Here again we see that, in a sense, Leuret is much more subtle, and more of a perfectionist, than the
psychiatrists
of his time.
Foucault-Psychiatric-Power-1973-74
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. "
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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
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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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? 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
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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. There are a number of easily identifiable reasons for this administration of needs, this mstitutionalization of deprivation.
First, because the reality of the things one needs will be imposed through the game of needs; money, which previously had no value, will now acquire value when one is deprived and needs it to make up lor this deprivation. So, the reality of what one needs will be perceived through this game of deprivation. This is the first effect of the system.
The second effect is that the reality of an external world, which previously the omnipotence of madness was inclined to deny, takes shape through the asylum lack, and this reality beyond the asylum's walls is increasingly imposed as being inaccessible, but as inaccessible only during the time of madness. This external world will be real in basically two ways. On the one hand it will be the world of non lack m contrast to the asylum world, and so it will appear as a desirable reality. On the other hand, the external world will appear at the same time as
a world into which one is initiated by learning to react to one's own lack, to one's own needs: When you have learned that you must work to
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leed yourself, to earn money even to defecate, then you will be able to reach the outside world. The outside world is thus real as the world ol non lack in contrast to the asylum world of deprivations, and as the world to which the lack of the asylum will serve as a propaedeutic.
The third eflect of this policy of deprivation is that in this materially reduced status in comparison with the real world, with life outside the asylum, the patient will recognize his unsatisfied state, his reduced sta- tus, his lack of rights to anything, and the reason for his lack being that he is, quite simply, ill. It won't be the reality of the external world that he sees, but the reality of his own madness through the system ol depri- vations that have been established around him. In other words, he must learn that he must pay for his madness, because madness really exists as something by which he is affected; and madness will be paid lor by a general lack of existence, by this systematic deprivation.
Finally, the fourth eifect of the organization of asylum deprivation is that by learning deprivation, by learning that to make up lor this depri- vation he must work, concede certain things, submit to discipline, etcetera, the patient will learn that basically the care given him, the cure that one attempts to obtain for him, are not owed to him; he is obliged to get them through the efforts of obedience to work, discipline, and remunerated production; he will pay with his work lor the good that society does him. As Belloc said: ". . . ll society gives the insane the care they need, the latter must relieve it of the burden according the degree of their strength. "'1 In other words, the mad person learns the lourth aspect o( reality: as a patient he must provide for his own needs by his work so that society does not have to pay for them. So we arrive at the conclusion that, on the one hand, one pays for one's madness, but that, on the other hand, recovery is purchased. The asylum is precisely what makes one pay for one's madness with artificially created needs, and, at the same time, pay for one's treatment through a certain discipline, a certain output. The asylum, by establishing a deprivation, makes possi ble the creation of a currency with which one will pay for this cure. At bottom, what constitutes the asylum is the creation of the means of pay ment for the therapy on the basis of systematically created needs, the moral reward of madness. And you can see that the problem of money linked to the needs of madness, which has its price, and of the recovery,
? which must be purchased, is deeply inscribed in the psychiatric maneuver and the asylum apparatus.
Finally, the [fifth] apparatus is that of the statement of truth. This is lhe final phase, although in the therapy proposed by Leuret it is the penultimate episode: the patient must be got to tell the truth. You will say that if this is true, and if this episode is so important in the unfold- ing of the therapy, how could I say that the problem of truth was not posed in the practice of the classical treatment? 42 But you will see how this problem of truth is posed.
This is what Leuret did with Dupre. Dupre asserted that Paris was not Paris, that the king was not the king, that he himself was Napoleon, and that Paris was only the town of Langres that some people had disguised as Paris. '3 According to Leuret, there is only one thing to do, which is to take his patient to Paris, and, in fact, he organizes a walk through Paris under the direction of an intern. He shows him the differ- ent monuments of Paris, and says to him: "Do you not recognize Paris? -- No, no, Dupre replies, we are here in the town of Langres. Several of the things in Paris have been copied. "44 The intern pretends not to know his way and asks Dupre to guide him to Place Vendome. Dupre finds it eas- ily and the intern then says to him: "So we are in Paris since you can find Place Vendome so well! --No, I recognize Langres disguised as Paris. "0 Dupre is taken back to the hospital at Bicetre where he refuses to recog nize that he has visited Pans, and, "since he persists in his refusal, he is put in the bath and cold water is poured over his head. Then he agrees to anything one likes," and that Paris really is Paris. However, out of the bath "he returns to his mad ideas. He is made to undress again and the affusion is repeated: he gives way again," recognizes that Paris is Paris,
but, as soon as he is dressed again "he maintains he is Napoleon. A third affusion corrects him; he gives way and goes to bed. "'6
However, Leuret is not fooled and is fully aware that these kinds of exercises are not sufficient. He moves on to an exercise at a higher level, as it were: "The following day I have him brought to me, and after some words about his trip the day before, I ask him. Your name? --I have been using another; my real name is Louis-Napoleon Bonaparte. --Your profession? -- Lieutenant discharged from the 19th line; but I must explain. Lieutenant means army chief. --Where were you born? --Ajaccio, or, if you like,
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Paris. --I see from this certilicate that you were insane at Charenton. --I was not insane at Charenton. I was at my chateau of Samt-Maur for nine years. Displeased with his answers, I have him taken to the bath; under the shower I give him a newspaper and want him to read out aloud. He obeys. I question him and satisfy mysell that he has understood what he has read. Then, after asking out loud if the shower tank is quite full, I have a notebook given to Dupre on which I order him to give written answers to the questions I put to him. Your name? --Dupre. --Your profession? --Lieutenant. --Your place of birth? --Paris. --How long were you at Charenton? --Nine years. --And at Saint Yon? --Two years and two months. --How long have you been in the section for the treatment oi the insane at Bicetre? --Three months; lor three years I have been incurably insane. --Where did you go yesterday? --In the town ol Paris. --Do the bears talk? --No. "4/ Progress, you see, compared with the earlier episode. And now we reach the third stage in the exercise of the statement of the truth, which is a crucial moment as you will see. "From his answers we can see that Monsieur Dupre is in a sort ol uncertainty between madness and reason "^ He has been insane lor fifteen years! And, Leuret thinks, "now is the time to require him to make a decisive reso lution, that ol writing the story ol his life. "'19 He only carries it out after several showers and "devotes the rest ol the day and the lollowing day to writing his story, with many details. He knows and writes everything that a man can recall ol his childhood. He gives the names ol his lodg mgs and of the schools where he studied, of his teachers and fellow stu- dents in great numbers. In his whole account there is not a lalse thought or a word out of place. "so
The problem arises here, which I am quite unable to resolve at pre sent, of the way in which the autobiographical account was actually introduced into psychiatric practice, and criminological practice, around 1825 to 18^0, and how, in lact, the account of one's own life came to be an essential component, with several uses, in all those processes of taking charge ol individuals and disciplining them. Why did telling one's life story become an episode within the disciplinary enterprise? How was recounting one's past, how was the memory of childhood, able to find a place within this? I don't really know. Anyway,
? concerning this maneuver of the statement of the truth, I would like to say that it seems to me we can accept certain things.
First of all, you can see that the truth is not what is perceived. Basically, when M. Dupre was taken to see Pans, it was not so much in order that his perception revealed to him that Paris really was there, and that it was Pans. This is not what was asked of him; we know full well that so far as he will perceive anything, he will perceive Paris as the imitation of Paris. What is asked of him--and this is how the statement of the truth becomes effective--is that he avow it. It does not have to be perceived, it has to be said, even if it is said under the constraint of the shower. The fact alone of saying something that is the truth has a func- tion in itself; a confession, even when constrained, is more effective in the therapy than a correct idea, or an idea with exact perception, which remains silent. So, the statement of the truth has a performative charac ter in the game of the cure.
Second, I think we should note that the essential point of the truth, what Leuret is especially attached to, is in part, of course, that Paris is Paris, but what he wants above all is that his patient pin himself to his own history. What is required is that the patient recognizes himself in a kind of identity constituted by certain episodes in his life. In other words, it is in this recognition of certain biographical episodes that the patient must firstly state the truth; the most effective statement of the truth will not bear on things, but rather on the patient himself.
Finally, third, I think we should notice that this biographical truth which is asked of the patient, and the confession of which is so effective in the therapy, is not so much the truth that he could say about himself, at the level of his actual experience, but a truth imposed on him in a canon ical form: cross examination of identity, the recall of certain episodes already known to the doctor, acknowledgement that he really was at Charenton at a given moment, that he really was ill between certain dates, etcetera? 1 A biographical corpus is established from the outside through the system of family, employment, civil status, and medical observation. Ultimately the patient must own to this entire corpus of identity, and it has to be one of the most fruitful moments of the therapy when he does so; it is when this does not take place that we must despair of the illness.
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I will quote, just for the beauty of the dialogue, from another of Leuret's cases. It is the story of a woman whom he said he would never be able to cure. And the fact that he could never cure this woman is attributed precisely to her inability to own to this biographical schema that carries her identity. Here is the dialogue that, according to Leuret, reveals her incurability: "How are you madam? --The person of myself is not a Mrs. (une dame), please call me Miss. --I do not know your name; would you like to tell me? --The person of myself does not have a name: she wishes that you do not write. --I would however really like to know what to call you, or rather what your name was formerly. --I understand what you mean. It was Catherine X, one must speak no more of what took place. The person of myself has lost her name, she gave it on enter ing Salpetriere. --How old are you? --The person of myself has no age. -- But this Catherine X you were talking about, how old is she? --I do not know (. . . )--II you are not the person about whom you speak, perhaps you are two people in one? --No, the person of myself does not know the one who was born in 1799- Maybe it is that lady whom you see there (. . . )--What have you done, and what has happened to you since you have been the person of yourself? --The person of myself has lived in the clinic for ( . . . ) . Physical and metaphysical experiments have been made on her and are still being made on her (. . . ) .
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
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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. "
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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
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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. There are a number of easily identifiable reasons for this administration of needs, this mstitutionalization of deprivation.
First, because the reality of the things one needs will be imposed through the game of needs; money, which previously had no value, will now acquire value when one is deprived and needs it to make up lor this deprivation. So, the reality of what one needs will be perceived through this game of deprivation. This is the first effect of the system.
The second effect is that the reality of an external world, which previously the omnipotence of madness was inclined to deny, takes shape through the asylum lack, and this reality beyond the asylum's walls is increasingly imposed as being inaccessible, but as inaccessible only during the time of madness. This external world will be real in basically two ways. On the one hand it will be the world of non lack m contrast to the asylum world, and so it will appear as a desirable reality. On the other hand, the external world will appear at the same time as
a world into which one is initiated by learning to react to one's own lack, to one's own needs: When you have learned that you must work to
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leed yourself, to earn money even to defecate, then you will be able to reach the outside world. The outside world is thus real as the world ol non lack in contrast to the asylum world of deprivations, and as the world to which the lack of the asylum will serve as a propaedeutic.
The third eflect of this policy of deprivation is that in this materially reduced status in comparison with the real world, with life outside the asylum, the patient will recognize his unsatisfied state, his reduced sta- tus, his lack of rights to anything, and the reason for his lack being that he is, quite simply, ill. It won't be the reality of the external world that he sees, but the reality of his own madness through the system ol depri- vations that have been established around him. In other words, he must learn that he must pay for his madness, because madness really exists as something by which he is affected; and madness will be paid lor by a general lack of existence, by this systematic deprivation.
Finally, the fourth eifect of the organization of asylum deprivation is that by learning deprivation, by learning that to make up lor this depri- vation he must work, concede certain things, submit to discipline, etcetera, the patient will learn that basically the care given him, the cure that one attempts to obtain for him, are not owed to him; he is obliged to get them through the efforts of obedience to work, discipline, and remunerated production; he will pay with his work lor the good that society does him. As Belloc said: ". . . ll society gives the insane the care they need, the latter must relieve it of the burden according the degree of their strength. "'1 In other words, the mad person learns the lourth aspect o( reality: as a patient he must provide for his own needs by his work so that society does not have to pay for them. So we arrive at the conclusion that, on the one hand, one pays for one's madness, but that, on the other hand, recovery is purchased. The asylum is precisely what makes one pay for one's madness with artificially created needs, and, at the same time, pay for one's treatment through a certain discipline, a certain output. The asylum, by establishing a deprivation, makes possi ble the creation of a currency with which one will pay for this cure. At bottom, what constitutes the asylum is the creation of the means of pay ment for the therapy on the basis of systematically created needs, the moral reward of madness. And you can see that the problem of money linked to the needs of madness, which has its price, and of the recovery,
? which must be purchased, is deeply inscribed in the psychiatric maneuver and the asylum apparatus.
Finally, the [fifth] apparatus is that of the statement of truth. This is lhe final phase, although in the therapy proposed by Leuret it is the penultimate episode: the patient must be got to tell the truth. You will say that if this is true, and if this episode is so important in the unfold- ing of the therapy, how could I say that the problem of truth was not posed in the practice of the classical treatment? 42 But you will see how this problem of truth is posed.
This is what Leuret did with Dupre. Dupre asserted that Paris was not Paris, that the king was not the king, that he himself was Napoleon, and that Paris was only the town of Langres that some people had disguised as Paris. '3 According to Leuret, there is only one thing to do, which is to take his patient to Paris, and, in fact, he organizes a walk through Paris under the direction of an intern. He shows him the differ- ent monuments of Paris, and says to him: "Do you not recognize Paris? -- No, no, Dupre replies, we are here in the town of Langres. Several of the things in Paris have been copied. "44 The intern pretends not to know his way and asks Dupre to guide him to Place Vendome. Dupre finds it eas- ily and the intern then says to him: "So we are in Paris since you can find Place Vendome so well! --No, I recognize Langres disguised as Paris. "0 Dupre is taken back to the hospital at Bicetre where he refuses to recog nize that he has visited Pans, and, "since he persists in his refusal, he is put in the bath and cold water is poured over his head. Then he agrees to anything one likes," and that Paris really is Paris. However, out of the bath "he returns to his mad ideas. He is made to undress again and the affusion is repeated: he gives way again," recognizes that Paris is Paris,
but, as soon as he is dressed again "he maintains he is Napoleon. A third affusion corrects him; he gives way and goes to bed. "'6
However, Leuret is not fooled and is fully aware that these kinds of exercises are not sufficient. He moves on to an exercise at a higher level, as it were: "The following day I have him brought to me, and after some words about his trip the day before, I ask him. Your name? --I have been using another; my real name is Louis-Napoleon Bonaparte. --Your profession? -- Lieutenant discharged from the 19th line; but I must explain. Lieutenant means army chief. --Where were you born? --Ajaccio, or, if you like,
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Paris. --I see from this certilicate that you were insane at Charenton. --I was not insane at Charenton. I was at my chateau of Samt-Maur for nine years. Displeased with his answers, I have him taken to the bath; under the shower I give him a newspaper and want him to read out aloud. He obeys. I question him and satisfy mysell that he has understood what he has read. Then, after asking out loud if the shower tank is quite full, I have a notebook given to Dupre on which I order him to give written answers to the questions I put to him. Your name? --Dupre. --Your profession? --Lieutenant. --Your place of birth? --Paris. --How long were you at Charenton? --Nine years. --And at Saint Yon? --Two years and two months. --How long have you been in the section for the treatment oi the insane at Bicetre? --Three months; lor three years I have been incurably insane. --Where did you go yesterday? --In the town ol Paris. --Do the bears talk? --No. "4/ Progress, you see, compared with the earlier episode. And now we reach the third stage in the exercise of the statement of the truth, which is a crucial moment as you will see. "From his answers we can see that Monsieur Dupre is in a sort ol uncertainty between madness and reason "^ He has been insane lor fifteen years! And, Leuret thinks, "now is the time to require him to make a decisive reso lution, that ol writing the story ol his life. "'19 He only carries it out after several showers and "devotes the rest ol the day and the lollowing day to writing his story, with many details. He knows and writes everything that a man can recall ol his childhood. He gives the names ol his lodg mgs and of the schools where he studied, of his teachers and fellow stu- dents in great numbers. In his whole account there is not a lalse thought or a word out of place. "so
The problem arises here, which I am quite unable to resolve at pre sent, of the way in which the autobiographical account was actually introduced into psychiatric practice, and criminological practice, around 1825 to 18^0, and how, in lact, the account of one's own life came to be an essential component, with several uses, in all those processes of taking charge ol individuals and disciplining them. Why did telling one's life story become an episode within the disciplinary enterprise? How was recounting one's past, how was the memory of childhood, able to find a place within this? I don't really know. Anyway,
? concerning this maneuver of the statement of the truth, I would like to say that it seems to me we can accept certain things.
First of all, you can see that the truth is not what is perceived. Basically, when M. Dupre was taken to see Pans, it was not so much in order that his perception revealed to him that Paris really was there, and that it was Pans. This is not what was asked of him; we know full well that so far as he will perceive anything, he will perceive Paris as the imitation of Paris. What is asked of him--and this is how the statement of the truth becomes effective--is that he avow it. It does not have to be perceived, it has to be said, even if it is said under the constraint of the shower. The fact alone of saying something that is the truth has a func- tion in itself; a confession, even when constrained, is more effective in the therapy than a correct idea, or an idea with exact perception, which remains silent. So, the statement of the truth has a performative charac ter in the game of the cure.
Second, I think we should note that the essential point of the truth, what Leuret is especially attached to, is in part, of course, that Paris is Paris, but what he wants above all is that his patient pin himself to his own history. What is required is that the patient recognizes himself in a kind of identity constituted by certain episodes in his life. In other words, it is in this recognition of certain biographical episodes that the patient must firstly state the truth; the most effective statement of the truth will not bear on things, but rather on the patient himself.
Finally, third, I think we should notice that this biographical truth which is asked of the patient, and the confession of which is so effective in the therapy, is not so much the truth that he could say about himself, at the level of his actual experience, but a truth imposed on him in a canon ical form: cross examination of identity, the recall of certain episodes already known to the doctor, acknowledgement that he really was at Charenton at a given moment, that he really was ill between certain dates, etcetera? 1 A biographical corpus is established from the outside through the system of family, employment, civil status, and medical observation. Ultimately the patient must own to this entire corpus of identity, and it has to be one of the most fruitful moments of the therapy when he does so; it is when this does not take place that we must despair of the illness.
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I will quote, just for the beauty of the dialogue, from another of Leuret's cases. It is the story of a woman whom he said he would never be able to cure. And the fact that he could never cure this woman is attributed precisely to her inability to own to this biographical schema that carries her identity. Here is the dialogue that, according to Leuret, reveals her incurability: "How are you madam? --The person of myself is not a Mrs. (une dame), please call me Miss. --I do not know your name; would you like to tell me? --The person of myself does not have a name: she wishes that you do not write. --I would however really like to know what to call you, or rather what your name was formerly. --I understand what you mean. It was Catherine X, one must speak no more of what took place. The person of myself has lost her name, she gave it on enter ing Salpetriere. --How old are you? --The person of myself has no age. -- But this Catherine X you were talking about, how old is she? --I do not know (. . . )--II you are not the person about whom you speak, perhaps you are two people in one? --No, the person of myself does not know the one who was born in 1799- Maybe it is that lady whom you see there (. . . )--What have you done, and what has happened to you since you have been the person of yourself? --The person of myself has lived in the clinic for ( . . . ) . Physical and metaphysical experiments have been made on her and are still being made on her (. . . ) .
