proved to be futile when administered as a substitute for moral treatment. rather than supplementing or complementing it. When, to gain confidence in their interventions, they devised an organicist view which they felt established the. somatic foundations for insanity by ingeniously but unconvincingly locating derangement in the brain rather than in the mind, the seat of the soul, they could not even then pretend that they had been scientifically vindicated, since no empirical evidence showing physical lesions in the brain, in most cases of madness, was available. This did not. however, deter the psychiatrists from predicting that future advances in medical technology would reveal them, whether in their early functional or later structural forms. So clever a rationale for and defence of the somatic analysis of insanity was not forthcoming in France, but in both societies the crucial aspects of the development of psychiatry had very little to do with its cognitive strength or its arguments for the custodianship of the insane. Capitulation to the psychiatrists occurred at virtually the same time in Britain, between 1828 and 1845, as in France. And in Britain, too, the jealousy with which the psychiatrists guarded their prerogatives and justified their activities as constituting a branch of medicine, kept pace with the general profession’s mounting contempt for them. But they would not have been able to sustain their self-image or their monopoly without the conscious transfer to them by society of substantial power to act “as caretakers of custodial dumping institutions . . . for its deviants and misfits.“” The scientific validity of competing etiologies was clearly not at issue. Neither could command full assent in any case. The structure of asylum treatment was maintained not because it conformed to “objective” scientific canons, but because it could not escape from the conviction that it met the moral needs of the asylum’s patients and the imperative of social order. The interlacing nature and consequences of these double demands was powerful enough to permit the profession in France to meet a series of challenges to its central postulates. There were several. The organicist interpretation was followed by the dilemma caused by a series of homicides which could not easily be dealt with, since they were seen as spectacular crimes against nature, usually involving murder within the family, thought to be the first and most natural of “Id. at 303-304. “For a discussion of the unnatural crimes and the dilemmas they created for the legal and psychiatric professions, see M. Foucault, About the Concept of the “Dangerous Individual” in 19rh-Centur.v Legal
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social organizations. I8 To the diagnosis of mania. seen as originating in the dipturbance of mental capacity in a disorder of the understanding which produced a disequilibrium effect on the passions, was added the new disturbance of monomania arising from a disorder of the passions which acted on the understanding. This distinction was developed to help overcome problems affecting both the administration of justice and the control of the insane. Before the problems came to engage specialized attention, the criminal act was assumed to be inseparable, as we saw, from its rationality and its responsibility. Because of the difficulty of establishing proof of irresponsibility in crimes against nature, the etiology of monomania was invented to help dissolve psychiatric perplexity over acts without d&e, without a major loss of understanding. The legal profession had to deal with acts which could not be called insane, but which resulted from the perpetrator’s failure to extinguish the impulse to commit them. Hence the idea of monomania, which Esquirol described as a partial kind of delirium, was introduced to cover up the gap in the law. Legists and psychiatrists confronted one another, asserting mutual respect for one another’s domain of expertise. The first worked for the legitimation of and the rationalization for the right to punish: the second pathologized newly-discovered aspects of human behaviour. The long range importance of this strategy was that the courts would increasingly turn to psychiatry to assist them with difficult cases. not only, however, the extraordinary cases: but those arising from the mundane infractions committed in the family or neighbourhood setting, acts connected with alcoholism and eventually with drugs. Simultaneously, psychiatrists increased the range of their concerns and began. under the multiple stresses of industrialization and the fears aroused by their own latent uneasiness over available treatments, to question the finality of cures, to pathologize more and more areas of life, and to acknowledge that the asylum was not the place to discriminate among several and various cases of behaviour deemed to depart from “normal” behaviour. The asylum lost its universal goals in the face of men and women whose behaviour was thought to be unpredictable, impulsive, perverse. and the result of de-. generescence, djsorders caused by congenital and hereditary defects. People could no longer easily be divided into sane and insane. Long before the fuller, but not the fullest, implications of this mutual professional and moral reinforcement came to disturb the dreams of the experts, the asylum was clearly showing signs of disease. It could not take in all the newer cases, because its facilities would suffer financial and physical strain. On the other hand, psychiatrists argued that the failure to give ‘them complete autonomy, both in their administration of the asylum and finances to run it, was forcing them to maintain generalized, instead of freeing them to introduce individualized. treatment. “If only . . . ” they kept saying in defence of their position, with the result that in this important instance, they could continue to advocate the 1838 legislation as a proper model for all states and societies at all times and to find nothing in that prescription to contradict their tolerance of private asylums where paying patients received individualized therapy. That there were psychiatrists working dually in public and private capacities is one Psychiatry. Int. J. Law. Psychiatry 1 (1978). The earlier essays in Moi. Pierre Rivikre 04. Foucault ed. 1973, translated by F. Jellinek as 1. Pierre Riviere . (1975)). contains Castel’s essay, The Physicians and the Judges.
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of the more interesting phenomena in this period of mental medicine. Their intellectual gymnastics in reconciling (assuming that this was always necessary) the therapies in each of the two settings do not require any extra effort of the imagination. Only the bourgeoisie could seek private treatment, or in time avail themselves of psychoanalysis through the university. The rest of the population was offered the psychiatry of the asylum: there existed a psychiatry for the poor, but it was also poor psychiatry (p. 258). The attention given paying clients might have passed as psychiatry, but the attention given the poor in the asylum was hardly that. It became identified unmistakably with rigid forms of guardianship and ,@telage and owed its continuing power, despite its internal bankruptcy, to the symbolic power it exerted on delinquent sections of the population who knew the costs of transgressing the prevailing standards of normality and the permanent stigmata attached to internment in the asylum. In the century preceding the total breakdown of the originai metamorphosis which culminated in the emergence of the present system, the critiques of the first grew and came from the legal profession which began to seek equal power with the psychiatrists to determine selection procedures: from others who became aware of institutionalized care different from the asylum, for example, in the agricultural colony of Gheel in Belgium which treated its inmates in conditions of semi-freedom; from early antipsychiatric individuals who, like Jean Tissot (Brother Hilarion) inveighed against professionalism. gave a mystical interpretation of madness, and even spoke of a kind of group therapy, or like Garsonnet who summed up his position by questioning the “science” of psychiatry and observed that the meaning of the laws governing the insane could be understood by judging the therapist; as well as from the widening of theory to encompass, as we saw, the hidden causes of mental disturbance. In consequence, psychiatry began what Caste1 calls a process of recomposition which assumed two main directions: specificity of treatment within discrete spaces for the senile, criminally insane, the chronically ill, alcoholics, epileptics, and the indigent as well as “free services” within psychiatric hospitals: and policies of prevention - seeking out the causes of mental disturbance in the family, school, army, and very soon, modifying the environment by hygienic measures. The divergence of the response within psychiatric circles was responsible, Caste1 remarks, for the delays in the creation of a new metamorphosis. But, of course, such an explanation for the transformation, which Caste1 will presumably deal with in greater detail in his next volume, is necessarily partial, for it would rest on a totally unrealistic intemalist analysis of psychiatric theory. Instead, the interconnectedness of internal and external, the dynamics of doubly reflecting systems of power, and the proliferation of new areas of specialized fields of knowledge are producing new areas of professionalism, pathologizations of behaviour, and technologies of power which have become part of the present social and intellectual landscape. The movement deinstitutionalizing the mentally ill lacks convincing scientific basis, since the effectiveness of the psychoactive drugs is highly overrated, and the policy of early discharge was in fact initiated before the pharmacological attack was launched. The argument that the mental institution was itself a serious fact in reinforcing irrationality (“infantilism”) and was an independent source of mental disturbance, has perhaps more validity. But serious students of the phenomenon of decarcer-
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have concluded that the enormous social investment in welfare programpossessing strategies that are making custodial treatment superfluous as as contributing strain on treasuries, must carry the burden of the explanafor the latest metamorphosis.” hundred and eighty years ago, Pine1 wrote: In general it is pleasant for a sick person to be in the bosom of his family, receiving from it the cares and consolations of tender and compassionate love, that I must painfully state a sad truth but one established by the most regular experiences, the absolute need to entrust the mad to the hands of strangers, and to isolate them from their relatives.20
By the mid-point
of the present
century,
a profound
change had occurred:
After all. considering what current research had shown, surely “the worst home is better than the best mental hospital . . . so that in the long run the abandonment of the state hospitals might be one of the greatest humanitarian reforms and the greatest financial economy ever achieved. . . .“21
I9 A. Scull. Decarceration: Community Treatment and the Individual. A Radical View (1976). 2”Quotcd in Caste1 at 93. x E. and J. Cumming. Closed Ranks 55 (1957) and I. Belknap. Human Problems of a State Mental Hospital 212 (1956) quoted in Scull, The Decarceratiort o.f the Mentally Ill: A Critical View. 6 Politics and Society 184 (1976).
