Psychiatry is eminently corruptible. Soviet psychiatrists of the 1950s disgracefully organized themselves into the medical arm of the Gulag state. Political dissidence became prima facie evidence of impaired reality testing, of “sluggish schizophrenia.” We like to believe in the benefits of scientific progress, but for Soviet inmates, progress was prefixed with a minus sign; every apparent advance in psychiatric technology left them more tightly controlled and worse off.
What if we were doing the same thing? Might our every step forward in brain imaging, genetics, and psychopharmacology promote unconscious agendas of domination and conformity? Not likely. We still live in a democracy of sorts and most Americans—if they’ve had the good fortune not to join the National Guard—still don’t take orders from the government.
Who could seriously promote such a perverse idea? Only someone with an intuitive sympathy for the most abased and marginal members of society and with a violent contempt for science, medicine, and authority in general. And, if he were to convince anyone else of his outlandish views, he would be a dialectical and rhetorical genius. But that was Michel Foucault (1926-1984)—a lifelong political and philosophical radical, erstwhile Communist, a votary of the student insurrections of 1968, apologist for the Iranian revolution, prison rights campaigner, AIDS activist, and early AIDS victim. Yet, Foucault was equally a mâitre penseur, an intellectual rock star in the mold of Camus and Sartre, and a professor installed at the apex of honor and respect in his nation’s rigidly hierarchical university system. Only in France!
Madness and Civilization, a reworking of Foucault’s doctoral dissertation, undertakes an “archaeology” of our system of psychiatric nosology and treatment.1 Foucault is a relativist concerning mental illnesses; our medicalized understanding of them is a social invention, localized to our episteme, or conceptual scheme. Knowledge generally, and psychiatric practice in particular, cannot be understood in isolation from other institutions of coercion and discipline.
This modern conceptual framework began to form in the “Classical” period of the 17th and 18th centuries. The midsection of Madness and Civilization is a dreary recital of the unfounded theorizing and hopeless treatments of that time—a tale of vapors, humors, shackles, purges, and cold showers. But this account is bracketed by Foucault’s provocative description of 2 great historical discontinuities: steps backward that looked like steps forward.
Foucault contrasts classical theory with a medieval and a Renaissance view of madness that he reconstructs from contempora-neous art and literature, especially the hallucinatory images created by Pieter Bruegel and Matthias Grünewald, and the caricatures in Erasmus’s The Praise of Folly. This view holds that madness is a sinful state, a fall from grace, an alternative to reason. Madness is accorded a fearful respect, as temptation and delusive freedom. By contrast, in the protoscientific classical view, madness is externalized, isolated, and investigated. The dialogue with madness ceases.
The objective correlative of this conceptual reorganization and the first of Foucault’s discontinuities, is the “Great Confinement” of the 17th century; the abrupt incarceration of mass populations within a newly organized network of custodial institutions throughout Europe. With his Frankocentric perspective, Foucault fastens particularly on an edict of 1656 that established the Hôpital Général of Paris. The name is deceptive; the Hôpital was not a medical institution. It, and kindred establishments, housed not just the insane (a term that covered psychosis, mental retardation, dementia, epilepsy, and all the rest of organic psychiatry) but also debtors, vagrants, petty criminals, and political and religious dissenters. Officially, the Confinement took aim at poverty and idleness. Foucault suggests that it was really a moral panic provoked by rural displacement, industrialization, and a new class of urban surplus labor. Whatever the reason, millions were locked away without any recourse.
Foucault’s second discontinuity is the dismantling of these institutions at the end of the 18th century. The heroes of this movement are the Quaker Samuel Tuke (founder of the York Asylum) and Philippe Pinel (representative of the French Revolution, who reorganized the French hospitals). In the received view, Tuke and Pinel brought liberation, understanding, and kindness to the mentally ill. (Every textbook of medical history reproduces a painting by Robert-Fleury of Pinel righteously striking the chains from the inmates of the Salpêtrière).
Foucault, controversially, will have none of this. He describes the work of these reformers as “a gigantic moral imprisonment.” They merely replaced crude force with more subtle, intimate, and pervasive means of control. Mental illness was reconceptualized as moral failure, to be treated with constant observation and regimentation, with appeals to guilt and religious sentiment. The inmate is perpetually judged, threatened, and corrected. The hospital caricatures the family—with the psychiatrist assuming the mantle of benign but demanding paternal authority. Crucially, the patient internalizes this authority, becoming more compliant but also more self-alienated, divided, and less free even than his or her enchained predecessors. Foucault even suggests that the grand hysteria described by Charcot, Freud, and Pierre Janet 100 years later is the “precipitate” of this authoritarian regime.
A central metaphor for Foucault is the Panopticon of Jeremy Bentham. Bentham, a British philosopher, was the founder of Utilitarianism and an avatar of instrumental reason gone wild. His Panopticon was a cunningly designed prison—never actually built—that permitted a few guards to observe a huge number of inmates. Bentham’s scheme relied on internalization: once prisoners know that someone may always be watching, they watch themselves. (Just as in George Orwell’s 1984, state terror is maintained even when no one knows whether the omnipresent telescreens are actually operating.) Never mind The Matrix . . . modern psychiatry and penology have converged. Foucault claims that we all live inside the Panopticon. And if you’ve tried to board an airplane recently, you might agree.
Foucault’s writings have offered intellectual heft to enemies of organized psychiatry, from the anti-psychiatrists of the 1960s to today’s Scientologists. But his greatest influence came in that unlikely alignment of doctrinaire Libertarianism, pharmacological presumption, and Foucauldian cynicism that produced our own “Great Deconfinement”—the emptying of our state psychiatric hospitals. To paraphrase Foucault’s compatriot Anatole France, “the mentally ill are once again free to beg in the streets and sleep under bridges.”