THE ESSENTIAL FUNCTION OF
psychiatric
power is to be an effective agent of reality, a sort of mtensifier of reality to madness.
Foucault-Psychiatric-Power-1973-74
p.
15.
7. Ibid.
8. Ibid. p. V\. 9. Ibid.
10. P. Pinel, Traite medico-philosophique, section VI, ? iv: "Essai lente pour guerir une melancolie profonde produile par une cause morale" pp. 233 237; A Treatise on Insanity, "An attempt to cure a case ol melancholia produced by a moral cause" pp. 227i 227.
11. Joseph Mason Cox, Practical Observations on Insanity, Case II, p. 51; Observations sur la de? nence,(^06), p. 77.
12. Ibid. p. 51; ibid. p. 78.
13. Ibid. p. 52; ibid. pp. 78 79.
V\. F. Leuret, Fragments psychologiques sur la folie (Paris: Crochard, 1837|) ch. 2: "Delirium ol
intelligence": "The chair hirer of a Parisian parish, treated by Monsieur Esquirol,. . . said he had bishops in his belly who were holding a council. . . Descartes thought it an established tact that the pineal gland is a mirror which reflected the image ol external bodies . . . Is one of these assertions better proved than the other? " p. 7i3. Leuret is referring to Descartes' analysis of the role ol the pineal gland in the lormation of ideas ol objects which strike the senses: R. Descartes, Traite de VFlomme (Paris: Clerselier, 1667|) in Descartes, CEuvrcs el Lettres, ed. A. Bridoux, pp. 8 5 0 853; English translation, "Treatise on Man," trans. Robert Slootholl, in The Philosophical Writings oj Descartes, trans. John Cottingham, Robert Slootholl, Dugald Murdoch (Cambridge: Cambridge University Press, 1985) vol. 1, p. 106.
15. In this conception, "Judging is the action in which the mind, bringing together dillerent ideas, aflirms ol one that it is the other, or denies ol one that it is the other. This occurs when, for example, having the idea ol the earth and the idea ol round, I affirm or deny ol the earth that it is round" A. Arnauld and P. Nicole, La Logique, ou VArl depenser, contcnanl, outre les regies communes, plusieurs observations nouvelles propres a former le jugemenl ( 1 6 6 2 ) (Paris: Desprez, 1683, 51'1 edition) p. 36; English translation, Logic, or, The art of thinking, trans. J. V. Buroker (Cambridge: Cambridge University Press, 1996) p. 23. See, L. Mann, La Critique du discours. Sur la "Logique de Port-Royal" et les "Pensees de Pascal" ( P a r i s : E d . d e Minuit, 1975) pp. 275 299; and Foucault's comments in Les Mots et let Choses, Part One, "Representer," pp. 72 81; The Order oj Things, pp. 58 67; and, "Introduction" to A. Arnauld and C. Lancelot, Grammaire generale et raisonnee conlenanl lesJondements de Part de
parler expliques d'une maniere claire et nalurelle (Paris: Republications Paulet, 1969),
reprinted in Dits el Ecrits, vol. 1, pp. 732 752.
16. On this theatrical production, see Michel Foucault, Histoirc de lafolie, pp. 350 354; Madness
and Civilisation, pp. 187 191. The second lecture ol the College de France course of 1970 1971, "The Will to Knowledge," speaks of this "theatricalization" of madness as an "ordeal test" which involves "seeing which oi the two, patient or doctor, would keep up the game of truth the longest, all this theater of madness by which the doctor objectively real- ized as it were the patient's delirium and, on the basis ol this feigned truth, reached the patient's truth" (personal notes;J. L. ).
? 17. Whereas paralytic disorders were considered to be intercurrent affections ol the develop ment of dementia or, as Esquirol said, a "complication" of the illness (sec the article " D e m e n c e " in Dictiotmairc des sciences medicates, par unc sociele de medecins et de chirurgiens | Paris: C. L. F. Panckoucke, 1814] vol. VIII, p. 283, and the article "Folie" vol. XVI, 1816), in 1822, Antoine Laurent Jesse Bayle (1799-1858), on the basis of six observations lol lowed by anatomical checks, gathered in the department ol Royer Collard at Salpetnere, identified a morbid entity which, following the anatomical cause to which he attributed it, he called "chronic arachnitis," using the tact that "in all the periods ol the illness, there is a constant relationship between the paralysis and the delirium . . . we therelore could not reluse to accept that these two orders ol phenomena are the symptoms ol a single illness, that is to say of a chronic arachnitis," to which he devotes a first part ol his thesis defended on 21 November 1822 (Recherches sur les maladies mentales, Medical Thesis, Paris, no. 1/|7 [Paris: Didot Jean, 1822j): Recherches sur /'arachnitis chronique, la gastrile, la gaslro-enterite, et la goutle, considerees comme causes de {'alienation menlale (Pans: Gabon, 1822; centenary repub licalion Paris: Masson, 1922) vol. 1, p. 32. Bayle later extended his conception to most men tal tllnesses: "Most mental illnesses are the symptoms of an original chronic phlegmasia ol the 'membranes of the brain' " Traitc des maladies et de scs membranes (Paris: Gabon, 1826) p. xxiv. See also his text, "De la cause orgamque de l'alienation mentale accompagnee de paralysie generale" (read at the Imperial Academy ol Medicine) Annales medico-
psychologiques, 3rJ series, vol. 1,July 1855, pp. 409 425.
18. In the 1820s, a group ol young doctors turned to pathological anatomy on which it tried to graft clinical psychiatry. Felix Voisin set out the programme: "Given the symptoms, how can the seat ol the disease be determined. This is the problem that medicine illuminated by physiology can address today" Des causes morales et physiques des maladies mentales, et de quelcjues aulres afjeclions telles que I'hyslerie, la nymphomanie el le salyriasis ( Paris: J. B. Bailliere, 1826) p. 329. In 1821, two students of Leon Rostan (1791 1866), Achille |de| Foville (1799 1878) and Jean Baptiste Delaye (1789 1879), presented a paper for the Prix Esquirol: "Considerations sur les causes de la folie et de leur mode d'action, suivies de recherches sur la nature et le siege special de cette maladie" (Paris: 1821). On 31 December
1819, Jean Pierre Falret (1794-1870) defended his thesis: Observations et propositions medico-chirurgicales, Medical Thesis, Paris, no. 296 (Paris: Didot, 1919) belore publishing his, De rhypocondrie el du suicide. Considerations sur les causes, sur le siege el le traitemenl du ces maladies, sur les moyens d'en arrctcr les progres et d'en prevoir les developpements ( P a n s : Croullebois, 1822). On 6 December 1823, Falret gave a lecture to the Athenee de Medecine: "Inductions ttrees de Pouverture des corps des alienes pour servir an diagnostic et an traitemenl des maladies mentales" (Paris: Bibliotheque Medicale, 182/|).
In 1830 a debate on the organic causes ol madness was started on the occasion ol the thesis ol one ol Esquirol's students, Etienne Georget (who entered Salpetriere in 1816 and in 1819 won the Prix Esquirol with his paper: "Des ouvertures du corps des alienes") which was defended on 8 February 1820, Dissertation sur les causes de la folie, Medical Thesis, Paris, no. 31 (Pans: Didot Jeune, 1820), and in which he criticizes Pinel and Esquirol lor being satisfied with observation of the phenomena of madness without seeking to connect them to a productive cause. In his work, De lafolie, p. 72, Georget declares: "I must not tear linding mysell in opposition to my teachers . . . by demonstrating that madness is a cerebral
idiopathic allection. "
19. It was Jean Pierre Falret who asserted that, thanks to isolation, "the lamily, in the silence
ol a positive law, overcoming the fear of committing an arbitrary act, and making use of the imprescriptible right of reason over delirium, subscribes to the teachings ol science in order to obtain the benefit of the cure of the insane. " J. -P. Falret, Observations sur le projel de loi relalij aux alienes, presented le 6 Janvier 1837 a la Chambrc des deputes par le ministre de Vlnterieur (Paris: Everal, 1837) p. 6.
20. The problem of simulation was raised in 1800 by P. Pinel who devoted a chapter to it in his Traile medico-philosophique section VI, ? xxii: "Mania simulee; moyens de la reconnoitre" pp. 297 302; A Treatise on Insanity, "Feigned mania: the method of ascertaining it," pp. 282 287. See also, A. Laurent, Etude medico-Iegalc sur la simulation de lafolie. Considerations cliniques et
pratiques a I'usage des medecins experts, des magistrals el desjurisconsulles (Paris: Masson, 1866); H. Bayard, "Memoire sur les maladies simulees," Annales d'hygiene publique et de medecine
72 December 7973 141
? 142
PSYCHIATRIC POWER
21.
legate, lsl series, vol. XXXVIII, 1867, p. 277; E. Boisseau, "Maladies simulees" in A. Dechambre and others, eds. Diclionnaire encyclopedic/ue des sciences medicates, 2,H series, vol. 2 (Paris: Masson/Asselin, 1876) pp. 266-281; G. Tourcles, "Simulation" ibid. pp. 681 715. Charcot dealt with the question on several occasions: ( l ) "Ataxie locomotnce, forme anormale" (20 March 1888) in Lecons du mardi a la Salpelriere. Policlinique 1887-1888, notes of the course of M. Blin,J. Charcot, and H. Colin (Paris: Lecrosnier & Babe, 1889) vol. 1, pp. 281-284; (2) Lecture IX: "De 1'ischurie hyslerique," (1873) in Lecons sur les maladies du systeme nervcux, vol. 1, collected and published by D. M. Bourneville (Pans: Delahaye et Lecroisner, 1884, 5th edition) pp. 281 283; English translation, J. M. Charcot, Clinical Lectures on Diseases of the Nervous System, vol. 1, trans. George Sigerson (London: New Sydcnham Society, 1877) Lecture 10, "Hysterical ischuria" pp. 230-232; (}) Lecture 1: "Lec,on d'ouverture de la chaire de clinique des maladies du systeme nerveux" (23 April 1882), and Lecture XXVI: "Cas du mutisme hystenque chez l'homme," both in Lecons sur les maladies du systeme nerveux, vol. 3, collected and published by Babinski, Bernard, Fere, Guinon, Marie and Gilles de La Tourcttc (1887) (Paris: Lecroisner & Babe, 1890), pp. 17 22 and 452-433; English translation, J. M. Charcot, Clinical Lectures on Diseases of the Nervous System, trans. Thomas Savill (London and New York: Tavistock/Routledge, 1991) vol. 3, Lecture I, "Introductory," pp. 14 19, and Lecture 26, "A Case ot Hysterical Mutism in a man," pp. 368 570.
In 1821, at Salpetnere, Etienne Georget, attracted by the experiments conducted by the Baron Jules Dupotet de Sennevoy in October 1820 at the Hotel Dieu in the department ol Hussun, with the help of Leon Rostan, converted two patients into somnambulistic experimental subjects: Petronille and Manoury, the widow Brouillard, called "Braguette. " See A. Dechambre, "Nouvelles experiences sur le magnetisme animal" Gazette medicale de Paris, 12 September 1835, p. 585- Georget reports these experiments, without revealing the identity ol the patients, in De la physiologie du systeme nerveux, et specialement du ccrveau, vol. 1, ch. 3: "Somnambulisme magnetique" (Paris:J. B. Bailliere, 1821) p. 404. See also, A. Gauthier, Histoire du somnambulisme: che^ tous les peuples, sous les noms divers d'extases, songes, oracles, visions, etc. (Paris: F. Maltese, 1842) vol. 2, p. 324; A. Dechambre, "Deuxieme lettre sur le magnetisme animal," Gazette medicale de Paris, 1840, pp. 13-14, and "Mesmensme," in Diclionnaire encyclopedique des sciences medicates, 2ml series (Paris: Masson/Asselin, 1877) vol. VII, pp. 164 165.
? se^en
19 DECEMBER 1973*
Psychiatric power. ^ A treatment by Francois Leuret and its strategic elements: 1-creating an imbalance of power; 2-the reuse of language; 3-the management of needs; 4-the statement of truth. ^ The pleasure of the illness. ^ The asylum apparatus
(dispositif).
THE ESSENTIAL FUNCTION OF psychiatric power is to be an effective agent of reality, a sort of mtensifier of reality to madness. In what respect can this power be defined as a surplus-power of reality?
To begin to sort out this question a little, I would like to take the example ot a psychiatric treatment of around the years 1838-1840. How did psychiatric treatment take place at this time?
At first sight, at the time of the establishment, the organization, of the asylum world, there was no treatment, because recovery was expected as a sort of, if not spontaneous, at least automatic process of reaction to the combination of four elements. These were: first, isolation in the asylum; second, physical or physiological medication with opiates,1 laudanum,2 etcetera; third, a series of restraints peculiar to asylum life, such as discipline, obedience to a regulation,3 a precise diet/1 times of sleep and of work,5 and physical instruments of constraint; and then, finally, a sort of psychophysical, both punitive and therapeutic medication,
* In the manuscript this lecture is given the title: "The psychiatric cure. "
? 144 PSYCHIATRIC POWER
like the shower,6 the rotary swing,7 etcetera. These combined elements defined the framework oi treatment from which recovery was expected without any theory or explanation ever being given for this recovery*
Despite this initial appearance, I think psychiatric treatment devel- oped in terms of a number of plans, tactical procedures, and strategic elements that can be defined and are, I believe, very important for the constitution of psychiatric knowledge, maybe up until our own time.
I will take one cure as an example that, to my knowledge, is the most developed example in the French psychiatric literature. Sadly the psy chiatrist who provided this example has an unfortunate reputation: Leuret, the man of moral treatment, who for a long time was reproached for his abuse of punishment and the shower, and other such methods. 8 He is certainly the person who not only defined the classical psychiatric cure in the most precise, meticulous way, and who left the most docu ments concerning his treatments, but I think he is also the person who developed his practices, his strategies of treatment, and pushed them to a point of perlection which makes it possible both to understand the general mechanisms which were put to work by other psychiatrists, his contemporaries, and to see them in slow motion, as it were, m detail and in terms of their subtle mechanisms.
The treatment is that of a M. Dupre and is reported in the final chapter of the Traitement moral de lafolie in I87i0. 9 "M. Dupre is a short, fat man, given to stoutness; he walks alone and never addresses a word to anyone. His gaze is uncertain, his countenance vacant. He is con stantly belching and farting, and he frequently makes a very disagreeable little grunt with the aim of ridding himself of the emanations that have entered his body by means of necromancy. He is insensitive to the kind- nesses he may be shown and even seeks to avoid them. If one insists it puts him in a bad mood, but without him ever becoming violent, and he says to the supervisor, if one is there: 'Make these madmen who come to torment me go away' He never looks anyone in the face, and if one suc- ceeds in drawing him out from uncertainty and daydreaming for an instant, he immediately falls back into it (. . . ). There are three families
* The manuscript adds: "A code, in short, not a linguistic code of signifying conventions, but a tactical code enabling the establishment and definitive inscription of a certain relationship ol force. "
? on Earth whose nobility makes them pre-eminent over all others; these are the families of the Tartar princes, of Nigritie, and of the Congo. One particular race, the most illustrious of the family of Tartar princes, is that of the Halcyons, of which he is the head, Dupre so-called, but in reality born in Corsica, descendant of Cosroes: he is Napoleon, Delavigne, Picard, Audnent, Destouches, Bernardin de Saint-Pierre, all at the same time. The distinctive sign of his Halcyon status is his con stant ability to enjoy the pleasures of love. Beneath him are degenerate, less favored beings of his race, called three quarters, one quarter, or one hfth Halcyons, according to their amorous abilities. As a result of his excesses, he fell into a state of chronic illness, for the treatment of which his adviser sent him to his Saint-Maur chateau (this is what he calls Charenton), then to Saint-Yon, then to Bicetre. The Bicetre in which he hnds himself is not the one near Paris, and the town one points out to him, some distance from the home, is none other than the town of Langres, in which, in order to deceive him, there are representations ol monuments which bear some resemblance to those of the true Pans. He is the only man in the home; all the others are women, or rather combi- nations of several women, wearing well arranged masks provided with beards and side-whiskers. He positively recognizes the doctor who looks alter him as a cook who was once in his service. The house in which he slept, when coming from Saint-Yon to Bicetre, vanished when he left it. He never reads a newspaper and would not touch one for anything in the world; the newspapers he is given are false, they do not speak of him, Napoleon, and those who read them are accomplices in league with those who produce them. Money has no value; there is nothing but counterfeit money. He often hears the bears and apes talking in the jardm des Plantes. He remembers his stay in his Saint Maur chateau, and even some of the people he met there (. . . ). The multiplicity of his lalse ideas is no less remarkable than the confidence with which he
spouts them. "10
In the subsequent analysis of the lengthy treatment I think we can distinguish a number of game plans or maneuvers, which Leuret never theorizes and for which he provides no explanation founded on an eti ology of mental illness, or on a physiology of the nervous system, or even, more generally, on a physiology of madness. He merely dissects the
79 December 7973 145
? Vi6
PSYCHIA TRIC POWER
different operations he tried out and these maneuvers can, I think, be divided into four or five major types.
First, there is the maneuver of creating an imbalance of power, that is to say, right from the start or, anyway, as quickly as possible, making power flow in one and only one direction, that is to say, from the doctor. And this is what Leuret hastens to do; his first contact with Dupre consists in creating an imbalance of power: "The first time I approach M. Dupre in order to treat him, I find him in a huge room filled with the supposedly incurably insane. He is sitting, waiting for his meal with his stupid look, indifferent to everything going on around him, completely unaffected by the dirtiness of his neighbors and him self, and seeming to have only the instinct to eat. How to bring him out of his torpor, to give him some real sensations, to make him a bit attentive? Kind words do nothing; would severity be better? I pretend to be unhappy with his words and conduct; I accuse him of laziness, vanity and untruthfulness, and I demand that he stand upright and bareheaded before me. "11
I think this first meeting fully reveals what we could call the general ritual of the asylum. Basically, and Leuret is in no way different from his contemporaries in this respect, in all the asylums of this period, the first episode of contact between the doctor and his patient is indeed this cer- emony, this initial show of force; that is to say, the demonstration that the field of forces in which the patient finds himself in the asylum is unbalanced, that there is no sharing out, reciprocity, or exchange, that language will not pass freely and neutrally from one to the other, that all possible reciprocity or transparency between the different characters inhabiting the asylum must be banished. Right from the start one must be in a different world in which there is a break, an imbalance, between doctor and patient, a world in which there is a slope one can never reascend: at the top of the slope is the doctor; and at the bottom, the patient.
It is on the basis of this absolutely statutory difference of level, of potential, which will never disappear in asylum life, that the process of treatment can unfold. It is a commonplace of the advice given by alienists concerning different treatments that one should always begin by marking power in this way. Power is all on one side, Pinel said when
? he recommended approaching the patient with "a sort ol ceremony ol lear, an imposing air, which can act strongly on the imagination [ol the maniac; J. L. ] and convince him that all resistance is pointless. "12 Esquirol said the same: "In a home for the insane there must be one and only one chief to whom everything is subordinate. "H
Clearly, it is the "principle ol the foreign will" again, which we can call Falret's principle, which is the substitution ol a "loreign will" lor the patient's will. 11 The patient must leel himsell immediately con lronted by something in which all the reality he will lace in the asylum is summed up and concentrated in the doctor's foreign and omnipotent will. By this I do not mean that every other reality is suppressed to the advantage ol the single will ol the doctor, but that the element which carries all the reality that will be imposed on the patient, the support lor this reality the task of which is to get a hold on the illness, must be the doctor's will as a foreign will that is oflicially superior to the patient's will and so inaccessible to any relationship ol exchange, reciprocity, or equality.
This principle has basically two objectives. Its lirst objective is to establish a sort of state of docility that is necessary for the treatment: the patient, in fact, must accept the doctor's prescriptions. But it is not just a question ol subjecting the patient's wish to recover to the doctor's knowledge and power; establishing an absolute difference of power involves above all breaking down the fundamental assertion of omnipo tence in madness. In every madness, whatever its content, there is always an assertion of omnipotence, and this is the target ol the first ritual ol the assertion ol a loreign and absolutely superior will.
In the psychiatry of this time, the omnipotence of madness may man ilest itself in two ways. In some cases it will be expressed within the delirium in the lorm ol ideas of grandeur for example: thinking one is a king. In M. Dupre's case, believing he is Napoleon,'"^ that he is sexually superior to all humanity,16 that he is the only man and all the others are women,1' are all so many assertions, within the delirium itself, of a sort ol sovereignty or omnipotence. But clearly this only applies to cases of delusions of grandeur. Outside of this, when there is no delusion ol grandeur, there is still an assertion of omnipotence, not in the way the delirium is expressed, but in the way it is exercised.
79 December 7973 V\l
? 148 PSYCHIATRIC POWLR
Whatever the content of the delirium, even when one thinks one is persecuted, the fact of asserting one's delirium, that is to say refusing all discussion, reasoning, and proof, is in itself an assertion of omnipotence, and this is absolutely coextensive with all madness, whereas expressing omnipotence within the delirium is only the fact of having delusions of grandeur.
Asserting one's omnipotence in the delirium simply by the fact of being delirious is typical ol all madness.
Consequently, you can see how and why this first move, this first maneuver of the psychiatric operation is justified: it is a matter of break- ing down the omnipotence of madness, ol reducing it by demonstrating a different, more vigorous will endowed with greater power. Georget advises doctors: "Instead of. . . refusing to accord a lunatic the status ol king that he claims, prove to him that he is powerless and that you, who are anything but powerless, can do anything to him; perhaps he will reflect that actually, it may well be that he was in error. "18
So, this lirst contact, which I illustrated with the case ol M. Dupre, is inserted in the general context of asylum practice of this time, obvi- ously with many variants, in the form ol the delirium's omnipotence countered by the doctor's reality and omnipotence, which is accorded him by, precisely, the statutory imbalance ol the asylum. And all the internal discussions ol psychiatric discourse take place around this: some doctors think the doctor's power should be marked (rom time to time with violence, but also, on occasion, with the demand lor esteem and trust, in a compromise mode, with a sort of pact imposed on the patient. Then, on the other hand, there are psychiatrists who recom mend lear, violence, and threats in every case. Some see the fundamen- tal imbalance of power as sufficiently assured by the asylum system itself, its system of surveillance, internal hierarchy, and the arrangement of the buildings, the asylum walls themselves, carrying and defining the network and gradient of power. And then other psychiatrists consider rather that the doctor's own person, his prestige, presence, aggressive- ness, and polemical vigor all give him this mark. All these variants do not seem to me to be important with regard to the basic ritual, which I will show you that Leuret then develops throughout the treatment by clearly opting for the solution of the medical individualization of this
? surplus power conferred by the asylum, and by giving it the very direct lorm of aggression and violence.
One of the themes ol Dupre's delirium was belief m his sexual omnipotence, and that those around him in the asylum were women. Leuret asks Dupre if all the people around him really are women: "Yes" says Dupre. "Me too" asks Leuret. "Ol course, you too. " At this point Leuret takes hold ol Dupre and, "shaking him vigorously, asks him if this is a woman's arm. "19 Dupre is not very convinced, so to convince him more Leuret puts some "grains ol calomel" in his evening food and the unfortunate Dupre sullers violent diarrhea during the night. This enables Leuret to say to Dupre the next morning: "The only man in the asylum is so afraid ol the night that it's given him the runs. "20 This is how he marked his virile and physical supremacy, by producing this artificial sign of fear in Dupre.
We could cite a series ol elements like this throughout the treatment. Leuret puts Dupre in the shower. Dupre struggles, comes out with his delirious themes again, and says: "A woman is insulting me! " "A woman? " says Leuret, and directs the shower on him violently, deep in his throat, until the struggling Dupre recognizes that this really is a man's behavior, and "ends by agreeing that it is a man. "21 So, there is a ritual imbalance of power.
A second maneuver is what could be called the reuse of language. In Iact, Dupre did not recognize people for what they were, believed his doctor was his cook, and gave himsell a series of successive and simulta- neous identities, since he was "Destouches, Napoleon, Delavigne, Picard, Audrieux, Bernardin de Saint-Pierre, all at the same time. "22 Therefore--and this is what characterizes the second maneuver, which, with some overlap, more or less lollows the first chronologically-- Dupre must first of all relearn the names and be able to give each per- son his correct name: "As a result of being pestered, he becomes attentive and obeys. "2* He is made to repeat them until he knows them: "He must learn my name, those of the students, supervisors, and nurses. He must name all of us. "
Leuret makes him read books, recite verse, and forces him to speak the Latin he learned at school; he forces him to speak in Italian, which he had learned when he was in the army; he makes him "tell a story. "24
79 December 1973 149
? 150 PSYCHIATRIC POWER
Finally, on another occasion, he puts him in the bath, puts him under the shower as usual and, having done this, contrary to the usual practice, orders him to empty the bath. Now Dupre is not accustomed to obey ing orders. He is forced to obey this order and, when Dupre is emptying the bath with his pails, as soon as his back is turned, Leuret refills the bath again so that he can repeat the order a number of times until the mechanism of order and obedience are completely locked together. 2S
In this series of operations, which basically locus on language, it seems to me to be, first ol all, a matter of correcting the delirium ol polymorphous naming and ol constraining the patient to restore to each person the name by which he gets his individuality within the discipli nary pyramid ol the asylum. In a way which is quite typical, Dupre is not required to learn the names of the patients but rather those ol the doctor, of the doctor's students, and of the supervisors and nurses: the apprenticeship of naming will be an apprenticeship in hierarchy at the same time. Naming and showing respect, the distribution ol names and the way in which individuals are placed in a hierarchy, amount to one and the same thing.
You see too that he is required to read and recite verse, etcetera. This is, of course, a matter of occupying the mind, of diverting the delirious use of language, but it is equally a matter of re teaching the subject to use the lorms ol language of learning and discipline, the forms he learned at school, that kind ol artificial language which is not really the one he uses, but the one by which the school's discipline and system ol order are imposed. Finally, in the episode ol the bath that is tilled and he is made to empty on an indefinitely repeated order, it really is this language of orders, but this time of precise orders that the patient must be taught.
In general, I think what is at stake for Leuret here is making the patient accessible to all the imperative uses ol language: the use ol proper names with which one greets, shows one's respect and pays attention to others; school recital and ol languages learned; language of command. You can see that it is not at all a sort of re-apprenticeship-- that one might call dialectical--of the truth. It is not a question of show ing Dupre, on the basis of language, that his judgments were false; there is no discussion about whether or not it is right to consider everyone
? "Halcyons," as Dupre believes in his delirium. 26 It is not a matter of t urning the false into truth in a dialectic peculiar to language or discus- sion. In this game of orders and commands, it is simply a matter of putting the subject back in contact with language inasmuch as it is the carrier of imperatives; it is the imperative use of language that refers back to and is organized by a whole system of power. This is the lan- guage peculiar to the asylum; it fixes the names that define the asylum hierarchy; it is the master's language. It is this whole web of power that must be visible as reality behind the language one teaches. The language one re teaches to the patient is not the language through which he will be able to rediscover the truth; the language he is forced to re learn is a language in which the reality of an order, of a discipline, of a power imposed on him, must appear. This is what Leuret says, moreover, at the end ol these language exercises: "Here is M. Dupre who has become attentive [attention being the laculty of reality of course; M. F. ], he has entered into a relationship with me; I bring an action to bear on him, he obeys me. "27 "Attention," that is to say, a relationship with the doctor-- that is to say, with the person who gives orders and holds the power--a relationship that consists precisely in the doctor, who holds the power, performing an action in the form of an order. It is a language, therefore, which is transparent to this reality of power.
Here again we see that, in a sense, Leuret is much more subtle, and more of a perfectionist, than the psychiatrists of his time. Even so, what was called "moral treatment" at this time really was something like this, although less directly focused on the uses of language, of course, on that kind of rigged dialogue that was really a game of order and obedience, because, unlike Leuret, most psychiatrists put their faith in the internal mechanisms of the asylum institution rather than in this direct action of the psychiatrist as holder of power. 28 However, in the end, if you look at what the functioning of the asylum institution itself was for the psychi- atrists of this period, and where they sought the therapeutic character of the asylum's action, you see that the asylum was thought to be thera- peutic because it obliged people to submit to regulation, to a use of time, it forced them to obey orders, to line up, to submit to the regularity of certain actions and habits, to submit to work. And for the psychiatrists of the time, this whole system of order, both as orders given and, equally,
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as institutional regularities and constraints, is ultimately one of the major factors of asylum therapy. As Falret said in 1854, in a rather late text, "a strictly observed positive regulation, which fixes the use ol every hour of the day, forces every patient to react against the irregularity of his ten- dencies by submitting to the general law. Instead of being left to himself to follow the impulse ol his whim or his disordered will, the insane per- son is constrained to bend before a rule which is all the more powerful for being established for everyone. He is obliged to place himself in the hands of a foreign will and to make a constant effort on himself so as not to incur the punishments attached to infringements ol the rule. "29
Esquirol too thought that this system of the order, of the order given and the order followed, of the order as command and the order as regu larity, was the major effective agent of asylum treatment: "In such a home there is a movement, an activity, a whirl into which every person gradually enters; the most stubborn, defiant lypemaniac is forced to live outside of himself and, without being aware of it, is carried away by the general movement and example of others (. . . ); the maniac himsell, restrained by the harmony, order and rule ol the home, defends himself better against his impulses and abandons himself less to his eccentric activities. "^0 In other words, order is reality in the form of discipline.
The third maneuver in the apparatus of asylum therapy is what could be called the management or organization of needs. Psychiatric power ensures the advance of reality, the hold of reality on madness, through the management of needs, and even through the emergence of new needs, through the creation, maintenance and renewal of needs.
Here again, as a starting point, I think we can take the very subtle, very curious version that Leuret gives of this principle.
His patient, M. Dupre, did not want to work on the grounds that he did not believe in the value of money: "Money has no value; there is nothing but counterfeit money" said Dupre,51 since I, Napoleon, am the only person who has the right to mint coins. Consequently, the money given to him is counterfeit money: It's pointless to work! Now, the problem is precisely that of getting Dupre to understand the need for this money. One day he is forced to work, but he hardly does any work. At the end of the day it is suggested that he take a salary corresponding to his day's work; he refuses, giving as his reason that "money has no
? value. "52 He is seized and money forced into his pocket, but he is con- lined "without food or drink" tor the night and following day as pun- ishment for having resisted. A nurse however, who has been duly prepared in advance, is sent to him, and says: "Ah! Monsieur Dupre, how I pity you not eating! II I was not afraid of Monsieur Leuret's authority and punishment I would bring you something to eat; I am prepared to take this risk if you give me a little reward. " So in order to eat M. Dupre is obliged to take from his pocket three of the eight sous he had been given.
No doubt the meaning or, at least, the usefulness of money is already beginning to emerge for him on the basis of this artificially created need. He is well fed and, here again, a "dozen grains of calomel" are mixed in with "the vegetables eaten by M. Dupre who, quickly feeling the need to go to the lavatory, calls the servant and begs her to give him a free hand. A new pecuniary arrangement. "^ The following day Dupre goes to work and "seeks the price for his day's work. " This is, says Leuret, "the first reason- able act, made voluntarily and with reflection, that I have got from him. "M
Of course, we might wonder about this astonishing relationship Leuret establishes between money and defecation, but, as you can see, in the form of an imperative intervention. You can see that it is not a sym- bolic relationship of two terms--money-excrement--but a tactical rela- tionship between four terms: food, defecation, work, and money, and in which the fifth term, which runs through the four points of the tactical rectangle, is medical power. I think we see the relationship between money and defecation, which, as you know, was to have a well known future, emerging here for the first time and it is established through this game of medical power passing between these four terms. 55
It seems to me that generally, and here again in a particularly subtle, clever form, Leuret provided the formula of something very important in the system of psychiatric treatment at this time. Basically it involves establishing the patient in a carefully maintained state of deprivation: the patient's existence must be kept just below a certain average level. Hence a number of tactics, less subtle than Leuret's, but which also had a long future in the asylum institution and in the history of madness.
The clothing tactic: Ferrus, in his treatise Des alienes, from 1837I, pro vides a whole theory of asylum clothing, in which he says: "The clothing
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of the insane calls for special attention: almost all the mad are vain and proud. Before the onset of their illness, most of them led a life full of adventures; they often had wealth which their mental disorder led them to squander. "56 They therefore had fine clothes and jewelry, and in the asylum they recreate these costumes which are, at the same time, the sign of their old splendor, of their current poverty, and of the way in which their delirium operates: the mad must be deprived of all this. However, says Ferrus, we must not go too lar, because in asylums the mad are often allowed only torn and shameful clothes, which humiliate them too much and may excite their delirium or their disgust, and then they walk about naked. Something must be found between the orna- ments of delirium and obscene nudity, and this will be "clothing of unrefined and sturdy materials, but cut in a single style and kept clean, so as to moderate the puerile vanities ol madness. "*7
There is also the tactic of food, which must be plain, uniform, and not given on demand but in rations that, as lar as possible, are slightly less than the average. Furthermore, in addition to this general rationing of food within the asylum is added a policy ol punishment by withholding food, especially after the policy of no restraint, that is to say, after the sup pression of some of the contraptions of constraint:38 the great asylum punishment was deprivation of courses, fasting, etcetera.
Then there is the tactic of setting to work. Work is highly over- determined in the asylum system since, on the one hand, it ensures the necessary order, discipline, regularity, and constant occupation. Thus, very quickly, around the 1830s, work becomes obligatory withm asylums. The Sainte-Anne farm was initially an extension of the Bicetre hospital before taking over from it. 39 As Girard de Cailleux said when he was the director of the Auxerre hospital: "peeling and preparing veg etables is frequently a highly beneficial occupation in treatment. ",0 The interesting thing about this is that this work is not just imposed because it is a lactor in order, discipline, and regularity, but because it enables one to slip in a system of reward. Asylum work is not tree; it is paid, and this payment is not a supplementary favor but at the very heart of the function of work, for the remuneration must be sufficient to satisfy certain needs created by the underlying asylum deprivation: insufficient food, the absence of any extras (tobacco, a dessert, etcetera, must be paid for).
? I or the system of remuneration imposed with work to function, one has to have wanted, to have needed, and to have been deprived. So, these remunerations must be sufficient to satisfy the needs created by the basic deprivation and, at the same time, sufficiently low to remain below, oi course, normal and general remunerations.
Finally, and above all, the great deprivation developed by asylum dis- upline is, perhaps, quite simply deprivation of freedom. And you see how, in the psychiatrists of the first half of the nineteenth century, the iheory ol isolation gradually changes or, if you like, is deepened and completed. The theory of isolation I was talking about last week was basically demanded by the obligation to create a break between the ther- apeutic framework and the patient's family, the milieu in which the illness developed. Subsequently you see the birth of the idea that isola- tion has a supplementary advantage: it not only protects the family but gives rise to a new need in the patient, the need for freedom, of which he was previously unaware. Treatment can be developed on the basis of this artificially created need.
In the asylum form of this period, psychiatric power is therefore the creator of needs and the management of the deprivations it establishes.
7. Ibid.
8. Ibid. p. V\. 9. Ibid.
10. P. Pinel, Traite medico-philosophique, section VI, ? iv: "Essai lente pour guerir une melancolie profonde produile par une cause morale" pp. 233 237; A Treatise on Insanity, "An attempt to cure a case ol melancholia produced by a moral cause" pp. 227i 227.
11. Joseph Mason Cox, Practical Observations on Insanity, Case II, p. 51; Observations sur la de? nence,(^06), p. 77.
12. Ibid. p. 51; ibid. p. 78.
13. Ibid. p. 52; ibid. pp. 78 79.
V\. F. Leuret, Fragments psychologiques sur la folie (Paris: Crochard, 1837|) ch. 2: "Delirium ol
intelligence": "The chair hirer of a Parisian parish, treated by Monsieur Esquirol,. . . said he had bishops in his belly who were holding a council. . . Descartes thought it an established tact that the pineal gland is a mirror which reflected the image ol external bodies . . . Is one of these assertions better proved than the other? " p. 7i3. Leuret is referring to Descartes' analysis of the role ol the pineal gland in the lormation of ideas ol objects which strike the senses: R. Descartes, Traite de VFlomme (Paris: Clerselier, 1667|) in Descartes, CEuvrcs el Lettres, ed. A. Bridoux, pp. 8 5 0 853; English translation, "Treatise on Man," trans. Robert Slootholl, in The Philosophical Writings oj Descartes, trans. John Cottingham, Robert Slootholl, Dugald Murdoch (Cambridge: Cambridge University Press, 1985) vol. 1, p. 106.
15. In this conception, "Judging is the action in which the mind, bringing together dillerent ideas, aflirms ol one that it is the other, or denies ol one that it is the other. This occurs when, for example, having the idea ol the earth and the idea ol round, I affirm or deny ol the earth that it is round" A. Arnauld and P. Nicole, La Logique, ou VArl depenser, contcnanl, outre les regies communes, plusieurs observations nouvelles propres a former le jugemenl ( 1 6 6 2 ) (Paris: Desprez, 1683, 51'1 edition) p. 36; English translation, Logic, or, The art of thinking, trans. J. V. Buroker (Cambridge: Cambridge University Press, 1996) p. 23. See, L. Mann, La Critique du discours. Sur la "Logique de Port-Royal" et les "Pensees de Pascal" ( P a r i s : E d . d e Minuit, 1975) pp. 275 299; and Foucault's comments in Les Mots et let Choses, Part One, "Representer," pp. 72 81; The Order oj Things, pp. 58 67; and, "Introduction" to A. Arnauld and C. Lancelot, Grammaire generale et raisonnee conlenanl lesJondements de Part de
parler expliques d'une maniere claire et nalurelle (Paris: Republications Paulet, 1969),
reprinted in Dits el Ecrits, vol. 1, pp. 732 752.
16. On this theatrical production, see Michel Foucault, Histoirc de lafolie, pp. 350 354; Madness
and Civilisation, pp. 187 191. The second lecture ol the College de France course of 1970 1971, "The Will to Knowledge," speaks of this "theatricalization" of madness as an "ordeal test" which involves "seeing which oi the two, patient or doctor, would keep up the game of truth the longest, all this theater of madness by which the doctor objectively real- ized as it were the patient's delirium and, on the basis ol this feigned truth, reached the patient's truth" (personal notes;J. L. ).
? 17. Whereas paralytic disorders were considered to be intercurrent affections ol the develop ment of dementia or, as Esquirol said, a "complication" of the illness (sec the article " D e m e n c e " in Dictiotmairc des sciences medicates, par unc sociele de medecins et de chirurgiens | Paris: C. L. F. Panckoucke, 1814] vol. VIII, p. 283, and the article "Folie" vol. XVI, 1816), in 1822, Antoine Laurent Jesse Bayle (1799-1858), on the basis of six observations lol lowed by anatomical checks, gathered in the department ol Royer Collard at Salpetnere, identified a morbid entity which, following the anatomical cause to which he attributed it, he called "chronic arachnitis," using the tact that "in all the periods ol the illness, there is a constant relationship between the paralysis and the delirium . . . we therelore could not reluse to accept that these two orders ol phenomena are the symptoms ol a single illness, that is to say of a chronic arachnitis," to which he devotes a first part ol his thesis defended on 21 November 1822 (Recherches sur les maladies mentales, Medical Thesis, Paris, no. 1/|7 [Paris: Didot Jean, 1822j): Recherches sur /'arachnitis chronique, la gastrile, la gaslro-enterite, et la goutle, considerees comme causes de {'alienation menlale (Pans: Gabon, 1822; centenary repub licalion Paris: Masson, 1922) vol. 1, p. 32. Bayle later extended his conception to most men tal tllnesses: "Most mental illnesses are the symptoms of an original chronic phlegmasia ol the 'membranes of the brain' " Traitc des maladies et de scs membranes (Paris: Gabon, 1826) p. xxiv. See also his text, "De la cause orgamque de l'alienation mentale accompagnee de paralysie generale" (read at the Imperial Academy ol Medicine) Annales medico-
psychologiques, 3rJ series, vol. 1,July 1855, pp. 409 425.
18. In the 1820s, a group ol young doctors turned to pathological anatomy on which it tried to graft clinical psychiatry. Felix Voisin set out the programme: "Given the symptoms, how can the seat ol the disease be determined. This is the problem that medicine illuminated by physiology can address today" Des causes morales et physiques des maladies mentales, et de quelcjues aulres afjeclions telles que I'hyslerie, la nymphomanie el le salyriasis ( Paris: J. B. Bailliere, 1826) p. 329. In 1821, two students of Leon Rostan (1791 1866), Achille |de| Foville (1799 1878) and Jean Baptiste Delaye (1789 1879), presented a paper for the Prix Esquirol: "Considerations sur les causes de la folie et de leur mode d'action, suivies de recherches sur la nature et le siege special de cette maladie" (Paris: 1821). On 31 December
1819, Jean Pierre Falret (1794-1870) defended his thesis: Observations et propositions medico-chirurgicales, Medical Thesis, Paris, no. 296 (Paris: Didot, 1919) belore publishing his, De rhypocondrie el du suicide. Considerations sur les causes, sur le siege el le traitemenl du ces maladies, sur les moyens d'en arrctcr les progres et d'en prevoir les developpements ( P a n s : Croullebois, 1822). On 6 December 1823, Falret gave a lecture to the Athenee de Medecine: "Inductions ttrees de Pouverture des corps des alienes pour servir an diagnostic et an traitemenl des maladies mentales" (Paris: Bibliotheque Medicale, 182/|).
In 1830 a debate on the organic causes ol madness was started on the occasion ol the thesis ol one ol Esquirol's students, Etienne Georget (who entered Salpetriere in 1816 and in 1819 won the Prix Esquirol with his paper: "Des ouvertures du corps des alienes") which was defended on 8 February 1820, Dissertation sur les causes de la folie, Medical Thesis, Paris, no. 31 (Pans: Didot Jeune, 1820), and in which he criticizes Pinel and Esquirol lor being satisfied with observation of the phenomena of madness without seeking to connect them to a productive cause. In his work, De lafolie, p. 72, Georget declares: "I must not tear linding mysell in opposition to my teachers . . . by demonstrating that madness is a cerebral
idiopathic allection. "
19. It was Jean Pierre Falret who asserted that, thanks to isolation, "the lamily, in the silence
ol a positive law, overcoming the fear of committing an arbitrary act, and making use of the imprescriptible right of reason over delirium, subscribes to the teachings ol science in order to obtain the benefit of the cure of the insane. " J. -P. Falret, Observations sur le projel de loi relalij aux alienes, presented le 6 Janvier 1837 a la Chambrc des deputes par le ministre de Vlnterieur (Paris: Everal, 1837) p. 6.
20. The problem of simulation was raised in 1800 by P. Pinel who devoted a chapter to it in his Traile medico-philosophique section VI, ? xxii: "Mania simulee; moyens de la reconnoitre" pp. 297 302; A Treatise on Insanity, "Feigned mania: the method of ascertaining it," pp. 282 287. See also, A. Laurent, Etude medico-Iegalc sur la simulation de lafolie. Considerations cliniques et
pratiques a I'usage des medecins experts, des magistrals el desjurisconsulles (Paris: Masson, 1866); H. Bayard, "Memoire sur les maladies simulees," Annales d'hygiene publique et de medecine
72 December 7973 141
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PSYCHIATRIC POWER
21.
legate, lsl series, vol. XXXVIII, 1867, p. 277; E. Boisseau, "Maladies simulees" in A. Dechambre and others, eds. Diclionnaire encyclopedic/ue des sciences medicates, 2,H series, vol. 2 (Paris: Masson/Asselin, 1876) pp. 266-281; G. Tourcles, "Simulation" ibid. pp. 681 715. Charcot dealt with the question on several occasions: ( l ) "Ataxie locomotnce, forme anormale" (20 March 1888) in Lecons du mardi a la Salpelriere. Policlinique 1887-1888, notes of the course of M. Blin,J. Charcot, and H. Colin (Paris: Lecrosnier & Babe, 1889) vol. 1, pp. 281-284; (2) Lecture IX: "De 1'ischurie hyslerique," (1873) in Lecons sur les maladies du systeme nervcux, vol. 1, collected and published by D. M. Bourneville (Pans: Delahaye et Lecroisner, 1884, 5th edition) pp. 281 283; English translation, J. M. Charcot, Clinical Lectures on Diseases of the Nervous System, vol. 1, trans. George Sigerson (London: New Sydcnham Society, 1877) Lecture 10, "Hysterical ischuria" pp. 230-232; (}) Lecture 1: "Lec,on d'ouverture de la chaire de clinique des maladies du systeme nerveux" (23 April 1882), and Lecture XXVI: "Cas du mutisme hystenque chez l'homme," both in Lecons sur les maladies du systeme nerveux, vol. 3, collected and published by Babinski, Bernard, Fere, Guinon, Marie and Gilles de La Tourcttc (1887) (Paris: Lecroisner & Babe, 1890), pp. 17 22 and 452-433; English translation, J. M. Charcot, Clinical Lectures on Diseases of the Nervous System, trans. Thomas Savill (London and New York: Tavistock/Routledge, 1991) vol. 3, Lecture I, "Introductory," pp. 14 19, and Lecture 26, "A Case ot Hysterical Mutism in a man," pp. 368 570.
In 1821, at Salpetnere, Etienne Georget, attracted by the experiments conducted by the Baron Jules Dupotet de Sennevoy in October 1820 at the Hotel Dieu in the department ol Hussun, with the help of Leon Rostan, converted two patients into somnambulistic experimental subjects: Petronille and Manoury, the widow Brouillard, called "Braguette. " See A. Dechambre, "Nouvelles experiences sur le magnetisme animal" Gazette medicale de Paris, 12 September 1835, p. 585- Georget reports these experiments, without revealing the identity ol the patients, in De la physiologie du systeme nerveux, et specialement du ccrveau, vol. 1, ch. 3: "Somnambulisme magnetique" (Paris:J. B. Bailliere, 1821) p. 404. See also, A. Gauthier, Histoire du somnambulisme: che^ tous les peuples, sous les noms divers d'extases, songes, oracles, visions, etc. (Paris: F. Maltese, 1842) vol. 2, p. 324; A. Dechambre, "Deuxieme lettre sur le magnetisme animal," Gazette medicale de Paris, 1840, pp. 13-14, and "Mesmensme," in Diclionnaire encyclopedique des sciences medicates, 2ml series (Paris: Masson/Asselin, 1877) vol. VII, pp. 164 165.
? se^en
19 DECEMBER 1973*
Psychiatric power. ^ A treatment by Francois Leuret and its strategic elements: 1-creating an imbalance of power; 2-the reuse of language; 3-the management of needs; 4-the statement of truth. ^ The pleasure of the illness. ^ The asylum apparatus
(dispositif).
THE ESSENTIAL FUNCTION OF psychiatric power is to be an effective agent of reality, a sort of mtensifier of reality to madness. In what respect can this power be defined as a surplus-power of reality?
To begin to sort out this question a little, I would like to take the example ot a psychiatric treatment of around the years 1838-1840. How did psychiatric treatment take place at this time?
At first sight, at the time of the establishment, the organization, of the asylum world, there was no treatment, because recovery was expected as a sort of, if not spontaneous, at least automatic process of reaction to the combination of four elements. These were: first, isolation in the asylum; second, physical or physiological medication with opiates,1 laudanum,2 etcetera; third, a series of restraints peculiar to asylum life, such as discipline, obedience to a regulation,3 a precise diet/1 times of sleep and of work,5 and physical instruments of constraint; and then, finally, a sort of psychophysical, both punitive and therapeutic medication,
* In the manuscript this lecture is given the title: "The psychiatric cure. "
? 144 PSYCHIATRIC POWER
like the shower,6 the rotary swing,7 etcetera. These combined elements defined the framework oi treatment from which recovery was expected without any theory or explanation ever being given for this recovery*
Despite this initial appearance, I think psychiatric treatment devel- oped in terms of a number of plans, tactical procedures, and strategic elements that can be defined and are, I believe, very important for the constitution of psychiatric knowledge, maybe up until our own time.
I will take one cure as an example that, to my knowledge, is the most developed example in the French psychiatric literature. Sadly the psy chiatrist who provided this example has an unfortunate reputation: Leuret, the man of moral treatment, who for a long time was reproached for his abuse of punishment and the shower, and other such methods. 8 He is certainly the person who not only defined the classical psychiatric cure in the most precise, meticulous way, and who left the most docu ments concerning his treatments, but I think he is also the person who developed his practices, his strategies of treatment, and pushed them to a point of perlection which makes it possible both to understand the general mechanisms which were put to work by other psychiatrists, his contemporaries, and to see them in slow motion, as it were, m detail and in terms of their subtle mechanisms.
The treatment is that of a M. Dupre and is reported in the final chapter of the Traitement moral de lafolie in I87i0. 9 "M. Dupre is a short, fat man, given to stoutness; he walks alone and never addresses a word to anyone. His gaze is uncertain, his countenance vacant. He is con stantly belching and farting, and he frequently makes a very disagreeable little grunt with the aim of ridding himself of the emanations that have entered his body by means of necromancy. He is insensitive to the kind- nesses he may be shown and even seeks to avoid them. If one insists it puts him in a bad mood, but without him ever becoming violent, and he says to the supervisor, if one is there: 'Make these madmen who come to torment me go away' He never looks anyone in the face, and if one suc- ceeds in drawing him out from uncertainty and daydreaming for an instant, he immediately falls back into it (. . . ). There are three families
* The manuscript adds: "A code, in short, not a linguistic code of signifying conventions, but a tactical code enabling the establishment and definitive inscription of a certain relationship ol force. "
? on Earth whose nobility makes them pre-eminent over all others; these are the families of the Tartar princes, of Nigritie, and of the Congo. One particular race, the most illustrious of the family of Tartar princes, is that of the Halcyons, of which he is the head, Dupre so-called, but in reality born in Corsica, descendant of Cosroes: he is Napoleon, Delavigne, Picard, Audnent, Destouches, Bernardin de Saint-Pierre, all at the same time. The distinctive sign of his Halcyon status is his con stant ability to enjoy the pleasures of love. Beneath him are degenerate, less favored beings of his race, called three quarters, one quarter, or one hfth Halcyons, according to their amorous abilities. As a result of his excesses, he fell into a state of chronic illness, for the treatment of which his adviser sent him to his Saint-Maur chateau (this is what he calls Charenton), then to Saint-Yon, then to Bicetre. The Bicetre in which he hnds himself is not the one near Paris, and the town one points out to him, some distance from the home, is none other than the town of Langres, in which, in order to deceive him, there are representations ol monuments which bear some resemblance to those of the true Pans. He is the only man in the home; all the others are women, or rather combi- nations of several women, wearing well arranged masks provided with beards and side-whiskers. He positively recognizes the doctor who looks alter him as a cook who was once in his service. The house in which he slept, when coming from Saint-Yon to Bicetre, vanished when he left it. He never reads a newspaper and would not touch one for anything in the world; the newspapers he is given are false, they do not speak of him, Napoleon, and those who read them are accomplices in league with those who produce them. Money has no value; there is nothing but counterfeit money. He often hears the bears and apes talking in the jardm des Plantes. He remembers his stay in his Saint Maur chateau, and even some of the people he met there (. . . ). The multiplicity of his lalse ideas is no less remarkable than the confidence with which he
spouts them. "10
In the subsequent analysis of the lengthy treatment I think we can distinguish a number of game plans or maneuvers, which Leuret never theorizes and for which he provides no explanation founded on an eti ology of mental illness, or on a physiology of the nervous system, or even, more generally, on a physiology of madness. He merely dissects the
79 December 7973 145
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PSYCHIA TRIC POWER
different operations he tried out and these maneuvers can, I think, be divided into four or five major types.
First, there is the maneuver of creating an imbalance of power, that is to say, right from the start or, anyway, as quickly as possible, making power flow in one and only one direction, that is to say, from the doctor. And this is what Leuret hastens to do; his first contact with Dupre consists in creating an imbalance of power: "The first time I approach M. Dupre in order to treat him, I find him in a huge room filled with the supposedly incurably insane. He is sitting, waiting for his meal with his stupid look, indifferent to everything going on around him, completely unaffected by the dirtiness of his neighbors and him self, and seeming to have only the instinct to eat. How to bring him out of his torpor, to give him some real sensations, to make him a bit attentive? Kind words do nothing; would severity be better? I pretend to be unhappy with his words and conduct; I accuse him of laziness, vanity and untruthfulness, and I demand that he stand upright and bareheaded before me. "11
I think this first meeting fully reveals what we could call the general ritual of the asylum. Basically, and Leuret is in no way different from his contemporaries in this respect, in all the asylums of this period, the first episode of contact between the doctor and his patient is indeed this cer- emony, this initial show of force; that is to say, the demonstration that the field of forces in which the patient finds himself in the asylum is unbalanced, that there is no sharing out, reciprocity, or exchange, that language will not pass freely and neutrally from one to the other, that all possible reciprocity or transparency between the different characters inhabiting the asylum must be banished. Right from the start one must be in a different world in which there is a break, an imbalance, between doctor and patient, a world in which there is a slope one can never reascend: at the top of the slope is the doctor; and at the bottom, the patient.
It is on the basis of this absolutely statutory difference of level, of potential, which will never disappear in asylum life, that the process of treatment can unfold. It is a commonplace of the advice given by alienists concerning different treatments that one should always begin by marking power in this way. Power is all on one side, Pinel said when
? he recommended approaching the patient with "a sort ol ceremony ol lear, an imposing air, which can act strongly on the imagination [ol the maniac; J. L. ] and convince him that all resistance is pointless. "12 Esquirol said the same: "In a home for the insane there must be one and only one chief to whom everything is subordinate. "H
Clearly, it is the "principle ol the foreign will" again, which we can call Falret's principle, which is the substitution ol a "loreign will" lor the patient's will. 11 The patient must leel himsell immediately con lronted by something in which all the reality he will lace in the asylum is summed up and concentrated in the doctor's foreign and omnipotent will. By this I do not mean that every other reality is suppressed to the advantage ol the single will ol the doctor, but that the element which carries all the reality that will be imposed on the patient, the support lor this reality the task of which is to get a hold on the illness, must be the doctor's will as a foreign will that is oflicially superior to the patient's will and so inaccessible to any relationship ol exchange, reciprocity, or equality.
This principle has basically two objectives. Its lirst objective is to establish a sort of state of docility that is necessary for the treatment: the patient, in fact, must accept the doctor's prescriptions. But it is not just a question ol subjecting the patient's wish to recover to the doctor's knowledge and power; establishing an absolute difference of power involves above all breaking down the fundamental assertion of omnipo tence in madness. In every madness, whatever its content, there is always an assertion of omnipotence, and this is the target ol the first ritual ol the assertion ol a loreign and absolutely superior will.
In the psychiatry of this time, the omnipotence of madness may man ilest itself in two ways. In some cases it will be expressed within the delirium in the lorm ol ideas of grandeur for example: thinking one is a king. In M. Dupre's case, believing he is Napoleon,'"^ that he is sexually superior to all humanity,16 that he is the only man and all the others are women,1' are all so many assertions, within the delirium itself, of a sort ol sovereignty or omnipotence. But clearly this only applies to cases of delusions of grandeur. Outside of this, when there is no delusion ol grandeur, there is still an assertion of omnipotence, not in the way the delirium is expressed, but in the way it is exercised.
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Whatever the content of the delirium, even when one thinks one is persecuted, the fact of asserting one's delirium, that is to say refusing all discussion, reasoning, and proof, is in itself an assertion of omnipotence, and this is absolutely coextensive with all madness, whereas expressing omnipotence within the delirium is only the fact of having delusions of grandeur.
Asserting one's omnipotence in the delirium simply by the fact of being delirious is typical ol all madness.
Consequently, you can see how and why this first move, this first maneuver of the psychiatric operation is justified: it is a matter of break- ing down the omnipotence of madness, ol reducing it by demonstrating a different, more vigorous will endowed with greater power. Georget advises doctors: "Instead of. . . refusing to accord a lunatic the status ol king that he claims, prove to him that he is powerless and that you, who are anything but powerless, can do anything to him; perhaps he will reflect that actually, it may well be that he was in error. "18
So, this lirst contact, which I illustrated with the case ol M. Dupre, is inserted in the general context of asylum practice of this time, obvi- ously with many variants, in the form ol the delirium's omnipotence countered by the doctor's reality and omnipotence, which is accorded him by, precisely, the statutory imbalance ol the asylum. And all the internal discussions ol psychiatric discourse take place around this: some doctors think the doctor's power should be marked (rom time to time with violence, but also, on occasion, with the demand lor esteem and trust, in a compromise mode, with a sort of pact imposed on the patient. Then, on the other hand, there are psychiatrists who recom mend lear, violence, and threats in every case. Some see the fundamen- tal imbalance of power as sufficiently assured by the asylum system itself, its system of surveillance, internal hierarchy, and the arrangement of the buildings, the asylum walls themselves, carrying and defining the network and gradient of power. And then other psychiatrists consider rather that the doctor's own person, his prestige, presence, aggressive- ness, and polemical vigor all give him this mark. All these variants do not seem to me to be important with regard to the basic ritual, which I will show you that Leuret then develops throughout the treatment by clearly opting for the solution of the medical individualization of this
? surplus power conferred by the asylum, and by giving it the very direct lorm of aggression and violence.
One of the themes ol Dupre's delirium was belief m his sexual omnipotence, and that those around him in the asylum were women. Leuret asks Dupre if all the people around him really are women: "Yes" says Dupre. "Me too" asks Leuret. "Ol course, you too. " At this point Leuret takes hold ol Dupre and, "shaking him vigorously, asks him if this is a woman's arm. "19 Dupre is not very convinced, so to convince him more Leuret puts some "grains ol calomel" in his evening food and the unfortunate Dupre sullers violent diarrhea during the night. This enables Leuret to say to Dupre the next morning: "The only man in the asylum is so afraid ol the night that it's given him the runs. "20 This is how he marked his virile and physical supremacy, by producing this artificial sign of fear in Dupre.
We could cite a series ol elements like this throughout the treatment. Leuret puts Dupre in the shower. Dupre struggles, comes out with his delirious themes again, and says: "A woman is insulting me! " "A woman? " says Leuret, and directs the shower on him violently, deep in his throat, until the struggling Dupre recognizes that this really is a man's behavior, and "ends by agreeing that it is a man. "21 So, there is a ritual imbalance of power.
A second maneuver is what could be called the reuse of language. In Iact, Dupre did not recognize people for what they were, believed his doctor was his cook, and gave himsell a series of successive and simulta- neous identities, since he was "Destouches, Napoleon, Delavigne, Picard, Audrieux, Bernardin de Saint-Pierre, all at the same time. "22 Therefore--and this is what characterizes the second maneuver, which, with some overlap, more or less lollows the first chronologically-- Dupre must first of all relearn the names and be able to give each per- son his correct name: "As a result of being pestered, he becomes attentive and obeys. "2* He is made to repeat them until he knows them: "He must learn my name, those of the students, supervisors, and nurses. He must name all of us. "
Leuret makes him read books, recite verse, and forces him to speak the Latin he learned at school; he forces him to speak in Italian, which he had learned when he was in the army; he makes him "tell a story. "24
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Finally, on another occasion, he puts him in the bath, puts him under the shower as usual and, having done this, contrary to the usual practice, orders him to empty the bath. Now Dupre is not accustomed to obey ing orders. He is forced to obey this order and, when Dupre is emptying the bath with his pails, as soon as his back is turned, Leuret refills the bath again so that he can repeat the order a number of times until the mechanism of order and obedience are completely locked together. 2S
In this series of operations, which basically locus on language, it seems to me to be, first ol all, a matter of correcting the delirium ol polymorphous naming and ol constraining the patient to restore to each person the name by which he gets his individuality within the discipli nary pyramid ol the asylum. In a way which is quite typical, Dupre is not required to learn the names of the patients but rather those ol the doctor, of the doctor's students, and of the supervisors and nurses: the apprenticeship of naming will be an apprenticeship in hierarchy at the same time. Naming and showing respect, the distribution ol names and the way in which individuals are placed in a hierarchy, amount to one and the same thing.
You see too that he is required to read and recite verse, etcetera. This is, of course, a matter of occupying the mind, of diverting the delirious use of language, but it is equally a matter of re teaching the subject to use the lorms ol language of learning and discipline, the forms he learned at school, that kind ol artificial language which is not really the one he uses, but the one by which the school's discipline and system ol order are imposed. Finally, in the episode ol the bath that is tilled and he is made to empty on an indefinitely repeated order, it really is this language of orders, but this time of precise orders that the patient must be taught.
In general, I think what is at stake for Leuret here is making the patient accessible to all the imperative uses ol language: the use ol proper names with which one greets, shows one's respect and pays attention to others; school recital and ol languages learned; language of command. You can see that it is not at all a sort of re-apprenticeship-- that one might call dialectical--of the truth. It is not a question of show ing Dupre, on the basis of language, that his judgments were false; there is no discussion about whether or not it is right to consider everyone
? "Halcyons," as Dupre believes in his delirium. 26 It is not a matter of t urning the false into truth in a dialectic peculiar to language or discus- sion. In this game of orders and commands, it is simply a matter of putting the subject back in contact with language inasmuch as it is the carrier of imperatives; it is the imperative use of language that refers back to and is organized by a whole system of power. This is the lan- guage peculiar to the asylum; it fixes the names that define the asylum hierarchy; it is the master's language. It is this whole web of power that must be visible as reality behind the language one teaches. The language one re teaches to the patient is not the language through which he will be able to rediscover the truth; the language he is forced to re learn is a language in which the reality of an order, of a discipline, of a power imposed on him, must appear. This is what Leuret says, moreover, at the end ol these language exercises: "Here is M. Dupre who has become attentive [attention being the laculty of reality of course; M. F. ], he has entered into a relationship with me; I bring an action to bear on him, he obeys me. "27 "Attention," that is to say, a relationship with the doctor-- that is to say, with the person who gives orders and holds the power--a relationship that consists precisely in the doctor, who holds the power, performing an action in the form of an order. It is a language, therefore, which is transparent to this reality of power.
Here again we see that, in a sense, Leuret is much more subtle, and more of a perfectionist, than the psychiatrists of his time. Even so, what was called "moral treatment" at this time really was something like this, although less directly focused on the uses of language, of course, on that kind of rigged dialogue that was really a game of order and obedience, because, unlike Leuret, most psychiatrists put their faith in the internal mechanisms of the asylum institution rather than in this direct action of the psychiatrist as holder of power. 28 However, in the end, if you look at what the functioning of the asylum institution itself was for the psychi- atrists of this period, and where they sought the therapeutic character of the asylum's action, you see that the asylum was thought to be thera- peutic because it obliged people to submit to regulation, to a use of time, it forced them to obey orders, to line up, to submit to the regularity of certain actions and habits, to submit to work. And for the psychiatrists of the time, this whole system of order, both as orders given and, equally,
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as institutional regularities and constraints, is ultimately one of the major factors of asylum therapy. As Falret said in 1854, in a rather late text, "a strictly observed positive regulation, which fixes the use ol every hour of the day, forces every patient to react against the irregularity of his ten- dencies by submitting to the general law. Instead of being left to himself to follow the impulse ol his whim or his disordered will, the insane per- son is constrained to bend before a rule which is all the more powerful for being established for everyone. He is obliged to place himself in the hands of a foreign will and to make a constant effort on himself so as not to incur the punishments attached to infringements ol the rule. "29
Esquirol too thought that this system of the order, of the order given and the order followed, of the order as command and the order as regu larity, was the major effective agent of asylum treatment: "In such a home there is a movement, an activity, a whirl into which every person gradually enters; the most stubborn, defiant lypemaniac is forced to live outside of himself and, without being aware of it, is carried away by the general movement and example of others (. . . ); the maniac himsell, restrained by the harmony, order and rule ol the home, defends himself better against his impulses and abandons himself less to his eccentric activities. "^0 In other words, order is reality in the form of discipline.
The third maneuver in the apparatus of asylum therapy is what could be called the management or organization of needs. Psychiatric power ensures the advance of reality, the hold of reality on madness, through the management of needs, and even through the emergence of new needs, through the creation, maintenance and renewal of needs.
Here again, as a starting point, I think we can take the very subtle, very curious version that Leuret gives of this principle.
His patient, M. Dupre, did not want to work on the grounds that he did not believe in the value of money: "Money has no value; there is nothing but counterfeit money" said Dupre,51 since I, Napoleon, am the only person who has the right to mint coins. Consequently, the money given to him is counterfeit money: It's pointless to work! Now, the problem is precisely that of getting Dupre to understand the need for this money. One day he is forced to work, but he hardly does any work. At the end of the day it is suggested that he take a salary corresponding to his day's work; he refuses, giving as his reason that "money has no
? value. "52 He is seized and money forced into his pocket, but he is con- lined "without food or drink" tor the night and following day as pun- ishment for having resisted. A nurse however, who has been duly prepared in advance, is sent to him, and says: "Ah! Monsieur Dupre, how I pity you not eating! II I was not afraid of Monsieur Leuret's authority and punishment I would bring you something to eat; I am prepared to take this risk if you give me a little reward. " So in order to eat M. Dupre is obliged to take from his pocket three of the eight sous he had been given.
No doubt the meaning or, at least, the usefulness of money is already beginning to emerge for him on the basis of this artificially created need. He is well fed and, here again, a "dozen grains of calomel" are mixed in with "the vegetables eaten by M. Dupre who, quickly feeling the need to go to the lavatory, calls the servant and begs her to give him a free hand. A new pecuniary arrangement. "^ The following day Dupre goes to work and "seeks the price for his day's work. " This is, says Leuret, "the first reason- able act, made voluntarily and with reflection, that I have got from him. "M
Of course, we might wonder about this astonishing relationship Leuret establishes between money and defecation, but, as you can see, in the form of an imperative intervention. You can see that it is not a sym- bolic relationship of two terms--money-excrement--but a tactical rela- tionship between four terms: food, defecation, work, and money, and in which the fifth term, which runs through the four points of the tactical rectangle, is medical power. I think we see the relationship between money and defecation, which, as you know, was to have a well known future, emerging here for the first time and it is established through this game of medical power passing between these four terms. 55
It seems to me that generally, and here again in a particularly subtle, clever form, Leuret provided the formula of something very important in the system of psychiatric treatment at this time. Basically it involves establishing the patient in a carefully maintained state of deprivation: the patient's existence must be kept just below a certain average level. Hence a number of tactics, less subtle than Leuret's, but which also had a long future in the asylum institution and in the history of madness.
The clothing tactic: Ferrus, in his treatise Des alienes, from 1837I, pro vides a whole theory of asylum clothing, in which he says: "The clothing
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of the insane calls for special attention: almost all the mad are vain and proud. Before the onset of their illness, most of them led a life full of adventures; they often had wealth which their mental disorder led them to squander. "56 They therefore had fine clothes and jewelry, and in the asylum they recreate these costumes which are, at the same time, the sign of their old splendor, of their current poverty, and of the way in which their delirium operates: the mad must be deprived of all this. However, says Ferrus, we must not go too lar, because in asylums the mad are often allowed only torn and shameful clothes, which humiliate them too much and may excite their delirium or their disgust, and then they walk about naked. Something must be found between the orna- ments of delirium and obscene nudity, and this will be "clothing of unrefined and sturdy materials, but cut in a single style and kept clean, so as to moderate the puerile vanities ol madness. "*7
There is also the tactic of food, which must be plain, uniform, and not given on demand but in rations that, as lar as possible, are slightly less than the average. Furthermore, in addition to this general rationing of food within the asylum is added a policy ol punishment by withholding food, especially after the policy of no restraint, that is to say, after the sup pression of some of the contraptions of constraint:38 the great asylum punishment was deprivation of courses, fasting, etcetera.
Then there is the tactic of setting to work. Work is highly over- determined in the asylum system since, on the one hand, it ensures the necessary order, discipline, regularity, and constant occupation. Thus, very quickly, around the 1830s, work becomes obligatory withm asylums. The Sainte-Anne farm was initially an extension of the Bicetre hospital before taking over from it. 39 As Girard de Cailleux said when he was the director of the Auxerre hospital: "peeling and preparing veg etables is frequently a highly beneficial occupation in treatment. ",0 The interesting thing about this is that this work is not just imposed because it is a lactor in order, discipline, and regularity, but because it enables one to slip in a system of reward. Asylum work is not tree; it is paid, and this payment is not a supplementary favor but at the very heart of the function of work, for the remuneration must be sufficient to satisfy certain needs created by the underlying asylum deprivation: insufficient food, the absence of any extras (tobacco, a dessert, etcetera, must be paid for).
? I or the system of remuneration imposed with work to function, one has to have wanted, to have needed, and to have been deprived. So, these remunerations must be sufficient to satisfy the needs created by the basic deprivation and, at the same time, sufficiently low to remain below, oi course, normal and general remunerations.
Finally, and above all, the great deprivation developed by asylum dis- upline is, perhaps, quite simply deprivation of freedom. And you see how, in the psychiatrists of the first half of the nineteenth century, the iheory ol isolation gradually changes or, if you like, is deepened and completed. The theory of isolation I was talking about last week was basically demanded by the obligation to create a break between the ther- apeutic framework and the patient's family, the milieu in which the illness developed. Subsequently you see the birth of the idea that isola- tion has a supplementary advantage: it not only protects the family but gives rise to a new need in the patient, the need for freedom, of which he was previously unaware. Treatment can be developed on the basis of this artificially created need.
In the asylum form of this period, psychiatric power is therefore the creator of needs and the management of the deprivations it establishes.
