The quotation comes from his article: "De la construction et de la
direction
des asiles d'alienes" Annales d'hygiene publique et de medecine legate, vol.
Foucault-Psychiatric-Power-1973-74
] See, L.
Amard, Traite analytique de la folie et des moyens de la guerir (Lyon: printed by Ballanche, 1807)
pp. 80 93; J. Guislain, Traite sur Valienation mentale, vol. I, book IV, and, Moyens diriges sur le systeme nerveux cerebral. De la rotation (Amsterdam: Van der Hey, 1826) p. 374 and p. 404; C. Buvat Pochon, Les Traitemenls de choc d'autrejois en psychiatric Leurs liens avec les therapeu- tiques modernes, Medical thesis, Paris, no. 1262 (Paris: Le Francois, 1939). See Histoire de la
Jolie, pp. 341 342; Madness and Civilisation, pp. 176-177.
8. While he was alive, Leuret had to defend himself from critics who condemned his practice
as, in his own words, "retrograde and dangerous" (DM traitement moral de lafolie, p. 68). His main opponent was E. S. Blanche, in his paper to the royal Academy of medicine, Du dan-
ger des rigueurs corporelles dans le traitement de lajolie (Paris: Gardembas, 1839), as well as in his short work, De Fetal actuel du traitement de lajolie en France (Paris: Gardembas, 1840). These polemics were echoed in Leuret's obituary notices: U. Trelat, "Notice sur Leuret" Annales d'hygiene publique et de medecine legale, vol. 45, 1851, pp. 241-262; and A. Brierre de Boismont, "Notice biographique sur M. F. Leuret" Annales medico-psychologiques, 2nd series, vol. III,July 1851, pp. 512 527.
9. It is Observation XXII: "Bearers ol imaginary titles and ranks" Du traitement moral de la folie, pp. 418-462.
10. 11. 12.
Ibid. pp. 421-424.
Ibid. p. 429.
P. Pinel, Traile medico-philosophique, op. cit. , section II, ? ix: "Intimider Pahene, mais ne point se permettre aucun acte de violence" p. 61; A Treatise on Insanity, "Intimidation too often associated with violence" pp. 64-65.
13. J. E. D. Esquirol, "De la folie" (1816) in Des maladies mentales vol. 1, p. 126; Mental Maladies, "Insanity," p. 76.
14. See above note 3. Already, for J. Guislain, this was one ol the advantages of "isolation in the treatment oi insanity": "Based on a leeling of dependence that he makes the insane person feel ( . . . ) lorced to conform to a loreign will" Traile sur I'alienation mentale, vol. I, p. 409.
19 December 1973 169
? 170 PSYCHIATRIC POWER
15- F. Leuret, Du irailemenl moral de lajolie, p. 422: "Dupre is a name oi convenience, a name oi disguise; his true name, as we well know, is Napoleon. "
16. Ibid. p. 423: "The distinctive sign of his Halcyon status is his constant ability to enjoy the pleasures of love. "
17. Ibid. p. 423: "Only he in the home is a man; all the others are women. "
18. EJ. Georgct, De lafolie. Considerations sur cette maladie, p. 284.
19. F. Leuret, Du traitement moral de lafolie, p. 429.
20. Ibid. p. 430. 21. Ibid. p. 430. 22. Ibid. p. 422. 23. Ibid. p. 431.
24. Ibid. p. 431. 25. Ibid. p. 432. 26. Ibid. p. 422.
27. Ibid. , p. 432.
28. Leuret defined his treatment thus: "I understand by moral treatment oi madness the reasoned use o( all means that act directly on the intelligence and passions of the insane" ibid. p. 156.
29. J. P. Falret, Des maladies mentales et des asiles d'alienes, p. 690.
30.
31.
32. 33. 34. 35-
J. E. D. Esquirol, "De la folie" (1816) in Des maladies mentales, vol. I, p. 126; Mental Maladies, "Insanity," p. 76.
F. Leuret, Du traitement moral de lajolie, p. 424.
Ibid. p. 434.
Ibid. p. 435.
Ibid.
Michel Foucault is alluding here to the "money-excrement" relationship, which had a great
iuture in psychoanalytic literature. Mentioned by Freud in a letter to Fliess of 22 December
1897 (French translation in La Naissance de la psychanalyse. Lettres a Wilhelm Fliess, 1887-1902, trans. A Berman [Paris: P. U. F. , 19561 p. 212; English translation, The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887-190/I, trans. J. M. Masson [Cambridge, Mass. : The Belknap Press of Harvard University Press, 1985] p. 288), this symbolic relationship
is developed in the theory of anal eroticism. See, S. Freud, "Charakter und Analerotik"
( 1 9 0 8 ) in Gesammelle Werke | hereafter, GW] (Frankfurt: S. Fischer Verlag, 1941) vol. VII,
pp. 201 209; English translation "Character and Anal Eroticism" in The Standard Edition
oj the Complete Psychological Works of Sigmund Freud | hereaiter Standard Edition], trans, under General Editorship of James Strachey (London: The Hogarth Press, 1953 1974) vol. 9; "Uber Triebumsetzung insbesondere der Analerotik" (1917) in GW (1946) vol. X,
pp. 401 410; "On Transformations of Instinct as Exemplified in Anal Eroticism," Standard Edition, vol. 17. See also, E. Borneman, Psychoanalyse des Geldes. Eine kritische Untersuchungpsy- choanalytisher Geldtheorien (Frankiurt: Suhrkamp Verlag, 1973); French translation, Psychanalyse de Vargent. Une recherche critique sur les theories psychanalytiques de I'argent, trans. D. Guerineau (Paris: P. U. F. , 1978); English translation, The Psychoanalysis of Money
(New York: Urizen Books, 1976).
G. Ferrus, Des alienes. Considerations sur I'etat des maisons qui leur sont destinees, lanl en France qu'en Anglelerre; sur le regime hygienique et moral auquel ces malades doivent etre soumis; sur quelques questions de medecine legale el de legislation relatives a leur elat civil (Pains: printed by Mme. Huzard, 1834) p. 234.
36.
37. Ibid.
38. See above, lecture of 5 December 1973, note 18.
39. The "Sainte Anne iarm" derived irom the donation made by Anne of Austria in 1651 for
the construction of an establishment for taking in the sick during epidemics. Partially con structed, the land remained under cultivation. In 1833, Guillaume Ferrus (1784-1861), head doctor at Bicetre, decided to use it to put to work convalescents and able bodied incurables irom the three sections of the asylum. A decision oi the commission set up on 27 December i860 by the prefect Haussmann to "study the improvements and reforms to be carried out in the service for the insane of the Seine department" marked the end oi the iarm. The construction of an asylum, begun in 1863 according to the plans established
? under the directive oi Girard de Cailleux, was inaugurated on 1 May 1867. See, C. Guesstel,
AsHe d'alienes de Saintc-Anne a Paris (Versailles: Aubert, 1880).
'lO. Henri Girard de Cailleux (1814 1884) iilled the posts of head doctor and director ol the
Auxerre insane asylum lrom 20 June 1840 until his appointment in i860 as Inspector General for the Seine service for the insane.
The quotation comes from his article: "De la construction et de la direction des asiles d'alienes" Annales d'hygiene publique et de medecine legate, vol. 40, 1st Part, July 1848, p. 30.
11. H. Belloc, Les Asiles d'alienes transformed en centres d'exploitation rurale, moyen d'exonerer en tout ou en partie les departements des depenses c/u'ils font pour leurs alienes en augmentant le bien-etre de ces maladcs, et en les rapprochant des conditions d'existence de Vhomme en societe (Pans: Bechet, 1862) p. 15.
|2. Foucault is alluding here to several earlier propositions: (a) In the lecture of 7 November 1973 he argues that the doctor's therapeutic process does not require "any discourse ol truth" (above, p. 10); ( b ) in that of 14 November Foucault claims that the "game ol truth, within delirium and of delirium, will be completely suppressed in the psychiatric practice that commences at the start oi the nineteenth century" (above, p. 35); and (c) in the lec- ture of 12 December 1973 he concludes that in psychiatric power the question of truth is never posed (above, p. 134).
15. F. Leu ret, Du traitement moral de lajolie, p. 423 and pp. 435 436.
14. Ibid.
15. Ibid. 16. Ibid. 17. Ibid. 18. Ibid. 19. Ibid.
50. Ibid.
51. Ibid,
p. 438.
p. 439.
p. 440.
pp. 440 442. p. 444.
pp. 444 445.
pp. 441 442.
52. F. Leuret, Fragments psychologiques sur lajolie, pp. 121-124.
53. T. Leuret, Du traitement moral de la /olie, pp. 449450.
54. Ibid. p. 449.
55. Ibid. p. 451.
56. Ibid. p. 425: "He does not dream of leaving the hospital and no longer fears the treatments with which he is threatened or that he has been made to undergo. "
57. Ibid. p. 426: "A red hot iron was applied once to the top of his head, and twice to the nape of his neck. "
58. Ibid. p. 429: "He then asks me ii it is a question oi his treatment; in which case he will resign himself to whatever I would like to do. "
59. Ibid. p. 430.
6 0 . Ibid. p. 453: "In a very short letter he let pass a dozen spelling mistakes, and it would have
been better if he had not aspired for a job of this kind. "
61. Ibid. p. 454: "I let the struggle get under way; M. Dupre detended himseli the best
he could, then, when he was too greatly pressed, I came to his aid, taking the role oi
conciliator. "
62. Ibid. p. 461.
19 December 1973 171
? eight
9 JANUARY 1974
Psychiatric power and the practice of "direction ". ^ The game of "reality" in the asylum. ^ The asylum, a medically demarcated
space and the question of its medical or administrative direction. ^ The tokens of psychiatric knowledge: (a) the technique of questioning; (b) the interplay of medication and punishment; (c) the clinical presentation. ^ Asylum "microphysics ofpower. " ^ Emergence of the Psyfunction and of neuropathology. ^ The triple destiny of psychiatric power.
I HAVE SHOWN THAT psychiatric power in its both archaic and elementary form, as it functioned in the proto-psychiatry of the first thirty or forty years of the nineteenth century, essentially operated as a supplement of power given to reality.
This means, first of all, that psychiatric power is above all a certain way of managing, of administering, before being a cure or therapeutic intervention: it is a regime. Or rather, it is because and to the extent that it is a regime of isolation, regularity, the use of time, a system of measured deprivations, and the obligation to work, etcetera, that certain therapeutic effects are expected from it.
Psychiatric power is a regime, but at the same time--and I have stressed this aspect--it seems to me that in the nineteenth century it is a struggle against madness conceived as a will in revolt, as an unbounded will, whatever nosographic analysis or description may ultimately be given of its phenomena. Even in a case of delirium, it is the will to
? 17xl PSYCHIATRIC POWER
believe in that delirium, the will to assert that delirium, the will at the heart of that assertion of the delirium, which is the target ol the strug gle that runs through and drives the psychiatric regime throughout its development.
Psychiatric power is therefore mastery, an endeavor to subjugate, and my impression is that the word that best corresponds to this function ing of psychiatric power, and which is found in all the texts Irom Pinel to Leuret,1 the term that recurs most frequently and appears to me to be entirely typical of this enterprise of both regime and mastery, of regu- larity and struggle, is the notion of "direction" (direction)* The history of this notion should be studied, because it did not originate in psychiatry--lar lrom it. In the nineteenth century this notion still carries a whole set of connotations arising lrom religious practice. For three or four centuries before the nineteenth century, "spiritual direction" (direction de conscience) defined a general field of techniques and objects. 2 At a certain point, some of these techniques and objects, along with this practice of direction, were imported into the psychiatric iield. It would be a history worth doing. Anyway, there's a track here: the psychiatrist is someone who directs the operations of the hospital and who directs individuals.
Just to indicate not only its existence, but also the clear awareness of this practice on the part of psychiatrists themselves, I will quote a text from 1861 which comes from the director of the Saint-Yon asylum: "In the asylum I direct, I praise, reward, reprimand, command, constrain, threaten, and punish every day; and for why? Am I not then a madman myself? And everything I do, my colleagues all do likewise; all, without exception, because it derives from the nature of things. "3
What is the aim of this "direction"? This is the point I got to last week. I think it is basically to give reality a constraining power. This means two things.
First of all it means making this reality inevitable and, as it were, commanding, making it function like power, giving it that supplement
* Nineteenth century English psychiatrists, and English translations of French psychiatrists, such as Pinel, generally use "management," or "moral treatment" etcetera, where the French use "direction," although the latter is occasionally used as well. Since Foucault explicitly draws attention to the term and its history I have left it as direction in English.
? oi vigor which will enable it to match up to madness, or to give it that extra reach which will enable it to get through to those individuals who are mad who flee it or turn away from it. So it is a supplement given to reality.
But at the same time, and this is the other aspect of psychiatric power, its aim is to validate the power exercised within the asylum as being quite simply the power of reality itself. What does this intra-asylum power claim to bring about by the way it functions within this planned space, and in the name of what does it justify itself as power? It justifies itself as power in the name of reality itself. Thus you find both the principle that the asylum must function as a closed milieu, absolutely independent ol pressures like those exerted by the family, etcetera--an absolute power therefore--and, at the same time, the principle that this asylum, in itseH, entirely cut off, must be the reproduction of reality itself. Its buildings must be as similar as possible to ordinary dwellings; relationships between those within the asylum must be like those between citizens; the general obligation to work must be represented within the asylum, and the system of needs and the economy must be reactivated. So, there is the reduplication of the system of reality within the asylum.
So, giving power to reality and founding power on reality is the asylum tautology.
But in fact, and more exactly, what is actually introduced within the asylum in the name of reality? What is given power? What is it exactly that is made to function as reality? What is given the supplement of power, and on what type of reality is asylum power lounded? This is the problem, and it was in an attempt to disentangle it a little that last week I quoted the long account of a cure that appeared to me to be absolutely exemplary of how psychiatric treatment functions.
I think we can identify precisely how the game of reality within the asylum is introduced and how it functions. I would like to summarize schematically what emerges from it quite naturally. What basically can we identify as reality in "moral treatment" in general, and in the case we have been considering in particular?
I think it is, first of all, the other's will. The reality the patient must con- front, the reality to which his attention--distracted by his insubordinate
9 January 1974 175
? 176 PSYCHIA TRIC POWER
will--must submit and by which he must be subjugated, is first of all the other as a center of will, as a source of power, the other inasmuch as he has, and will always have, greater power than the mad person. The greater part of power is on the other's side: the other is always the holder of a greater part of power in relation to the mad person's power. This is the first yoke of reality to which the mad person must be subjected.
Second, we found another type, or another yoke of reality to which the mad person is subjected. This was shown by the apprenticeship of the name, of the past, the obligation of anamnesis--you remember [the way in which] Leuret required and got his patient to recount his life, under the threat of eight pails of water. ^ So: name, identity, the biogra phy recited in the first person, and recognized consequently in the rit- ual of something close to confession. This is the reality imposed on the mad person.
The third reality is the reality of the illness itself or, rather, the ambiguous, contradictory, vertiginous reality of the madness, since, on the one hand, in a moral cure it is always a question of showing the mad person that his madness is madness and that he really is ill, thus forcing him to abandon any possible denial of his own madness and subjecting him to the inflexibility of his real illness. And then, at the same time, he is shown that at the heart of his madness is not illness but fault, wicked- ness, lack of attention, presumption. At every moment--you remember M. Dupre's cure--Leuret requires his patient to acknowledge that, in the past, he was at Charenton and not in his chateau of Saint-Maur,5 that he really is ill, and that his status is that of a patient. This is the truth to which the subject must be subjected.
However, at the same time, when he is subjecting him to a shower, Leuret actually says to M. Dupre: But I am not doing this in order to care for you, because you are ill; I am doing this because you are bad, because you harbor an unacceptable desire. 6 And you know how far Leuret pushed the tactic, since he goes so far as to force his patient to leave so that he does not enjoy his illness within the asylum, and so that he does not shelter the symptoms of his illness in the surrounds of the asylum. Consequently, in order to deny illness its status as illness, the bad desire within it and sustaining it, must be driven out. So it is
? necessary both to impose the reality of the illness and also to impose on the consciousness of the illness the reality of a desire that is not ill, which sustains and is the very root of the illness. Leuret's tactic broadly revolves around this reality and unreality of the illness, this reality and unreality of madness, and this constitutes the third yoke of reality to which, generally speaking, patients are subjected in moral treatment.
Finally, the fourth form of reality is everything corresponding to the techniques concerning money, need, the necessity to work, the whole system of exchanges and services, and the obligation to provide for his needs.
These four elements--the other's will and the surplus power situated definitively on the side of the other; the yoke of identity, of the name and biography; the non-real reality of madness and the reality of the desire which constitutes the reality of madness and nullifies it as madness; and the reality of need, exchange, and work--are, I think, the kind of nervures of reality which penetrate the asylum and constitute the points within the asylum on which its system is articulated and on the basis of which tactics are formed in the asylum struggle. Asylum power is really the power exerted to assert these realities as reality itself.
It seems to me that the existence of these four elements of reality, or the filtering that asylum power carries out in reality in order to let these four elements penetrate the asylum, is important for several reasons.
The first is that these four elements introduce a number of questions into psychiatric practice that stubbornly recur throughout the history of psychiatry. First, they introduce the question of dependence on and sub- mission to the doctor as someone who, for the patient, holds an inescapable power. Second, they also introduce the question, or practice rather, of confession, anamnesis, of the account and recognition of one- self. This also introduces into asylum practice the procedure by which all madness is posed the question of the secret and unacceptable desire that really makes it exist as madness. And finally, fourth, they intro duce, of course, the problem of money, of financial compensation; the problem of how to provide for oneself when one is mad and how to establish the system of exchange within madness which will enable the mad person's existence to be financed. You see all of this taking shape, already fairly clearly, in these techniques of proto-psychiatry.
9 January 1974 177
? 178 PSYCHIATRIC POWER
I think these elements are equally important, not only through these techniques, through these problems deposited in the history of psychia- try, in the corpus of its practices, [but also]* because through these elements we see the definition of the cured individual. What is a cured individual if not precisely someone who will accept these four yokes of dependence, of confession, of the unacceptability of desire, and of money? The cure is the process of daily, immediate physical subjection carried out in the asylum that constitutes the cured individual as the bearer of a fourfold reality. And this fourfold reality ol which the indi- vidual must be the bearer, that is to say, the receiver, is the law of the other, self-identity, the unacceptability of desire, and the insertion of need in an economic system. These are the four elements which, when they have been effectively taken on by the individual treated, will qua! ify him as a cured individual. The fourfold system of adjustment,1 which cures by itself, through its effectuation, restores the individual.
I would now like to deal with another set of consequences that I would like to develop further and which will be the object of my remarks. This fourfold subjection is brought about therefore in a disci- plinary space, and thanks to this disciplinary space. To that extent, and until now, what I have been able to tell you about the asylum does not differ that much from what we could have said about barracks, schools, orphanages, and prisons for example. Nevertheless, there is a funda- mental difference between these establishments or institutions and the asylum. The difference is, of course, that the asylum has a medical stamp.
How did the things I have been talking about--the general regime of the asylum, the technique of struggle, and the extra power given to real ity in this intra asylum struggle--concern medicine, and why was a doc- tor needed? What is the meaning of the hospital's medical status? What is the meaning of the fact that, at a certain moment, and precisely at the start of the nineteenth century, the mad had to be put not only in a dis- ciplinary place, but, what's more, in one that was medical? In other words, why was a doctor needed to convey this supplementary power of reality?
* (Recording:) it is equally important
' The manuscript has "subjection" rather than "adjustment. "
? Concretely, again, you know that until the end oi the eighteenth century the places in which the mad were put, the places which served lo disciplinanze their mad existence, were not medical places: neither Bicetre,7 nor Salpetnere,8 nor Samt-Lazare9 were medical institutions, nor even, when it comes to it, was Charenton,10 even though, unlike the other establishments, it was specifically intended for the cure of the mad. None of these were really medical places. Certainly, there were doctors, but what doctors there were had the responsibilities and role of an ordinary doctor, that is to say, providing the care entailed by the condition of the individuals confined and by the treatment itself. The cure of the mad was not demanded irom the doctor as doctor; the Iramework ensured by religious personnel, the discipline imposed on individuals, did not need a medical guarantee for one to expect them to provide what was considered to be a cure.
All this, which is very clear until the end of the eighteenth century, suddenly changes in the last years | of thej century, and in the nineteenth century we find, then, on the one hand, an absolutely general asser- tion that the mad need to be directed, that they need a regime, and, on the other hand, the paradoxical assertion, which up to a point is not entailed by the first assertion, that this direction must be in the hands ol medical personnel. Why is there this requirement ol medicalization at the moment that the discipline I have been talking about is redefined? What is the meaning of the fact that henceforth the hospital must be the place where a medical knowledge is put to work? Does it mean that the direction of the mad must be organized on the basis of a knowledge, of an analysis, nosography, and etiology of mental illness?
I don't think so. I think we must absolutely insist on the fact that in the nineteenth century there was, on the one hand, a development of nosographies, of etiologies ol mental illness, of the research of patholog ical anatomy on the possible organic correlations of mental illness, and then, on the other hand, the set of these tactical phenomena of direc- tion. This gap, this discrepancy, between what could be called a medical theory and what was the actual practice of direction, is revealed in many ways.
First, in a hospital the relationship that was possible between con- fined individuals and a doctor as someone with a particular knowledge
9 January 1974 179
? 180 PSYCHIATRIC POWER
that he can apply to the patient was infinitely slight or, if you like, com pletely random.
pp. 80 93; J. Guislain, Traite sur Valienation mentale, vol. I, book IV, and, Moyens diriges sur le systeme nerveux cerebral. De la rotation (Amsterdam: Van der Hey, 1826) p. 374 and p. 404; C. Buvat Pochon, Les Traitemenls de choc d'autrejois en psychiatric Leurs liens avec les therapeu- tiques modernes, Medical thesis, Paris, no. 1262 (Paris: Le Francois, 1939). See Histoire de la
Jolie, pp. 341 342; Madness and Civilisation, pp. 176-177.
8. While he was alive, Leuret had to defend himself from critics who condemned his practice
as, in his own words, "retrograde and dangerous" (DM traitement moral de lafolie, p. 68). His main opponent was E. S. Blanche, in his paper to the royal Academy of medicine, Du dan-
ger des rigueurs corporelles dans le traitement de lajolie (Paris: Gardembas, 1839), as well as in his short work, De Fetal actuel du traitement de lajolie en France (Paris: Gardembas, 1840). These polemics were echoed in Leuret's obituary notices: U. Trelat, "Notice sur Leuret" Annales d'hygiene publique et de medecine legale, vol. 45, 1851, pp. 241-262; and A. Brierre de Boismont, "Notice biographique sur M. F. Leuret" Annales medico-psychologiques, 2nd series, vol. III,July 1851, pp. 512 527.
9. It is Observation XXII: "Bearers ol imaginary titles and ranks" Du traitement moral de la folie, pp. 418-462.
10. 11. 12.
Ibid. pp. 421-424.
Ibid. p. 429.
P. Pinel, Traile medico-philosophique, op. cit. , section II, ? ix: "Intimider Pahene, mais ne point se permettre aucun acte de violence" p. 61; A Treatise on Insanity, "Intimidation too often associated with violence" pp. 64-65.
13. J. E. D. Esquirol, "De la folie" (1816) in Des maladies mentales vol. 1, p. 126; Mental Maladies, "Insanity," p. 76.
14. See above note 3. Already, for J. Guislain, this was one ol the advantages of "isolation in the treatment oi insanity": "Based on a leeling of dependence that he makes the insane person feel ( . . . ) lorced to conform to a loreign will" Traile sur I'alienation mentale, vol. I, p. 409.
19 December 1973 169
? 170 PSYCHIATRIC POWER
15- F. Leuret, Du irailemenl moral de lajolie, p. 422: "Dupre is a name oi convenience, a name oi disguise; his true name, as we well know, is Napoleon. "
16. Ibid. p. 423: "The distinctive sign of his Halcyon status is his constant ability to enjoy the pleasures of love. "
17. Ibid. p. 423: "Only he in the home is a man; all the others are women. "
18. EJ. Georgct, De lafolie. Considerations sur cette maladie, p. 284.
19. F. Leuret, Du traitement moral de lafolie, p. 429.
20. Ibid. p. 430. 21. Ibid. p. 430. 22. Ibid. p. 422. 23. Ibid. p. 431.
24. Ibid. p. 431. 25. Ibid. p. 432. 26. Ibid. p. 422.
27. Ibid. , p. 432.
28. Leuret defined his treatment thus: "I understand by moral treatment oi madness the reasoned use o( all means that act directly on the intelligence and passions of the insane" ibid. p. 156.
29. J. P. Falret, Des maladies mentales et des asiles d'alienes, p. 690.
30.
31.
32. 33. 34. 35-
J. E. D. Esquirol, "De la folie" (1816) in Des maladies mentales, vol. I, p. 126; Mental Maladies, "Insanity," p. 76.
F. Leuret, Du traitement moral de lajolie, p. 424.
Ibid. p. 434.
Ibid. p. 435.
Ibid.
Michel Foucault is alluding here to the "money-excrement" relationship, which had a great
iuture in psychoanalytic literature. Mentioned by Freud in a letter to Fliess of 22 December
1897 (French translation in La Naissance de la psychanalyse. Lettres a Wilhelm Fliess, 1887-1902, trans. A Berman [Paris: P. U. F. , 19561 p. 212; English translation, The Complete Letters of Sigmund Freud to Wilhelm Fliess, 1887-190/I, trans. J. M. Masson [Cambridge, Mass. : The Belknap Press of Harvard University Press, 1985] p. 288), this symbolic relationship
is developed in the theory of anal eroticism. See, S. Freud, "Charakter und Analerotik"
( 1 9 0 8 ) in Gesammelle Werke | hereafter, GW] (Frankfurt: S. Fischer Verlag, 1941) vol. VII,
pp. 201 209; English translation "Character and Anal Eroticism" in The Standard Edition
oj the Complete Psychological Works of Sigmund Freud | hereaiter Standard Edition], trans, under General Editorship of James Strachey (London: The Hogarth Press, 1953 1974) vol. 9; "Uber Triebumsetzung insbesondere der Analerotik" (1917) in GW (1946) vol. X,
pp. 401 410; "On Transformations of Instinct as Exemplified in Anal Eroticism," Standard Edition, vol. 17. See also, E. Borneman, Psychoanalyse des Geldes. Eine kritische Untersuchungpsy- choanalytisher Geldtheorien (Frankiurt: Suhrkamp Verlag, 1973); French translation, Psychanalyse de Vargent. Une recherche critique sur les theories psychanalytiques de I'argent, trans. D. Guerineau (Paris: P. U. F. , 1978); English translation, The Psychoanalysis of Money
(New York: Urizen Books, 1976).
G. Ferrus, Des alienes. Considerations sur I'etat des maisons qui leur sont destinees, lanl en France qu'en Anglelerre; sur le regime hygienique et moral auquel ces malades doivent etre soumis; sur quelques questions de medecine legale el de legislation relatives a leur elat civil (Pains: printed by Mme. Huzard, 1834) p. 234.
36.
37. Ibid.
38. See above, lecture of 5 December 1973, note 18.
39. The "Sainte Anne iarm" derived irom the donation made by Anne of Austria in 1651 for
the construction of an establishment for taking in the sick during epidemics. Partially con structed, the land remained under cultivation. In 1833, Guillaume Ferrus (1784-1861), head doctor at Bicetre, decided to use it to put to work convalescents and able bodied incurables irom the three sections of the asylum. A decision oi the commission set up on 27 December i860 by the prefect Haussmann to "study the improvements and reforms to be carried out in the service for the insane of the Seine department" marked the end oi the iarm. The construction of an asylum, begun in 1863 according to the plans established
? under the directive oi Girard de Cailleux, was inaugurated on 1 May 1867. See, C. Guesstel,
AsHe d'alienes de Saintc-Anne a Paris (Versailles: Aubert, 1880).
'lO. Henri Girard de Cailleux (1814 1884) iilled the posts of head doctor and director ol the
Auxerre insane asylum lrom 20 June 1840 until his appointment in i860 as Inspector General for the Seine service for the insane.
The quotation comes from his article: "De la construction et de la direction des asiles d'alienes" Annales d'hygiene publique et de medecine legate, vol. 40, 1st Part, July 1848, p. 30.
11. H. Belloc, Les Asiles d'alienes transformed en centres d'exploitation rurale, moyen d'exonerer en tout ou en partie les departements des depenses c/u'ils font pour leurs alienes en augmentant le bien-etre de ces maladcs, et en les rapprochant des conditions d'existence de Vhomme en societe (Pans: Bechet, 1862) p. 15.
|2. Foucault is alluding here to several earlier propositions: (a) In the lecture of 7 November 1973 he argues that the doctor's therapeutic process does not require "any discourse ol truth" (above, p. 10); ( b ) in that of 14 November Foucault claims that the "game ol truth, within delirium and of delirium, will be completely suppressed in the psychiatric practice that commences at the start oi the nineteenth century" (above, p. 35); and (c) in the lec- ture of 12 December 1973 he concludes that in psychiatric power the question of truth is never posed (above, p. 134).
15. F. Leu ret, Du traitement moral de lajolie, p. 423 and pp. 435 436.
14. Ibid.
15. Ibid. 16. Ibid. 17. Ibid. 18. Ibid. 19. Ibid.
50. Ibid.
51. Ibid,
p. 438.
p. 439.
p. 440.
pp. 440 442. p. 444.
pp. 444 445.
pp. 441 442.
52. F. Leuret, Fragments psychologiques sur lajolie, pp. 121-124.
53. T. Leuret, Du traitement moral de la /olie, pp. 449450.
54. Ibid. p. 449.
55. Ibid. p. 451.
56. Ibid. p. 425: "He does not dream of leaving the hospital and no longer fears the treatments with which he is threatened or that he has been made to undergo. "
57. Ibid. p. 426: "A red hot iron was applied once to the top of his head, and twice to the nape of his neck. "
58. Ibid. p. 429: "He then asks me ii it is a question oi his treatment; in which case he will resign himself to whatever I would like to do. "
59. Ibid. p. 430.
6 0 . Ibid. p. 453: "In a very short letter he let pass a dozen spelling mistakes, and it would have
been better if he had not aspired for a job of this kind. "
61. Ibid. p. 454: "I let the struggle get under way; M. Dupre detended himseli the best
he could, then, when he was too greatly pressed, I came to his aid, taking the role oi
conciliator. "
62. Ibid. p. 461.
19 December 1973 171
? eight
9 JANUARY 1974
Psychiatric power and the practice of "direction ". ^ The game of "reality" in the asylum. ^ The asylum, a medically demarcated
space and the question of its medical or administrative direction. ^ The tokens of psychiatric knowledge: (a) the technique of questioning; (b) the interplay of medication and punishment; (c) the clinical presentation. ^ Asylum "microphysics ofpower. " ^ Emergence of the Psyfunction and of neuropathology. ^ The triple destiny of psychiatric power.
I HAVE SHOWN THAT psychiatric power in its both archaic and elementary form, as it functioned in the proto-psychiatry of the first thirty or forty years of the nineteenth century, essentially operated as a supplement of power given to reality.
This means, first of all, that psychiatric power is above all a certain way of managing, of administering, before being a cure or therapeutic intervention: it is a regime. Or rather, it is because and to the extent that it is a regime of isolation, regularity, the use of time, a system of measured deprivations, and the obligation to work, etcetera, that certain therapeutic effects are expected from it.
Psychiatric power is a regime, but at the same time--and I have stressed this aspect--it seems to me that in the nineteenth century it is a struggle against madness conceived as a will in revolt, as an unbounded will, whatever nosographic analysis or description may ultimately be given of its phenomena. Even in a case of delirium, it is the will to
? 17xl PSYCHIATRIC POWER
believe in that delirium, the will to assert that delirium, the will at the heart of that assertion of the delirium, which is the target ol the strug gle that runs through and drives the psychiatric regime throughout its development.
Psychiatric power is therefore mastery, an endeavor to subjugate, and my impression is that the word that best corresponds to this function ing of psychiatric power, and which is found in all the texts Irom Pinel to Leuret,1 the term that recurs most frequently and appears to me to be entirely typical of this enterprise of both regime and mastery, of regu- larity and struggle, is the notion of "direction" (direction)* The history of this notion should be studied, because it did not originate in psychiatry--lar lrom it. In the nineteenth century this notion still carries a whole set of connotations arising lrom religious practice. For three or four centuries before the nineteenth century, "spiritual direction" (direction de conscience) defined a general field of techniques and objects. 2 At a certain point, some of these techniques and objects, along with this practice of direction, were imported into the psychiatric iield. It would be a history worth doing. Anyway, there's a track here: the psychiatrist is someone who directs the operations of the hospital and who directs individuals.
Just to indicate not only its existence, but also the clear awareness of this practice on the part of psychiatrists themselves, I will quote a text from 1861 which comes from the director of the Saint-Yon asylum: "In the asylum I direct, I praise, reward, reprimand, command, constrain, threaten, and punish every day; and for why? Am I not then a madman myself? And everything I do, my colleagues all do likewise; all, without exception, because it derives from the nature of things. "3
What is the aim of this "direction"? This is the point I got to last week. I think it is basically to give reality a constraining power. This means two things.
First of all it means making this reality inevitable and, as it were, commanding, making it function like power, giving it that supplement
* Nineteenth century English psychiatrists, and English translations of French psychiatrists, such as Pinel, generally use "management," or "moral treatment" etcetera, where the French use "direction," although the latter is occasionally used as well. Since Foucault explicitly draws attention to the term and its history I have left it as direction in English.
? oi vigor which will enable it to match up to madness, or to give it that extra reach which will enable it to get through to those individuals who are mad who flee it or turn away from it. So it is a supplement given to reality.
But at the same time, and this is the other aspect of psychiatric power, its aim is to validate the power exercised within the asylum as being quite simply the power of reality itself. What does this intra-asylum power claim to bring about by the way it functions within this planned space, and in the name of what does it justify itself as power? It justifies itself as power in the name of reality itself. Thus you find both the principle that the asylum must function as a closed milieu, absolutely independent ol pressures like those exerted by the family, etcetera--an absolute power therefore--and, at the same time, the principle that this asylum, in itseH, entirely cut off, must be the reproduction of reality itself. Its buildings must be as similar as possible to ordinary dwellings; relationships between those within the asylum must be like those between citizens; the general obligation to work must be represented within the asylum, and the system of needs and the economy must be reactivated. So, there is the reduplication of the system of reality within the asylum.
So, giving power to reality and founding power on reality is the asylum tautology.
But in fact, and more exactly, what is actually introduced within the asylum in the name of reality? What is given power? What is it exactly that is made to function as reality? What is given the supplement of power, and on what type of reality is asylum power lounded? This is the problem, and it was in an attempt to disentangle it a little that last week I quoted the long account of a cure that appeared to me to be absolutely exemplary of how psychiatric treatment functions.
I think we can identify precisely how the game of reality within the asylum is introduced and how it functions. I would like to summarize schematically what emerges from it quite naturally. What basically can we identify as reality in "moral treatment" in general, and in the case we have been considering in particular?
I think it is, first of all, the other's will. The reality the patient must con- front, the reality to which his attention--distracted by his insubordinate
9 January 1974 175
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will--must submit and by which he must be subjugated, is first of all the other as a center of will, as a source of power, the other inasmuch as he has, and will always have, greater power than the mad person. The greater part of power is on the other's side: the other is always the holder of a greater part of power in relation to the mad person's power. This is the first yoke of reality to which the mad person must be subjected.
Second, we found another type, or another yoke of reality to which the mad person is subjected. This was shown by the apprenticeship of the name, of the past, the obligation of anamnesis--you remember [the way in which] Leuret required and got his patient to recount his life, under the threat of eight pails of water. ^ So: name, identity, the biogra phy recited in the first person, and recognized consequently in the rit- ual of something close to confession. This is the reality imposed on the mad person.
The third reality is the reality of the illness itself or, rather, the ambiguous, contradictory, vertiginous reality of the madness, since, on the one hand, in a moral cure it is always a question of showing the mad person that his madness is madness and that he really is ill, thus forcing him to abandon any possible denial of his own madness and subjecting him to the inflexibility of his real illness. And then, at the same time, he is shown that at the heart of his madness is not illness but fault, wicked- ness, lack of attention, presumption. At every moment--you remember M. Dupre's cure--Leuret requires his patient to acknowledge that, in the past, he was at Charenton and not in his chateau of Saint-Maur,5 that he really is ill, and that his status is that of a patient. This is the truth to which the subject must be subjected.
However, at the same time, when he is subjecting him to a shower, Leuret actually says to M. Dupre: But I am not doing this in order to care for you, because you are ill; I am doing this because you are bad, because you harbor an unacceptable desire. 6 And you know how far Leuret pushed the tactic, since he goes so far as to force his patient to leave so that he does not enjoy his illness within the asylum, and so that he does not shelter the symptoms of his illness in the surrounds of the asylum. Consequently, in order to deny illness its status as illness, the bad desire within it and sustaining it, must be driven out. So it is
? necessary both to impose the reality of the illness and also to impose on the consciousness of the illness the reality of a desire that is not ill, which sustains and is the very root of the illness. Leuret's tactic broadly revolves around this reality and unreality of the illness, this reality and unreality of madness, and this constitutes the third yoke of reality to which, generally speaking, patients are subjected in moral treatment.
Finally, the fourth form of reality is everything corresponding to the techniques concerning money, need, the necessity to work, the whole system of exchanges and services, and the obligation to provide for his needs.
These four elements--the other's will and the surplus power situated definitively on the side of the other; the yoke of identity, of the name and biography; the non-real reality of madness and the reality of the desire which constitutes the reality of madness and nullifies it as madness; and the reality of need, exchange, and work--are, I think, the kind of nervures of reality which penetrate the asylum and constitute the points within the asylum on which its system is articulated and on the basis of which tactics are formed in the asylum struggle. Asylum power is really the power exerted to assert these realities as reality itself.
It seems to me that the existence of these four elements of reality, or the filtering that asylum power carries out in reality in order to let these four elements penetrate the asylum, is important for several reasons.
The first is that these four elements introduce a number of questions into psychiatric practice that stubbornly recur throughout the history of psychiatry. First, they introduce the question of dependence on and sub- mission to the doctor as someone who, for the patient, holds an inescapable power. Second, they also introduce the question, or practice rather, of confession, anamnesis, of the account and recognition of one- self. This also introduces into asylum practice the procedure by which all madness is posed the question of the secret and unacceptable desire that really makes it exist as madness. And finally, fourth, they intro duce, of course, the problem of money, of financial compensation; the problem of how to provide for oneself when one is mad and how to establish the system of exchange within madness which will enable the mad person's existence to be financed. You see all of this taking shape, already fairly clearly, in these techniques of proto-psychiatry.
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? 178 PSYCHIATRIC POWER
I think these elements are equally important, not only through these techniques, through these problems deposited in the history of psychia- try, in the corpus of its practices, [but also]* because through these elements we see the definition of the cured individual. What is a cured individual if not precisely someone who will accept these four yokes of dependence, of confession, of the unacceptability of desire, and of money? The cure is the process of daily, immediate physical subjection carried out in the asylum that constitutes the cured individual as the bearer of a fourfold reality. And this fourfold reality ol which the indi- vidual must be the bearer, that is to say, the receiver, is the law of the other, self-identity, the unacceptability of desire, and the insertion of need in an economic system. These are the four elements which, when they have been effectively taken on by the individual treated, will qua! ify him as a cured individual. The fourfold system of adjustment,1 which cures by itself, through its effectuation, restores the individual.
I would now like to deal with another set of consequences that I would like to develop further and which will be the object of my remarks. This fourfold subjection is brought about therefore in a disci- plinary space, and thanks to this disciplinary space. To that extent, and until now, what I have been able to tell you about the asylum does not differ that much from what we could have said about barracks, schools, orphanages, and prisons for example. Nevertheless, there is a funda- mental difference between these establishments or institutions and the asylum. The difference is, of course, that the asylum has a medical stamp.
How did the things I have been talking about--the general regime of the asylum, the technique of struggle, and the extra power given to real ity in this intra asylum struggle--concern medicine, and why was a doc- tor needed? What is the meaning of the hospital's medical status? What is the meaning of the fact that, at a certain moment, and precisely at the start of the nineteenth century, the mad had to be put not only in a dis- ciplinary place, but, what's more, in one that was medical? In other words, why was a doctor needed to convey this supplementary power of reality?
* (Recording:) it is equally important
' The manuscript has "subjection" rather than "adjustment. "
? Concretely, again, you know that until the end oi the eighteenth century the places in which the mad were put, the places which served lo disciplinanze their mad existence, were not medical places: neither Bicetre,7 nor Salpetnere,8 nor Samt-Lazare9 were medical institutions, nor even, when it comes to it, was Charenton,10 even though, unlike the other establishments, it was specifically intended for the cure of the mad. None of these were really medical places. Certainly, there were doctors, but what doctors there were had the responsibilities and role of an ordinary doctor, that is to say, providing the care entailed by the condition of the individuals confined and by the treatment itself. The cure of the mad was not demanded irom the doctor as doctor; the Iramework ensured by religious personnel, the discipline imposed on individuals, did not need a medical guarantee for one to expect them to provide what was considered to be a cure.
All this, which is very clear until the end of the eighteenth century, suddenly changes in the last years | of thej century, and in the nineteenth century we find, then, on the one hand, an absolutely general asser- tion that the mad need to be directed, that they need a regime, and, on the other hand, the paradoxical assertion, which up to a point is not entailed by the first assertion, that this direction must be in the hands ol medical personnel. Why is there this requirement ol medicalization at the moment that the discipline I have been talking about is redefined? What is the meaning of the fact that henceforth the hospital must be the place where a medical knowledge is put to work? Does it mean that the direction of the mad must be organized on the basis of a knowledge, of an analysis, nosography, and etiology of mental illness?
I don't think so. I think we must absolutely insist on the fact that in the nineteenth century there was, on the one hand, a development of nosographies, of etiologies ol mental illness, of the research of patholog ical anatomy on the possible organic correlations of mental illness, and then, on the other hand, the set of these tactical phenomena of direc- tion. This gap, this discrepancy, between what could be called a medical theory and what was the actual practice of direction, is revealed in many ways.
First, in a hospital the relationship that was possible between con- fined individuals and a doctor as someone with a particular knowledge
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? 180 PSYCHIATRIC POWER
that he can apply to the patient was infinitely slight or, if you like, com pletely random.
