358 PSYCHIATRIC POWER
terrain of violence and exclusion inherent in the socio-political system.
terrain of violence and exclusion inherent in the socio-political system.
Foucault-Psychiatric-Power-1973-74
346 PSYCHIA TRIC POWER
power relationship that gives rise to a knowledge, which in turn founds the rights of this power, is the characteristic feature of "classical" psychiatry. It is this circle that antipsychiatry undertakes to unravel: giving the individual the task and right of taking his madness to the limit, of taking it right to the end, in an experience to which others may contribute, but never in the name of a power conlerred on them by their reason or normality; detaching behavior, suffering, and desire from the medical status given to them, freeing them from a diagnosis and symp tomatology that had the value not just of classification, but of decision and decree; invalidating, finally, the great retranscription of madness as mental illness that was begun in the seventeenth and completed in the nineteenth century.
Demedicalization of madness is correlative with this fundamental questioning of power in antipsychiatric practice. This enables us to take the measure of the latter's opposition to "depsychiatrization," which seemed to be the characteristic feature of both psychoanalysis and psychopharmacology, both of which stemmed rather from an overmedical ization of madness. Straightaway the problem opens up of the possibility of freeing madness from that singular lorm of power-knowledge (pouvoir-savoir) that is knowledge (connaissance). Is it possible for the production of the truth of madness to be carried out in forms other than those of the knowledge relation? It will be said that this is a fictitious problem, a question that arises only in Utopia. Actually, it is posed con- cretely every day with regard to the role of the doctor--of the statutory subject of knowledge--in the depsychiatrization project.
*
The seminar was devoted alternately to two subjects: the history of the hospital institution and of hospital architecture in the eighteenth century; and the study of medico-legal expertise in psychiatric questions since 1820.
? 2. }. \.
5.
6. 7. 8.
9-
10.
11.
Ibid.
Esquirol, De lafolie, ? 5: "Traitenient de la lolie," pp. 132 1}3; Mental Maladies, p. 79.
D. Cooper, Psychiatry and Antipsychiatry (London: Tavistock, 1967), p. V\', French translation, Psychiatric el Antipsychia/rie, trans. M. Braudeau (Pans: Ed. du Seuil, 1970), p. 33. F. Basaglia, ed. VLtitu^ione negata. Rapporto da un ospedale psichiatrico (Turin: Nuovo politecnico, 1 9 6 8 ) ; French translation, Les Institutions de la violence, in F. Basaglia, ed. , Vlnstitution en negation. Rapport sur I'hopital psychiatrique de Gori^ia, t r a n s . L. B o n a l u m i (Paris: Ed. du Seuil, 1970), p. 105.
On this subject, see R. Caslel, Le Psychanalysme ( Paris: Maspero, 197$), pp. 150 15*.
F. Basaglia, Vinstitution en negation, p. 111.
Thomas Stephen Szasz, is an American psychiatrist and psychoanalyst, born in Budapest in 1920. Professor ol psychiatry al the University of Syracuse (New York), he was the only American psychiatrist to join the "antipsychiatric" movement that developed in the 1960s. His work carries out a critique ol psychiatric institutions on the basis ol a liberal and humanist conception ol the subject and human rights. See his collection ol articles, Ideology and Insanity (London: Calder & Boyars, 1970); French translation, Ideologic et Folie. Essais sur la negation des oaleurs humanistes dans la psychiatric d'aujourd'hui, trans. P. Sullivan (Paris: P. U. F. , I976), and The Myth of Mental Illness (New York: Harper & Row, 1961); French translation, Le Mythe de la maladie menlale, trans. D. Berger (Paris: Payot, 1975).
Kingsley Hall is one of three reception centers created in the 1960s. Situated 111 a working class area ol London's East End, it is known through the account given by Mary Barnes, who spent live years there, and her therapist, Joe Berke, in their book, Two Accounts of a
Journey Through Madness (London: MacGibbon and Kee, 1971); French translation, Ma/y Barnes, un voyage autour de la folie, trans. M. Davidovici (Pans: Seuil, 1973).
The experiment al Villa 21,which began inJanuary 1962 in a psychiatric hospital in North Wesl London, inaugurated the series ol anlipsychiatnc community experiments, one ol the best known of which is Kingsley Hall. David Cooper, its director until 1966, provides an account in Psychiatry and Antipsychiatry.
An Italian public psychiatric hospital in northern Trieste. In 196} Franco Basaglia and his team began to undertake its institutional translormation. Vinstitution en negation provides an account of this anti institutional struggle that became an example. Basaglia gave up the direction of Gorizia in 1968 in order to pursue his experiment in Trieste.
1. J. E. D. Esquirol, De la folie (1816), ? l, "Symplomes de la lolie," in Des maladies menlales considerees sous les rapports medical, hygienique el medico-legal, 2 volumes (Paris: Bailliere, 1838), vol. 1, p. 16 (republished, Paris: Frenesie, 1989, in the series "Les Inlrouvables de la psychiatric"); English translation, Mental Maladies. A Treatise on Insanity, trans. E. K. Hunt (Philadelphia: Lea and Blanchard, 18'|5) p. 27.
Course Summary 347
? COURSE CONTEXT Jacques Lagrange
THE LECTURES DEVOTED TO "Psychiatric Power," delivered between 7 November 1973 and 6 February 1974, have a paradoxical rela- tionship to earlier works. There is continuity to the extent that, as Michel Foucault himself notes, they take off at the "the point reached by my earlter work, Histoire de lafolie, or, at any rate, the point where it broke off" (lecture of 7 November 1973). In fact, Histoire de lafolie had opened a space for future research that would have reconstructed "the constitutive but historically mobile ground that made possible the development of concepts from Esquirol and Broussais up to Janet and Freud. "' This is confirmed by an (unpublished) interview with Colin Gordon and Paul Patton of 3 April 1978: "When I wrote Histoire de la
folie I had in mind that it would be the first chapter, or the beginning, of a study that would continue up to the present. "
But there is also discontinuity, as is evident from statements that are careful to mark shifts and, in his own words, "see what I had done from a new vantage point and in a clearer light. "2 The first works were inter ested in "mental illness" rather than "mental medicine,"3 and in the Preface to the first edition, Histoire de lafolie is presented as a "history not of psychiatry, but of madness itself, in its vivacity, before all capture by knowledge. "1 What's more, if the lectures take up the analysis at the
? 350 PSYCHIATRIC POWF. R
point it left off in Histoire de lafolie, they shift the stake and change both the terrain on which it is set out and the conceptual tools it puts to work. Hence, the question arises of what made these shifts possible and necessary? This involves understanding the production of this series of lectures, not only in the conceptual dynamic that leads them to give an important and strategic place to power and its apparatuses (dispositifs), but also in the held of problems that psychiatry had to confront in the 1970s that brought the question of power to the fore.
1. THE STAKE OF THE COURSE
The first lecture envisioned taking as a starting point the present situation ol psychiatry in the light of the contribution ol antipsychiatry to a reorientation of questions around the "power relations" that "con ditioned how the asylum institution functioned" and "governed the lorms ol medical intervention,""' and proceeding to a retrospective analysis, starting Irom the present, oi the historical formation of this apparatus ol power. This is what gives this way of writing the history of psychiatry its specificity. 6 In contrast to approaches engaged in recon structmg the evolution ol concepts and doctrines, or in analyzing the working ol institutions in which psychiatry produces its effects, this way of analyzing the history of the psychiatric apparatus seeks to reveal its lines of force or Iragility, its points of resistance or possible attack. Thus, it is no longer a question, as it was in the first writings, of putting psy chiatry on trial and accusing it of concealing the real conditions of men- tal pathology behind nosological abstractions and a causal way of thinking. 7 Neither is it a question, as in Histoire de lafolie, ol under- standing why, at a certain point in the history ol our relationships with the mad, the latter were placed in specific, supposedly curative institu- tions. Henceforth, history is used to bring to light obscure relations of continuity which connect our present apparatuses to old bases linked to a given system of power, with the aim ol isolating objectives of struggle: "In the domain ol psychiatry," Foucault stated in May 1973, "it seems to me interesting to know how psychiatric knowledge, the psychiatric institution, was installed at the beginning of the nineteenth century ( . . . ) i( we wish today to struggle against all the instances of normalization. "8
? Hence the originality of the course's problematic. For if at times there was a clear suspicion that the light of medical truth was supported by the shadow of force relations appearing in forms of authority and domination,9 this was not accompanied by an analysis of the extraordinarily meticu- lous and skillfully hierarchized power of the asylum. Concerning power, Foucault later recognized: "I'm perfectly aware that I scarcely ever used the word and never had such a field of analyses at my disposal. "10
What brought the problem of psychiatric power to the fore no doubt involved the conjunction of two elements: one spectfic to the conceptual dynamic of Foucault's research, and the other arising from the conjuncture of the 1970s.
This conjunction involves the shift carried out by Foucault that led him to replace references to institutional "violence" and modes of "domination" by what, in the 1971-1972 College de France lectures, "Penal Theories and Institutions," he will call "the basic forms of 'power knowledge. '"1] This reorientation is no doubt linked to the interest in medico-legal expertise--the subject matter of his seminar-- which confronted him with the need to consider how and why a discourse that claimed to be scientific, but which was also questionable, brought with it effects ol power in penal practice. This interest was strengthened by cases that had caused quite a stir: those of Denise Labbe and Jacques Algarron in 1955, or of Georges Rapin in 1960-- referred to in the lecture of 8 January 1975 in his lectures on "Les Anormaux. "12 His attention to problems of the prison also convinced him that the problem of power should be approached "in terms ol technology, in terms of tactics and strategy. "13 But, at the same time, the conjuncture must also have ensured that it was no longer a question of the theorettcal justification of psychiatry, as it was tn the fifties when, Foucault recalls, "one of the great problems that arose was that of the political status of science and the ideological functions it could serve,"1/| but suddenly revealed this elementary rock: power. Who has power? Over whom is it wielded? With regard to what is it exercised? How does it function? Of what use is it? What is its place amongst other powers? 15
Certainly, the first response to the crisis of psychiatry in the post war period was at least as much political as medical. Thus, the "desalieniste" movement initiated by the communist psychiatrist Lucien Bonnafe, who
Course Context 351
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set himself the goal of "opening our eyes to that alienated-alienating system established, with the assistance of the science of 'alienation* ( . . . ) in an order modeled on the principles and habits of a social order that excludes what dtsturbs it. "16
But these denunciations of a psychiatry (^alienisme) accused of complicity with procedures of discrimination and exclusion do not succeed in formulating the question of psychiatric "power" as such. There are several reasons for this.
First of all, because the legacy of the war raised the question of not so much psychiatric power as of "the destitution of psychiatry. "17 Then, as Foucault notes, because "those psychiatrists in France who, for political reasons, would have been in a position to question the psychiatric apparatus (. . . ) found themselves blocked by a political situation in which, basically, one did not want the questton to be raised at all, because of what was taking place in the Soviet Union. "18 Finally, criticism may well have questioned the means available to psychiatric practice, or denounced the contradiction between what the psychiatric institution claims to do and what it really does, but it was still expressed in terms of the institutional project and its own criteria, propostng new, more supple modalities of intervention, further removed from the "medical" model, and appealing to a "different psychiatry," to use the terms of Lucien Bonnafe and Tony Laine. 19 And if this questioning of psychiatric practices did not open up the question of "psychiatric power," it is no doubt because the struggles taken up could not get beyond the framework of psychiatric corporatism and defense of the medical corps of psychiatric hospitals, as Foucault emphasizes: "Because of the posi- tion of psychiatrists, most ol whom were state employees, many were brought to question psychiatry from a defensive trade-union angle. Thus, those individuals who, by virtue of their abilities, their interests, and their openness to so many things, would have been able to address the problems of psychiatry, were led into impasses. "20 As a result of this, the problem of power could only find expression in a derivative mode: the trade-union struggle of the medical corps of psychiatric hos- pitals. As Foucault notes, psychiatrists "could struggle against medicine and the administration without being able to Iree themselves from either one or the other. "21
? It needed the intervention of events Irom outside, therefore, for psychiatry to be posed the question ol its "power. " This was a new political activism that, after '68, challenged a doctor's power to decide on a person's mental state, and proposed giving space for a different mode of receptton of madness freed from psychiatric structures and ide- ology. Thus we see the development of local and dispersed sectional strug- gles in which Foucault saw "the insurrection of subjugated knowledge," that is to say, of forms of knowledge usually dismissed as poorly developed theoretically and of a lower status. There was, for example, the struggle of young psychiatrists whose less pronounced corporattst concerns allowed them to take a more political position that, on the model of GIP (Groupe Information Prisons), led to the creation of GIA (Groupe Information Asiles) in 1972, which was soon taken over by the "psychiatrized" themselves to denounce the scandals of arbitrary con- finement. New alliances were forged with the "psychiatrized" that gdv^ rise to the journal Psychiatrises en lutte and the chance for the voices of mental health workers and patients to be heard. 22 As a counterpoint to the Congress of Psychiatry and Neurology on the theme of the Formation et role de Vinfirmier en psychiatrie (Auxerre, September 1974), a movement developed that was run by nurses who were anxious to free themselves from a medical supervision that they accused of hiding their practice and knowledge, and who sought to reintegrate tnto their work social and political elements marginalized by "establishment" psychiatry. In this way the Association for the study and creation of the White Book of psychiatric institutions (AERLIP) was born, and the report of its counter-congress, Des infirmiers psychiatriques prennent la parole}7* Seeing reference to "specialized competence" as conferring social legitimacy on the psychiatrist's "power," some so-called "anti-psychiatric" tendencies undertook to break with all the ways of taking care of patients that reduce the complexity of their situation to a technical problem to be dealt with by competent specialists. This view inspired the title of a work by Roger Gentis: Psychiatry must be practiced/dismantled by everyone. 2'*
Learning from these movements, in June 1973 Foucault could say: "the importance of anti psychiatry is that it challenges the doctor's power to decide on an individual's state of mental health. "25
Course Context 353
? 354 PSYCHIATRIC POWER
2. THE REGISTER OF THE COURSE
Fixing for oneself a "histonco-political" stake involving the analysis of the conditions of formation of psychiatric knowledge and practice so as to define "strategies of struggle" calls for a shift of the points of problematization. It is difficult, in fact, to undertake such an analysis as long as the historical order is relativized by reference to some constitu- tive "ground," or, as in Maladie mentale et Psychologie, by reference to the original experience of a "true man. "26 Also, whereas in Histoire de la folk "the fine rectitude that leads rational thought to the analysis of madness as mental illness" is reinterpreted "in a vertical dimension,"27 the lectures abandon this imaginary of depth so as to keep to the reality of surface effects. The lectures thus seek to grasp the discursive practices of psychiatry at their point of formation: an "apparatus (dispositif)" of power bringing together heterogeneous elements like discourses, modes of treatment, administrative measures and laws, regulatory arrange- ments, architectural plans, and so forth. 28 This involves a problem of "proximity," therefore, rather than one of "foundation. " Hence a style of analysis according to a principle of "dispersion," one that multiplies knowledges and practices in order to bring out their components, recon- struct their associated spaces, and establish connections, thereby giving a "shape" to the documentary mass brought under analysis.
3. CONCEPTUAL TOOLS
Taking up the work begun by Histoire de lafolie on a fresh basis requires a change of conceptual tools. First of all, reference to an "apparatus of power" replaces the reference to forms of "representation" to which, on Foucault's own admission, Histoire de lafolie was still attached. Thus, the lectures replace a style of analysis that put a kind of "core of representations"29 at its center--the image constructed of madness, the dread it provoked, a madness that portrayed "the deja-la of death,"30 etcetera--with reference to an "apparatus ol power" that at a given moment has a dominant strategic function.
Second, recourse to the notion of "violence," which underlay analyses of the modes of treatment presented in the second and third parts of the
? work, has to be abandoned. In fact, the connotations of this notion make it particularly unsuitable for the analysis ot the power relations and tactics that permeate psychiatric practice. Suggesting the idea of imme- diate coercion, of the irregular, unreflected exercise of power, it cannot reconstruct the idea of a calculated and meticulous exercise of power put to work in the asylum, and for which "violence" represents only a limit figure. Moreover, this notion, which makes power an agency for solely negative effects--exclusion, repression, interdiction--tails to take into account the productivity of psychiatric power and its capacity to pro- duce discourses, forms of knowledge, and induce pleasure, etcetera. In short, bringing with it the idea ol an unbalanced relation ol lorce that makes it impossible for the other person to do anythtng other than what he is forced to do, this notion is hardly suited for reconstructing the complexity of games of power like the "great maneuvers" of the hysterics faced with medical power at Salpetnere. 31
Finally, the asylum "institution" is no longer to be taken as the essential reference, but analysis moves to its "outside" so as to resituate its con- stitution and operations within a technology of power typical ol society. Hence the distance taken from Histoire de lafolie, which, in Foucault's own words, claimed to be a "history of the psychiatric institution" and linked the formation of psychiatric knowledge to a process of the "institutionalization" of mental medicine. 32
This is what gives this course its originality in comparison with all the critical tendencies that developed after the war, and which have in common that they take the asylum "institution" as their target, either in order to reform it, or to sublimate it, or to deny its legitimacy.
3. 1. Reforming the asylum institution. Previously thought of as insepara- bly both a milieu for treatment and a space of segregation, shortly after the war there is a movement that accuses psychiatry (^alienisme) of com- plicity with practices of discrimination and exclusion, and that aims to free psychiatric intervention from the straitjacket of the asylum structure and its "stagnation" in order to make it an "activity entirely directed by a therapeutic perspective". 33 This is why Lucian Bonnafe calls his criti- cism "post-Esquirolism," demonstrating his concern to transform an inherited milieu of segregation into a real therapeutic instrument, by
Course Context 355
? 356 PSYCHIATRIC POWER
referring to "the mutation accomplished in the fundamental idea of the institution of treatment ( . . . ) formulated in 1822 with Esquirol's well- known clarity: Tn the hands of a skilled doctor, a lunatic asylum is an instrument of cure, tt is the most powerful therapeutic agent against mental illnesses'. "3^
However, by asserting "the unity and indivisibility of prevention, prophylaxis, cure and post-cure,"35 this movement at the same time increasingly took its distance from an asylum institution, constituted by the law of 30 June 1838 as the quasi exclusive site of psychiatric inter vention, in order to make it no more than one element among others in an apparatus directly linked to the community. 36 However, what repre- sents an aggiornamento of psychiatry does not break with the latter's stakes: the constitution of "pathological" social behavior as an object of medical intervention and the assembly of apparatuses for deploying a therapeutic activity. So, although this movement may well identify the contradictions between what the institution claims to do and what it really does, it does not succeed in addressing the question of "psychiatric power," since the criticism is formulated in terms of the institutional project and of its own criteria.
3. 2. Sublimating the institution. Whereas supporters of the first kind of "institutional psychotherapy" submitted to the existence of the estab- lishments to which they were appointed, trying to use them as best they could on the therapeutic level, those of the second kind of "insti- tutional psychotherapy" engaged in a radical modification of the thera- peutic institution on the basis of a supposed discontinuity between psychiatry and psychoanalysis. Taking place on a completely different scene, involving a completely different type of relationship between patient and therapist, and organizing a different mode and formation of discourse, psychoanalysis appeared as a permanent resource with regard to the problems posed by asylum life, making it possible to readapt the structures of care. It is as if the institution is "sublimated" from within through a sort of collectivization of analytic concepts: transferences become "institutional"37 and fantasies become "collective. " The "political" criticism of psychiatry is then expressed in the name of the logic of the unconscious, and sources of resistance to the truth of desire, the hierarchical structures of institutions, and the socio cultural
? representations of mental illness in which both therapists and patients are caught, are all equally denounced. Just as the hospital of Samt- Alban (Lozere) had been the reference point of the first "institutional psychotherapy," the La Borde clinic at Cour-Cheverny (Loir-et-Cher), opened in April 1953 by Jean Oury and Felix Guattari, represented the model realization of analytic "institutional psychotherapy" and its mam center of diffusion. 38
In a perspective focused on the institution's "interior," it was difficult to get back to what, outside the institution, determines its organization and role. So much so that the correlation of psychiatry with the public domain as organized by the law, which means that the psychiatrist takes on certain functions insofar as he exercises a public mandate, was dissolved in the field of discourses and the imaginary. Thus Tosquelles could say that "the problematic of power as it functions within treatment groups ends up, of itself, being expressed in the field of speech, usually as an imaginary projection in the collective discourse woven in the group in question. "39
The corresponding Italian version--although Franco Basaglia (1924- 1980) challenged the "anti psychiatry" label'0--criticized the asylum apparatus from a political point of view as the privileged site of the contradictions of capitalist society. Born in the very specific context of the law of 14 February 1904, which essentially gave the police and magistrates responsibility for aid to mental patients, and within the framework of Basaglia's experience of the deplorable conditions of the hospitahzation of patients in 1961,when he took over direction of the psychiatric hospital at Gorizia, near Trieste, the Italian current was situated in a decidedly revolutionary perspective. ^1 The Italians rejected the idea of a possible restructuring of the asylum, whether in the form of division into "sectors" or in that of "therapeutic communities," which they suspected of reviving the old apparatus of social control in a toler- ant form;/|2 they turned to practices based on a break with all the institu- tional mechanisms that could reproduce the separation and sequestration of the social life of those who have dealings with psychiatry: "Our action," Basaglia declared, "can only be continued in a negative dimen- sion that, in itself, is a destruction and overcoming that, going beyond the coercive-carceral system of psychiatric institutions ( . . . ) moves onto the
Course Context 357
?
358 PSYCHIATRIC POWER
terrain of violence and exclusion inherent in the socio-political system. "^3 With the aim of working towards the de-institutionalization of responsibility for patients, the Italian movement opted for an open- ing towards non professionals and an alliance with political and trade union forces of the left, which resulted in the constitution of Pskhiatrica Democratka in 1974.
However, it was the English current, coming out of the work of David Cooper (1931-1989), Aaron Esterson and Ronald Laing (1927 1989) on schizophrenics and their family circle, which had the greatest impact in France/^ In the sixties this movement developed a radical critique of psychiatry and its institutional and symbolic violence, accepting Cooper's label of "anti-psychiatry. "^ This violence was not only the physical violence of the constraints of confinement, but also the violence exercised by the analytic rationality that, through its nosological catego- rization, passes off as "mental illness"--which is subject to a specialized competence and calls for the establishment of a relationship of tutelage-- the way in which a subject tries to respond to the oppression of which he has been the victim since birth and which is continued through var- ious institutions delegated by society: family, school, work, etcetera. It is because of the "violence" of the psychiatric institution towards this "experience"--which the subject should take to its extreme limits if he would be "transformed" by it, in a process that Laing describes, in evangelical terms, as "conversion," or metanoia--that its space should be de medicalized and removed from the relations ol power deployed within it. "Instead of the mental hospital, a sort of re servicing factory for human breakdowns, we need a place where people who have trav elled further and, consequently, may be more lost than psychiatrists and other sane people, can find their wayfurther into inner space and time, and back again. ,,/|6 From this came the constitution of the Philadelphia Association, in April 1965, by Cooper, Esterson, and Laing, with the aim of "organising places to welcome people who are suffering from or have suffered from mental illnesses," and to "change the way in which the facts of 'mental health* and 'mental illness* are considered. ",7
Now, whereas these post-War critical currents focus on the psychi- atric institution as the point of problematization, the lectures shift the site by adopting the principle that "before tackling institutions, we have
? to deal with the relations of force in these tactical dispositions that per- meate institutions. "^8 Actually, the notion of the institution harbors a number of inadequacies and "dangers" to which Foucault returns on a number of occasions. First of all, approaching the problem of psychiatry through this notion amounts to starting with given, pre-constituted objects--the group and its functional regularities, the individual who is a member of the group, etcetera--when it would be more appropriate to analyze the procedures of its constitution at the level of dispositions of power and the processes of individualization they involve. Then again, by focusing on an institutional microcosm, one runs the risk of separat- ing it from the strategies in which it is formed and in which it produces its effects, consequently "throwing m," as the lectures say, "all the psychological or sociological discourses. " The problematic of the lee tures can be compared, for example, with that of Erving Goffman's Asylums, to which Foucault pays tribute on a number of occasions. "19 Certainly, one merit of the book is to make it possible to escape from medical rationalizations by "de-specifying" the psychiatric institution, so to speak, by placing it within a range of different structures--school, prison, etcetera--through the perspective of the notion of total institutions [English in original; G. B. J which typify establishments specialized in supervising individuals and controlling their mode of life. But this quasi-ethnographic approach to the asylum institution has its limits. Taking the latter as, in effect, an autonomous "totality," so as simply to situate it in a range of other institutions, it fails to show that the asylum is a response to an evolving historical problematic. Consequently, the nature of the break constitutive of the asylum site can only be thought in a static way, through binary oppositions like inside/outside, being confined/leaving, etcetera, which mark the barriers "to social intercourse with the outside and to departure that" total institutions often build "right into the physical plant, such as locked doors, high walls, barbed wire, cliffs, water, forests, or moors. "30 If, for this image of a "shut up" space, we substitute the idea of "an enclosed space for a confrontation,
the site of a duel, an institutional field in which victory and submission are at stake,"51 then the asylum break acquires a new dimension. This "enclosed" milieu then appears for what it really is: a milieu actively cut out, that is to say, captured from old forms of custody through historical
Course Context 359
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PSYCHIA TRIC POWER
processes that make the mad person emerge as someone who is differentiated less by reference to the family than within a technico- administrative field. This is emphasized in the lecture of 5 December 1973: "The mad individual now emerges ( . . . ) as a danger for society, and no longer as someone who may jeopardize the rights, wealth, and privileges of a family. " At the same time, the central place of the psychi- atrist, emphasized by Goffman, takes on another dimension; the psy- chiatrist is not distinguished from the madman by the fact that he is free, but by the fact that he intervenes as an ambassador of the external world, charged with imposing the norms of society within the asylum. He is "someone who must give reality that constraining force by which it will be able to take over the madness, completely penetrate it, and make it disappear as madness. "32
Whereas the problem for Goffman is the problem posed by the institution itself and its functioning, the problem to which the lectures are devoted is that of how a certain technique, connected to social and political structures, authorizes "the rationalization of the management of the individual. "53
From this derives the particular style of an archeology of the psychiatric institution, which, from George III to Charcot, multiplies wonderful panoptic "scenes" that reveal the operations and procedures making up this "microphysics" of power, and break up what solidity the asylum institution had. As the manuscript for the lecture of V\ November 1973 makes clear, by "scene" we should understand, "not a theatrical episode, but a ritual, a strategy, a battle"; scenes which, inserted in the work of the analysis like fragments of mirror, bring together, in a glance, the theoretical implications that the argument will develop.
Approaching the apparatus of psychiatry in this way, by reference to mechanisms of power, weakens the foundation on the basis of which psy- chiatry deployed its theoretical and practical conquests: a requirement of specificity. In fact, from its constitution as a "special medicine" endowed with "special establishments," "specialized" doctors, the psychiatrists, and "special" legislation, the law of 30 June 1838, up until the attempts at transforming its institutional structures just after the war, this idea of a "specificity" of mental medicine constitutes a main theme around which, we can say, the best part of the profession has rallied. 5''
? Course Context 361 4. POINTS OF PROBLEMATIZATION
The analysis of the psychiatric apparatus is structured around three axes: that of power, insofar as the psychiatrist is established as a subject acting on others; the axis of truth, insofar as the insane individual is constituted as an object of knowledge; and the axis of subjectivation, since the subject has to make the norms imposed on him his own.
4. 1. Power. Defined in the seventies with the problematic of knowledge- power, this axis shifts previous questionings. Basically, the first texts, in fact, addressed to psychiatry the question: "What you say is true? Give me the grounds of your truth! " Henceforth the question, the demand is: "Give us the grounds of your power! By what right do you exercise it? In whose name? To what advantage? " "Power" therefore, and no longer "violence" as in the previous works. As a result, there is a change in the paradigmatic figure around which the criticism of the Anglo-Saxon "anti-psychiatrists" was ordered, and which put the question of the "violence" exercised by society in general and psychiatry in particular at its core:55 the schizophrenic. 56
However, when we approach the psychiatric apparatus by reference to the mechanisms of power that organize it, it is the hysteric who, by laying the "trap" of the lie for a doctor like Charcot armed with the highest medical knowledge, paradigmatically portrays the militant underside of psychiatric power. 57 This is why, in Foucault's view, the hysteric deserves the title of the first "militant of anti-psychiatry," as he puts it in the lecture of 23 January 1974, since, by her "maneuvers," she challenges the doctor's role of "responsibility for producing the truth of illness within the hospital space. "5 Foucault can also declare in his contribution to a colloquium organized by Henri Ellenberger in May 1973: "The age of anti-psychiatry began when one suspected, and then, soon afterwards, was sure, that Charcot, the great master of mad- ness, the person who made it appear and disappear, was not the person who produced the truth of the illness, but the one who fabricated its artifice. "59
Now, this power to which the lectures are devoted has a double char- acteristic. In the final instance its point of application is bodies: their distribution in the asylum space, their ways of behaving, their needs,
? 362 PSYCHIA TRIC POWER
their pleasures; in short, it is a power "commanded by all the disposi tions of a kind of microphysics of bodies. " Moreover, the relations of power installed between the psychiatrist and his patient are fundamen- tally unstable, constituted by struggles and confrontations in which points of resistance are present at every moment. This is the case with these "counter maneuvers" by which the hysterics shake Charcot's power, escaping the categorizations to which he wanted to assign them, thereby giving a new impetus to the apparatus of medical power- knowledge on the basis of these resistances, to the point that, Foucault says, "a crisis" is opened up "that had to lead to anti-psychiatry. "60
4. 2. Knowledge and truth. As the lecture of 5 December 1973 recalls, "as a disciplinary system, the asylum is also a site for the formation of a certain type of discourse of truth. " Hence the analyses of the ways in which apparatuses of power and games of truth are articulated. This is the case for the "proto-psychiatric" modality, in which a game is orga- nized around the delirious conviction, within the regime of a "test" in which the doctor is posed as the ambiguous master of reality and truth, or, on the other hand, a game in which the question of truth no longer arises in the confrontation of doctor and patient, since it is now only posed within psychiatric power established as medical science. In this mode of analysis we can see that truth is called upon less as an intrinsic property of statements than at the level of its functionality, through the legitimation it provides for the discourses and practices on the basis of which psychiatric power organizes its exercise, and by the mode of exclusion it authorizes.
4. 3. Subjection (assujettissement). The therapist who approaches the individual to be treated from the outside, at the same time as he resorts to procedures that enable him to extract from this individual his inner subjectivity--questioning, anamnesis, etcetera--puts the subject in the position of having to interiorize the orders and norms imposed on him. In the lecture of 21 November 1973, the problem is also broached from the angle of the modes of subjection that make the subject appear as a complex and variable "function" of regimes of truth and discursive practices.
However, these lectures, which sought to give a sequel, on new bases, to Histoire de lafolie, will remain without future. For, in these years,
? circumstances are such as to give preference to participation in effective action, instead of, as Foucault says, the "scribbling of books. " Thus, from 1972 he recognized that "writing today a sequel to my Histoire de lafolie, which would continue up to the present, is for me without interest. On the other hand, a concrete political action in favor of prisoners seems to me to be highly meaningful. "61 However, at the same time, Foucault was preparing Discipline and Punish. Birth of the Prison.
Course Context 363
? 364 PSYCHIATRIC POWER
1. Michel Foucault, Histoire de la folie a I'dge dassique (Paris: Gallimard, 2ml edition, 1972) p. 541. This is omitted from the abridged English translation: Michel Foucault, Madness and Civilisation. A History of Insanity in the Age of Reason, trans. Richard Howard (New York: Random House, 1965 and London: Tavistock, 1967).
2. Michel Foucault, "Usage des plaisirs et techniques de soi," in Dits et Ecrits, 1954-1988, ed. D. Defert and F. Ewald, with the collaboration of J. Lagrange (Paris: Gallimard, 1994) vol. 4, p. 545; English translation, "Introduction," The Use of Pleasure. The History of Sexuality, vol. 2, trans. Robert Hurley (New York: Pantheon Books, 1985) p. 11.
3. Michel Foucault, Maladie mentale et Personnalite (Paris: Presses universitaires de France, 1954) and the modified version of this, Maladie mentale et Psychologie (Paris: Presses universitaires de France, 1962); English translation, Mental Illness and Psychology, trans. Alan Sheridan (New York: Harper and Row, 1976).
4. Michel Foucault, "Preface" to Folie et Deraison. Histoire de lafolie a /'age dassique (Paris: Plon, 1961) p. vii (omitted from the French 1972 edition and from the English translation); reprinted in Dits et Ecrits, vol. 1, p. 192.
5. "Course summary," above, p. 345-
6. That is, its specificity in relation to both earlier and later studies of the history of
psychiatry. See in particular, E. H. Ackerknecht, A Short History of Psychiatry (New York:
Hafner, 1968).
7. Thus, Foucault's "Introduction" to L. Bmswanger, Le Reve et I'Existence, trans. J. Verdeaux
(Paris: Desclee de Brouwer, 1954) denounces the tendency of psychiatrists to consider "the illness as an 'objective process,' and the patient as an inert thing in which the process takes place" p. 104. Reprinted in Dits et Ecrits, vol. 1, p. 109; English translation, "Dream, Imagination and Existence. An Introduction to Ludwig Binswanger's Dream and Existence" trans. Forrest Williams, in M. Foucault and Ludwig Binswanger, Dream and Existence, trans. Forrest Williams and Jacob Needleman, ed. Keith Hoeller, Special Issue from Review of Existential Psychology and Psychiatry, vol. XIX, no. 1,1984 85, p. 66.
8. "La verite et les formes juridiques" Dits et Ecrits, vol. 2, p. 644; English translation, "Truth and Juridical Forms" trans. Robert Hurley, The Essential Works of Michel Foucault 1954-1984, Vol. 3: Power, ed. James D. Faubion, trans. Robert Hurley and others (New York: The New
Press, 2 0 0 0 ) . See also the interview with Foucault on Radio France, 8 October 1972, "Punir ou guenr": "I think this historical analysis is politically important inasmuch as it is necessary to locate exactly what one is struggling against. "
9- "If the medical personage could isolate madness, it was not because he knew it, but because he mastered it; and what lor positivism would be an image of objectivity was only the other side of this domination" Histoire de lafolie, p. 525; Madness and Civilisation, p. 272.
10. "Entretien avec Michel Foucault" Dits el Ecrils, vol. 3, p. 146; English translation, "Truth and Power" trans. Colin Gordon, Essential Works of Foucault, 3, p. 117.
11. "Theories et institutions penales" Dits el Ecrits, vol. 2, p. 390; English translation, "Penal Theories and Institutions" trans. Robert Hurley, The Essential Works of Michel Foucault, 1954-1984, vol. 1: Ethics: subjectivity and truth, ed. Paul Rabinow, trans. Robert Hurley and others (New York: The New Press, 1997) p. 17.
12. Michel Foucault, Les Anormaux. Cours au College de France, 1974-1975, ed. V. Marchetti and A. Saomoni (Paris: Gallimard/Seuil, 1999) pp. 16 20 and pp. 143-144; English translation, Abnormal. Lectures at the College de France 1974-1975, ed. Valerio Marchetti and Antonella Salomoni, English series ed. Arnold I. Davidson, trans. Graham Burchell (New York: Picador, 2003) pp. 16-21 and pp. 154 156.
13. "Les rapports de pouvoir passent a l'interieur des corps" Dits et Ecrits, vol. 3, p. 229-
14. "Entretien avec Michel Foucault" p. 140; "Truth and Power" p. 111.
15. See above, "Course Summary. "
16. L. Bonnafe, "Sources du desalienisme" in Desaliener? Folie(s) et Societe(s) (Toulouse: Presses universitaires du Mirail/Privat, 1991) p. 221.
17. Esprit, 20th year, December 1952, "Misere de la psychiatric La vie asilaire. Attitudes de la societe (Textes de malades, de medecins, d'un infirmier, denoncanl la vie asilaire chroni- cisante, la surpopulation, le reglement modele de 1838). " Foucault refers to this "remarkable number of Esprit" in Maladie mentale et Personnalite, p. 109, n. 1.
? 18. An allusion to the cases of arbitrary confinement, the most famous cases of which arc those
of General Gngorenko, arrested in February 1964 under the charge of anti Soviet activi- ties and confined in the Serbski Institute in Moscow, and Vladimir Borissov, confined in the special psychiatric hospital of Leningrad--for the liberation of whom a campaign was led by Victor Fainberg, supported by some intellectuals including David Cooper and Michel Foucault. See, "Enlermement, psychiatrie, prison" Dits et Ecrits, vol. 3, pp. 332 360. There was also the confinement ol the dissident Wladimir Boukovski in autumn 1971. See W. Boukovski, Une nouvc/le maladie mentale en URSS: /'opposition (Paris: Le Seuil, 1971).
19- T. Laine, "Une psychiatrie differente pour le malaise a vivre," La Nouvelle Critique, no.
power relationship that gives rise to a knowledge, which in turn founds the rights of this power, is the characteristic feature of "classical" psychiatry. It is this circle that antipsychiatry undertakes to unravel: giving the individual the task and right of taking his madness to the limit, of taking it right to the end, in an experience to which others may contribute, but never in the name of a power conlerred on them by their reason or normality; detaching behavior, suffering, and desire from the medical status given to them, freeing them from a diagnosis and symp tomatology that had the value not just of classification, but of decision and decree; invalidating, finally, the great retranscription of madness as mental illness that was begun in the seventeenth and completed in the nineteenth century.
Demedicalization of madness is correlative with this fundamental questioning of power in antipsychiatric practice. This enables us to take the measure of the latter's opposition to "depsychiatrization," which seemed to be the characteristic feature of both psychoanalysis and psychopharmacology, both of which stemmed rather from an overmedical ization of madness. Straightaway the problem opens up of the possibility of freeing madness from that singular lorm of power-knowledge (pouvoir-savoir) that is knowledge (connaissance). Is it possible for the production of the truth of madness to be carried out in forms other than those of the knowledge relation? It will be said that this is a fictitious problem, a question that arises only in Utopia. Actually, it is posed con- cretely every day with regard to the role of the doctor--of the statutory subject of knowledge--in the depsychiatrization project.
*
The seminar was devoted alternately to two subjects: the history of the hospital institution and of hospital architecture in the eighteenth century; and the study of medico-legal expertise in psychiatric questions since 1820.
? 2. }. \.
5.
6. 7. 8.
9-
10.
11.
Ibid.
Esquirol, De lafolie, ? 5: "Traitenient de la lolie," pp. 132 1}3; Mental Maladies, p. 79.
D. Cooper, Psychiatry and Antipsychiatry (London: Tavistock, 1967), p. V\', French translation, Psychiatric el Antipsychia/rie, trans. M. Braudeau (Pans: Ed. du Seuil, 1970), p. 33. F. Basaglia, ed. VLtitu^ione negata. Rapporto da un ospedale psichiatrico (Turin: Nuovo politecnico, 1 9 6 8 ) ; French translation, Les Institutions de la violence, in F. Basaglia, ed. , Vlnstitution en negation. Rapport sur I'hopital psychiatrique de Gori^ia, t r a n s . L. B o n a l u m i (Paris: Ed. du Seuil, 1970), p. 105.
On this subject, see R. Caslel, Le Psychanalysme ( Paris: Maspero, 197$), pp. 150 15*.
F. Basaglia, Vinstitution en negation, p. 111.
Thomas Stephen Szasz, is an American psychiatrist and psychoanalyst, born in Budapest in 1920. Professor ol psychiatry al the University of Syracuse (New York), he was the only American psychiatrist to join the "antipsychiatric" movement that developed in the 1960s. His work carries out a critique ol psychiatric institutions on the basis ol a liberal and humanist conception ol the subject and human rights. See his collection ol articles, Ideology and Insanity (London: Calder & Boyars, 1970); French translation, Ideologic et Folie. Essais sur la negation des oaleurs humanistes dans la psychiatric d'aujourd'hui, trans. P. Sullivan (Paris: P. U. F. , I976), and The Myth of Mental Illness (New York: Harper & Row, 1961); French translation, Le Mythe de la maladie menlale, trans. D. Berger (Paris: Payot, 1975).
Kingsley Hall is one of three reception centers created in the 1960s. Situated 111 a working class area ol London's East End, it is known through the account given by Mary Barnes, who spent live years there, and her therapist, Joe Berke, in their book, Two Accounts of a
Journey Through Madness (London: MacGibbon and Kee, 1971); French translation, Ma/y Barnes, un voyage autour de la folie, trans. M. Davidovici (Pans: Seuil, 1973).
The experiment al Villa 21,which began inJanuary 1962 in a psychiatric hospital in North Wesl London, inaugurated the series ol anlipsychiatnc community experiments, one ol the best known of which is Kingsley Hall. David Cooper, its director until 1966, provides an account in Psychiatry and Antipsychiatry.
An Italian public psychiatric hospital in northern Trieste. In 196} Franco Basaglia and his team began to undertake its institutional translormation. Vinstitution en negation provides an account of this anti institutional struggle that became an example. Basaglia gave up the direction of Gorizia in 1968 in order to pursue his experiment in Trieste.
1. J. E. D. Esquirol, De la folie (1816), ? l, "Symplomes de la lolie," in Des maladies menlales considerees sous les rapports medical, hygienique el medico-legal, 2 volumes (Paris: Bailliere, 1838), vol. 1, p. 16 (republished, Paris: Frenesie, 1989, in the series "Les Inlrouvables de la psychiatric"); English translation, Mental Maladies. A Treatise on Insanity, trans. E. K. Hunt (Philadelphia: Lea and Blanchard, 18'|5) p. 27.
Course Summary 347
? COURSE CONTEXT Jacques Lagrange
THE LECTURES DEVOTED TO "Psychiatric Power," delivered between 7 November 1973 and 6 February 1974, have a paradoxical rela- tionship to earlier works. There is continuity to the extent that, as Michel Foucault himself notes, they take off at the "the point reached by my earlter work, Histoire de lafolie, or, at any rate, the point where it broke off" (lecture of 7 November 1973). In fact, Histoire de lafolie had opened a space for future research that would have reconstructed "the constitutive but historically mobile ground that made possible the development of concepts from Esquirol and Broussais up to Janet and Freud. "' This is confirmed by an (unpublished) interview with Colin Gordon and Paul Patton of 3 April 1978: "When I wrote Histoire de la
folie I had in mind that it would be the first chapter, or the beginning, of a study that would continue up to the present. "
But there is also discontinuity, as is evident from statements that are careful to mark shifts and, in his own words, "see what I had done from a new vantage point and in a clearer light. "2 The first works were inter ested in "mental illness" rather than "mental medicine,"3 and in the Preface to the first edition, Histoire de lafolie is presented as a "history not of psychiatry, but of madness itself, in its vivacity, before all capture by knowledge. "1 What's more, if the lectures take up the analysis at the
? 350 PSYCHIATRIC POWF. R
point it left off in Histoire de lafolie, they shift the stake and change both the terrain on which it is set out and the conceptual tools it puts to work. Hence, the question arises of what made these shifts possible and necessary? This involves understanding the production of this series of lectures, not only in the conceptual dynamic that leads them to give an important and strategic place to power and its apparatuses (dispositifs), but also in the held of problems that psychiatry had to confront in the 1970s that brought the question of power to the fore.
1. THE STAKE OF THE COURSE
The first lecture envisioned taking as a starting point the present situation ol psychiatry in the light of the contribution ol antipsychiatry to a reorientation of questions around the "power relations" that "con ditioned how the asylum institution functioned" and "governed the lorms ol medical intervention,""' and proceeding to a retrospective analysis, starting Irom the present, oi the historical formation of this apparatus ol power. This is what gives this way of writing the history of psychiatry its specificity. 6 In contrast to approaches engaged in recon structmg the evolution ol concepts and doctrines, or in analyzing the working ol institutions in which psychiatry produces its effects, this way of analyzing the history of the psychiatric apparatus seeks to reveal its lines of force or Iragility, its points of resistance or possible attack. Thus, it is no longer a question, as it was in the first writings, of putting psy chiatry on trial and accusing it of concealing the real conditions of men- tal pathology behind nosological abstractions and a causal way of thinking. 7 Neither is it a question, as in Histoire de lafolie, ol under- standing why, at a certain point in the history ol our relationships with the mad, the latter were placed in specific, supposedly curative institu- tions. Henceforth, history is used to bring to light obscure relations of continuity which connect our present apparatuses to old bases linked to a given system of power, with the aim ol isolating objectives of struggle: "In the domain ol psychiatry," Foucault stated in May 1973, "it seems to me interesting to know how psychiatric knowledge, the psychiatric institution, was installed at the beginning of the nineteenth century ( . . . ) i( we wish today to struggle against all the instances of normalization. "8
? Hence the originality of the course's problematic. For if at times there was a clear suspicion that the light of medical truth was supported by the shadow of force relations appearing in forms of authority and domination,9 this was not accompanied by an analysis of the extraordinarily meticu- lous and skillfully hierarchized power of the asylum. Concerning power, Foucault later recognized: "I'm perfectly aware that I scarcely ever used the word and never had such a field of analyses at my disposal. "10
What brought the problem of psychiatric power to the fore no doubt involved the conjunction of two elements: one spectfic to the conceptual dynamic of Foucault's research, and the other arising from the conjuncture of the 1970s.
This conjunction involves the shift carried out by Foucault that led him to replace references to institutional "violence" and modes of "domination" by what, in the 1971-1972 College de France lectures, "Penal Theories and Institutions," he will call "the basic forms of 'power knowledge. '"1] This reorientation is no doubt linked to the interest in medico-legal expertise--the subject matter of his seminar-- which confronted him with the need to consider how and why a discourse that claimed to be scientific, but which was also questionable, brought with it effects ol power in penal practice. This interest was strengthened by cases that had caused quite a stir: those of Denise Labbe and Jacques Algarron in 1955, or of Georges Rapin in 1960-- referred to in the lecture of 8 January 1975 in his lectures on "Les Anormaux. "12 His attention to problems of the prison also convinced him that the problem of power should be approached "in terms ol technology, in terms of tactics and strategy. "13 But, at the same time, the conjuncture must also have ensured that it was no longer a question of the theorettcal justification of psychiatry, as it was tn the fifties when, Foucault recalls, "one of the great problems that arose was that of the political status of science and the ideological functions it could serve,"1/| but suddenly revealed this elementary rock: power. Who has power? Over whom is it wielded? With regard to what is it exercised? How does it function? Of what use is it? What is its place amongst other powers? 15
Certainly, the first response to the crisis of psychiatry in the post war period was at least as much political as medical. Thus, the "desalieniste" movement initiated by the communist psychiatrist Lucien Bonnafe, who
Course Context 351
? 352 PSYCHIATRIC POWER
set himself the goal of "opening our eyes to that alienated-alienating system established, with the assistance of the science of 'alienation* ( . . . ) in an order modeled on the principles and habits of a social order that excludes what dtsturbs it. "16
But these denunciations of a psychiatry (^alienisme) accused of complicity with procedures of discrimination and exclusion do not succeed in formulating the question of psychiatric "power" as such. There are several reasons for this.
First of all, because the legacy of the war raised the question of not so much psychiatric power as of "the destitution of psychiatry. "17 Then, as Foucault notes, because "those psychiatrists in France who, for political reasons, would have been in a position to question the psychiatric apparatus (. . . ) found themselves blocked by a political situation in which, basically, one did not want the questton to be raised at all, because of what was taking place in the Soviet Union. "18 Finally, criticism may well have questioned the means available to psychiatric practice, or denounced the contradiction between what the psychiatric institution claims to do and what it really does, but it was still expressed in terms of the institutional project and its own criteria, propostng new, more supple modalities of intervention, further removed from the "medical" model, and appealing to a "different psychiatry," to use the terms of Lucien Bonnafe and Tony Laine. 19 And if this questioning of psychiatric practices did not open up the question of "psychiatric power," it is no doubt because the struggles taken up could not get beyond the framework of psychiatric corporatism and defense of the medical corps of psychiatric hospitals, as Foucault emphasizes: "Because of the posi- tion of psychiatrists, most ol whom were state employees, many were brought to question psychiatry from a defensive trade-union angle. Thus, those individuals who, by virtue of their abilities, their interests, and their openness to so many things, would have been able to address the problems of psychiatry, were led into impasses. "20 As a result of this, the problem of power could only find expression in a derivative mode: the trade-union struggle of the medical corps of psychiatric hos- pitals. As Foucault notes, psychiatrists "could struggle against medicine and the administration without being able to Iree themselves from either one or the other. "21
? It needed the intervention of events Irom outside, therefore, for psychiatry to be posed the question ol its "power. " This was a new political activism that, after '68, challenged a doctor's power to decide on a person's mental state, and proposed giving space for a different mode of receptton of madness freed from psychiatric structures and ide- ology. Thus we see the development of local and dispersed sectional strug- gles in which Foucault saw "the insurrection of subjugated knowledge," that is to say, of forms of knowledge usually dismissed as poorly developed theoretically and of a lower status. There was, for example, the struggle of young psychiatrists whose less pronounced corporattst concerns allowed them to take a more political position that, on the model of GIP (Groupe Information Prisons), led to the creation of GIA (Groupe Information Asiles) in 1972, which was soon taken over by the "psychiatrized" themselves to denounce the scandals of arbitrary con- finement. New alliances were forged with the "psychiatrized" that gdv^ rise to the journal Psychiatrises en lutte and the chance for the voices of mental health workers and patients to be heard. 22 As a counterpoint to the Congress of Psychiatry and Neurology on the theme of the Formation et role de Vinfirmier en psychiatrie (Auxerre, September 1974), a movement developed that was run by nurses who were anxious to free themselves from a medical supervision that they accused of hiding their practice and knowledge, and who sought to reintegrate tnto their work social and political elements marginalized by "establishment" psychiatry. In this way the Association for the study and creation of the White Book of psychiatric institutions (AERLIP) was born, and the report of its counter-congress, Des infirmiers psychiatriques prennent la parole}7* Seeing reference to "specialized competence" as conferring social legitimacy on the psychiatrist's "power," some so-called "anti-psychiatric" tendencies undertook to break with all the ways of taking care of patients that reduce the complexity of their situation to a technical problem to be dealt with by competent specialists. This view inspired the title of a work by Roger Gentis: Psychiatry must be practiced/dismantled by everyone. 2'*
Learning from these movements, in June 1973 Foucault could say: "the importance of anti psychiatry is that it challenges the doctor's power to decide on an individual's state of mental health. "25
Course Context 353
? 354 PSYCHIATRIC POWER
2. THE REGISTER OF THE COURSE
Fixing for oneself a "histonco-political" stake involving the analysis of the conditions of formation of psychiatric knowledge and practice so as to define "strategies of struggle" calls for a shift of the points of problematization. It is difficult, in fact, to undertake such an analysis as long as the historical order is relativized by reference to some constitu- tive "ground," or, as in Maladie mentale et Psychologie, by reference to the original experience of a "true man. "26 Also, whereas in Histoire de la folk "the fine rectitude that leads rational thought to the analysis of madness as mental illness" is reinterpreted "in a vertical dimension,"27 the lectures abandon this imaginary of depth so as to keep to the reality of surface effects. The lectures thus seek to grasp the discursive practices of psychiatry at their point of formation: an "apparatus (dispositif)" of power bringing together heterogeneous elements like discourses, modes of treatment, administrative measures and laws, regulatory arrange- ments, architectural plans, and so forth. 28 This involves a problem of "proximity," therefore, rather than one of "foundation. " Hence a style of analysis according to a principle of "dispersion," one that multiplies knowledges and practices in order to bring out their components, recon- struct their associated spaces, and establish connections, thereby giving a "shape" to the documentary mass brought under analysis.
3. CONCEPTUAL TOOLS
Taking up the work begun by Histoire de lafolie on a fresh basis requires a change of conceptual tools. First of all, reference to an "apparatus of power" replaces the reference to forms of "representation" to which, on Foucault's own admission, Histoire de lafolie was still attached. Thus, the lectures replace a style of analysis that put a kind of "core of representations"29 at its center--the image constructed of madness, the dread it provoked, a madness that portrayed "the deja-la of death,"30 etcetera--with reference to an "apparatus ol power" that at a given moment has a dominant strategic function.
Second, recourse to the notion of "violence," which underlay analyses of the modes of treatment presented in the second and third parts of the
? work, has to be abandoned. In fact, the connotations of this notion make it particularly unsuitable for the analysis ot the power relations and tactics that permeate psychiatric practice. Suggesting the idea of imme- diate coercion, of the irregular, unreflected exercise of power, it cannot reconstruct the idea of a calculated and meticulous exercise of power put to work in the asylum, and for which "violence" represents only a limit figure. Moreover, this notion, which makes power an agency for solely negative effects--exclusion, repression, interdiction--tails to take into account the productivity of psychiatric power and its capacity to pro- duce discourses, forms of knowledge, and induce pleasure, etcetera. In short, bringing with it the idea ol an unbalanced relation ol lorce that makes it impossible for the other person to do anythtng other than what he is forced to do, this notion is hardly suited for reconstructing the complexity of games of power like the "great maneuvers" of the hysterics faced with medical power at Salpetnere. 31
Finally, the asylum "institution" is no longer to be taken as the essential reference, but analysis moves to its "outside" so as to resituate its con- stitution and operations within a technology of power typical ol society. Hence the distance taken from Histoire de lafolie, which, in Foucault's own words, claimed to be a "history of the psychiatric institution" and linked the formation of psychiatric knowledge to a process of the "institutionalization" of mental medicine. 32
This is what gives this course its originality in comparison with all the critical tendencies that developed after the war, and which have in common that they take the asylum "institution" as their target, either in order to reform it, or to sublimate it, or to deny its legitimacy.
3. 1. Reforming the asylum institution. Previously thought of as insepara- bly both a milieu for treatment and a space of segregation, shortly after the war there is a movement that accuses psychiatry (^alienisme) of com- plicity with practices of discrimination and exclusion, and that aims to free psychiatric intervention from the straitjacket of the asylum structure and its "stagnation" in order to make it an "activity entirely directed by a therapeutic perspective". 33 This is why Lucian Bonnafe calls his criti- cism "post-Esquirolism," demonstrating his concern to transform an inherited milieu of segregation into a real therapeutic instrument, by
Course Context 355
? 356 PSYCHIATRIC POWER
referring to "the mutation accomplished in the fundamental idea of the institution of treatment ( . . . ) formulated in 1822 with Esquirol's well- known clarity: Tn the hands of a skilled doctor, a lunatic asylum is an instrument of cure, tt is the most powerful therapeutic agent against mental illnesses'. "3^
However, by asserting "the unity and indivisibility of prevention, prophylaxis, cure and post-cure,"35 this movement at the same time increasingly took its distance from an asylum institution, constituted by the law of 30 June 1838 as the quasi exclusive site of psychiatric inter vention, in order to make it no more than one element among others in an apparatus directly linked to the community. 36 However, what repre- sents an aggiornamento of psychiatry does not break with the latter's stakes: the constitution of "pathological" social behavior as an object of medical intervention and the assembly of apparatuses for deploying a therapeutic activity. So, although this movement may well identify the contradictions between what the institution claims to do and what it really does, it does not succeed in addressing the question of "psychiatric power," since the criticism is formulated in terms of the institutional project and of its own criteria.
3. 2. Sublimating the institution. Whereas supporters of the first kind of "institutional psychotherapy" submitted to the existence of the estab- lishments to which they were appointed, trying to use them as best they could on the therapeutic level, those of the second kind of "insti- tutional psychotherapy" engaged in a radical modification of the thera- peutic institution on the basis of a supposed discontinuity between psychiatry and psychoanalysis. Taking place on a completely different scene, involving a completely different type of relationship between patient and therapist, and organizing a different mode and formation of discourse, psychoanalysis appeared as a permanent resource with regard to the problems posed by asylum life, making it possible to readapt the structures of care. It is as if the institution is "sublimated" from within through a sort of collectivization of analytic concepts: transferences become "institutional"37 and fantasies become "collective. " The "political" criticism of psychiatry is then expressed in the name of the logic of the unconscious, and sources of resistance to the truth of desire, the hierarchical structures of institutions, and the socio cultural
? representations of mental illness in which both therapists and patients are caught, are all equally denounced. Just as the hospital of Samt- Alban (Lozere) had been the reference point of the first "institutional psychotherapy," the La Borde clinic at Cour-Cheverny (Loir-et-Cher), opened in April 1953 by Jean Oury and Felix Guattari, represented the model realization of analytic "institutional psychotherapy" and its mam center of diffusion. 38
In a perspective focused on the institution's "interior," it was difficult to get back to what, outside the institution, determines its organization and role. So much so that the correlation of psychiatry with the public domain as organized by the law, which means that the psychiatrist takes on certain functions insofar as he exercises a public mandate, was dissolved in the field of discourses and the imaginary. Thus Tosquelles could say that "the problematic of power as it functions within treatment groups ends up, of itself, being expressed in the field of speech, usually as an imaginary projection in the collective discourse woven in the group in question. "39
The corresponding Italian version--although Franco Basaglia (1924- 1980) challenged the "anti psychiatry" label'0--criticized the asylum apparatus from a political point of view as the privileged site of the contradictions of capitalist society. Born in the very specific context of the law of 14 February 1904, which essentially gave the police and magistrates responsibility for aid to mental patients, and within the framework of Basaglia's experience of the deplorable conditions of the hospitahzation of patients in 1961,when he took over direction of the psychiatric hospital at Gorizia, near Trieste, the Italian current was situated in a decidedly revolutionary perspective. ^1 The Italians rejected the idea of a possible restructuring of the asylum, whether in the form of division into "sectors" or in that of "therapeutic communities," which they suspected of reviving the old apparatus of social control in a toler- ant form;/|2 they turned to practices based on a break with all the institu- tional mechanisms that could reproduce the separation and sequestration of the social life of those who have dealings with psychiatry: "Our action," Basaglia declared, "can only be continued in a negative dimen- sion that, in itself, is a destruction and overcoming that, going beyond the coercive-carceral system of psychiatric institutions ( . . . ) moves onto the
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terrain of violence and exclusion inherent in the socio-political system. "^3 With the aim of working towards the de-institutionalization of responsibility for patients, the Italian movement opted for an open- ing towards non professionals and an alliance with political and trade union forces of the left, which resulted in the constitution of Pskhiatrica Democratka in 1974.
However, it was the English current, coming out of the work of David Cooper (1931-1989), Aaron Esterson and Ronald Laing (1927 1989) on schizophrenics and their family circle, which had the greatest impact in France/^ In the sixties this movement developed a radical critique of psychiatry and its institutional and symbolic violence, accepting Cooper's label of "anti-psychiatry. "^ This violence was not only the physical violence of the constraints of confinement, but also the violence exercised by the analytic rationality that, through its nosological catego- rization, passes off as "mental illness"--which is subject to a specialized competence and calls for the establishment of a relationship of tutelage-- the way in which a subject tries to respond to the oppression of which he has been the victim since birth and which is continued through var- ious institutions delegated by society: family, school, work, etcetera. It is because of the "violence" of the psychiatric institution towards this "experience"--which the subject should take to its extreme limits if he would be "transformed" by it, in a process that Laing describes, in evangelical terms, as "conversion," or metanoia--that its space should be de medicalized and removed from the relations ol power deployed within it. "Instead of the mental hospital, a sort of re servicing factory for human breakdowns, we need a place where people who have trav elled further and, consequently, may be more lost than psychiatrists and other sane people, can find their wayfurther into inner space and time, and back again. ,,/|6 From this came the constitution of the Philadelphia Association, in April 1965, by Cooper, Esterson, and Laing, with the aim of "organising places to welcome people who are suffering from or have suffered from mental illnesses," and to "change the way in which the facts of 'mental health* and 'mental illness* are considered. ",7
Now, whereas these post-War critical currents focus on the psychi- atric institution as the point of problematization, the lectures shift the site by adopting the principle that "before tackling institutions, we have
? to deal with the relations of force in these tactical dispositions that per- meate institutions. "^8 Actually, the notion of the institution harbors a number of inadequacies and "dangers" to which Foucault returns on a number of occasions. First of all, approaching the problem of psychiatry through this notion amounts to starting with given, pre-constituted objects--the group and its functional regularities, the individual who is a member of the group, etcetera--when it would be more appropriate to analyze the procedures of its constitution at the level of dispositions of power and the processes of individualization they involve. Then again, by focusing on an institutional microcosm, one runs the risk of separat- ing it from the strategies in which it is formed and in which it produces its effects, consequently "throwing m," as the lectures say, "all the psychological or sociological discourses. " The problematic of the lee tures can be compared, for example, with that of Erving Goffman's Asylums, to which Foucault pays tribute on a number of occasions. "19 Certainly, one merit of the book is to make it possible to escape from medical rationalizations by "de-specifying" the psychiatric institution, so to speak, by placing it within a range of different structures--school, prison, etcetera--through the perspective of the notion of total institutions [English in original; G. B. J which typify establishments specialized in supervising individuals and controlling their mode of life. But this quasi-ethnographic approach to the asylum institution has its limits. Taking the latter as, in effect, an autonomous "totality," so as simply to situate it in a range of other institutions, it fails to show that the asylum is a response to an evolving historical problematic. Consequently, the nature of the break constitutive of the asylum site can only be thought in a static way, through binary oppositions like inside/outside, being confined/leaving, etcetera, which mark the barriers "to social intercourse with the outside and to departure that" total institutions often build "right into the physical plant, such as locked doors, high walls, barbed wire, cliffs, water, forests, or moors. "30 If, for this image of a "shut up" space, we substitute the idea of "an enclosed space for a confrontation,
the site of a duel, an institutional field in which victory and submission are at stake,"51 then the asylum break acquires a new dimension. This "enclosed" milieu then appears for what it really is: a milieu actively cut out, that is to say, captured from old forms of custody through historical
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processes that make the mad person emerge as someone who is differentiated less by reference to the family than within a technico- administrative field. This is emphasized in the lecture of 5 December 1973: "The mad individual now emerges ( . . . ) as a danger for society, and no longer as someone who may jeopardize the rights, wealth, and privileges of a family. " At the same time, the central place of the psychi- atrist, emphasized by Goffman, takes on another dimension; the psy- chiatrist is not distinguished from the madman by the fact that he is free, but by the fact that he intervenes as an ambassador of the external world, charged with imposing the norms of society within the asylum. He is "someone who must give reality that constraining force by which it will be able to take over the madness, completely penetrate it, and make it disappear as madness. "32
Whereas the problem for Goffman is the problem posed by the institution itself and its functioning, the problem to which the lectures are devoted is that of how a certain technique, connected to social and political structures, authorizes "the rationalization of the management of the individual. "53
From this derives the particular style of an archeology of the psychiatric institution, which, from George III to Charcot, multiplies wonderful panoptic "scenes" that reveal the operations and procedures making up this "microphysics" of power, and break up what solidity the asylum institution had. As the manuscript for the lecture of V\ November 1973 makes clear, by "scene" we should understand, "not a theatrical episode, but a ritual, a strategy, a battle"; scenes which, inserted in the work of the analysis like fragments of mirror, bring together, in a glance, the theoretical implications that the argument will develop.
Approaching the apparatus of psychiatry in this way, by reference to mechanisms of power, weakens the foundation on the basis of which psy- chiatry deployed its theoretical and practical conquests: a requirement of specificity. In fact, from its constitution as a "special medicine" endowed with "special establishments," "specialized" doctors, the psychiatrists, and "special" legislation, the law of 30 June 1838, up until the attempts at transforming its institutional structures just after the war, this idea of a "specificity" of mental medicine constitutes a main theme around which, we can say, the best part of the profession has rallied. 5''
? Course Context 361 4. POINTS OF PROBLEMATIZATION
The analysis of the psychiatric apparatus is structured around three axes: that of power, insofar as the psychiatrist is established as a subject acting on others; the axis of truth, insofar as the insane individual is constituted as an object of knowledge; and the axis of subjectivation, since the subject has to make the norms imposed on him his own.
4. 1. Power. Defined in the seventies with the problematic of knowledge- power, this axis shifts previous questionings. Basically, the first texts, in fact, addressed to psychiatry the question: "What you say is true? Give me the grounds of your truth! " Henceforth the question, the demand is: "Give us the grounds of your power! By what right do you exercise it? In whose name? To what advantage? " "Power" therefore, and no longer "violence" as in the previous works. As a result, there is a change in the paradigmatic figure around which the criticism of the Anglo-Saxon "anti-psychiatrists" was ordered, and which put the question of the "violence" exercised by society in general and psychiatry in particular at its core:55 the schizophrenic. 56
However, when we approach the psychiatric apparatus by reference to the mechanisms of power that organize it, it is the hysteric who, by laying the "trap" of the lie for a doctor like Charcot armed with the highest medical knowledge, paradigmatically portrays the militant underside of psychiatric power. 57 This is why, in Foucault's view, the hysteric deserves the title of the first "militant of anti-psychiatry," as he puts it in the lecture of 23 January 1974, since, by her "maneuvers," she challenges the doctor's role of "responsibility for producing the truth of illness within the hospital space. "5 Foucault can also declare in his contribution to a colloquium organized by Henri Ellenberger in May 1973: "The age of anti-psychiatry began when one suspected, and then, soon afterwards, was sure, that Charcot, the great master of mad- ness, the person who made it appear and disappear, was not the person who produced the truth of the illness, but the one who fabricated its artifice. "59
Now, this power to which the lectures are devoted has a double char- acteristic. In the final instance its point of application is bodies: their distribution in the asylum space, their ways of behaving, their needs,
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their pleasures; in short, it is a power "commanded by all the disposi tions of a kind of microphysics of bodies. " Moreover, the relations of power installed between the psychiatrist and his patient are fundamen- tally unstable, constituted by struggles and confrontations in which points of resistance are present at every moment. This is the case with these "counter maneuvers" by which the hysterics shake Charcot's power, escaping the categorizations to which he wanted to assign them, thereby giving a new impetus to the apparatus of medical power- knowledge on the basis of these resistances, to the point that, Foucault says, "a crisis" is opened up "that had to lead to anti-psychiatry. "60
4. 2. Knowledge and truth. As the lecture of 5 December 1973 recalls, "as a disciplinary system, the asylum is also a site for the formation of a certain type of discourse of truth. " Hence the analyses of the ways in which apparatuses of power and games of truth are articulated. This is the case for the "proto-psychiatric" modality, in which a game is orga- nized around the delirious conviction, within the regime of a "test" in which the doctor is posed as the ambiguous master of reality and truth, or, on the other hand, a game in which the question of truth no longer arises in the confrontation of doctor and patient, since it is now only posed within psychiatric power established as medical science. In this mode of analysis we can see that truth is called upon less as an intrinsic property of statements than at the level of its functionality, through the legitimation it provides for the discourses and practices on the basis of which psychiatric power organizes its exercise, and by the mode of exclusion it authorizes.
4. 3. Subjection (assujettissement). The therapist who approaches the individual to be treated from the outside, at the same time as he resorts to procedures that enable him to extract from this individual his inner subjectivity--questioning, anamnesis, etcetera--puts the subject in the position of having to interiorize the orders and norms imposed on him. In the lecture of 21 November 1973, the problem is also broached from the angle of the modes of subjection that make the subject appear as a complex and variable "function" of regimes of truth and discursive practices.
However, these lectures, which sought to give a sequel, on new bases, to Histoire de lafolie, will remain without future. For, in these years,
? circumstances are such as to give preference to participation in effective action, instead of, as Foucault says, the "scribbling of books. " Thus, from 1972 he recognized that "writing today a sequel to my Histoire de lafolie, which would continue up to the present, is for me without interest. On the other hand, a concrete political action in favor of prisoners seems to me to be highly meaningful. "61 However, at the same time, Foucault was preparing Discipline and Punish. Birth of the Prison.
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1. Michel Foucault, Histoire de la folie a I'dge dassique (Paris: Gallimard, 2ml edition, 1972) p. 541. This is omitted from the abridged English translation: Michel Foucault, Madness and Civilisation. A History of Insanity in the Age of Reason, trans. Richard Howard (New York: Random House, 1965 and London: Tavistock, 1967).
2. Michel Foucault, "Usage des plaisirs et techniques de soi," in Dits et Ecrits, 1954-1988, ed. D. Defert and F. Ewald, with the collaboration of J. Lagrange (Paris: Gallimard, 1994) vol. 4, p. 545; English translation, "Introduction," The Use of Pleasure. The History of Sexuality, vol. 2, trans. Robert Hurley (New York: Pantheon Books, 1985) p. 11.
3. Michel Foucault, Maladie mentale et Personnalite (Paris: Presses universitaires de France, 1954) and the modified version of this, Maladie mentale et Psychologie (Paris: Presses universitaires de France, 1962); English translation, Mental Illness and Psychology, trans. Alan Sheridan (New York: Harper and Row, 1976).
4. Michel Foucault, "Preface" to Folie et Deraison. Histoire de lafolie a /'age dassique (Paris: Plon, 1961) p. vii (omitted from the French 1972 edition and from the English translation); reprinted in Dits et Ecrits, vol. 1, p. 192.
5. "Course summary," above, p. 345-
6. That is, its specificity in relation to both earlier and later studies of the history of
psychiatry. See in particular, E. H. Ackerknecht, A Short History of Psychiatry (New York:
Hafner, 1968).
7. Thus, Foucault's "Introduction" to L. Bmswanger, Le Reve et I'Existence, trans. J. Verdeaux
(Paris: Desclee de Brouwer, 1954) denounces the tendency of psychiatrists to consider "the illness as an 'objective process,' and the patient as an inert thing in which the process takes place" p. 104. Reprinted in Dits et Ecrits, vol. 1, p. 109; English translation, "Dream, Imagination and Existence. An Introduction to Ludwig Binswanger's Dream and Existence" trans. Forrest Williams, in M. Foucault and Ludwig Binswanger, Dream and Existence, trans. Forrest Williams and Jacob Needleman, ed. Keith Hoeller, Special Issue from Review of Existential Psychology and Psychiatry, vol. XIX, no. 1,1984 85, p. 66.
8. "La verite et les formes juridiques" Dits et Ecrits, vol. 2, p. 644; English translation, "Truth and Juridical Forms" trans. Robert Hurley, The Essential Works of Michel Foucault 1954-1984, Vol. 3: Power, ed. James D. Faubion, trans. Robert Hurley and others (New York: The New
Press, 2 0 0 0 ) . See also the interview with Foucault on Radio France, 8 October 1972, "Punir ou guenr": "I think this historical analysis is politically important inasmuch as it is necessary to locate exactly what one is struggling against. "
9- "If the medical personage could isolate madness, it was not because he knew it, but because he mastered it; and what lor positivism would be an image of objectivity was only the other side of this domination" Histoire de lafolie, p. 525; Madness and Civilisation, p. 272.
10. "Entretien avec Michel Foucault" Dits el Ecrils, vol. 3, p. 146; English translation, "Truth and Power" trans. Colin Gordon, Essential Works of Foucault, 3, p. 117.
11. "Theories et institutions penales" Dits el Ecrits, vol. 2, p. 390; English translation, "Penal Theories and Institutions" trans. Robert Hurley, The Essential Works of Michel Foucault, 1954-1984, vol. 1: Ethics: subjectivity and truth, ed. Paul Rabinow, trans. Robert Hurley and others (New York: The New Press, 1997) p. 17.
12. Michel Foucault, Les Anormaux. Cours au College de France, 1974-1975, ed. V. Marchetti and A. Saomoni (Paris: Gallimard/Seuil, 1999) pp. 16 20 and pp. 143-144; English translation, Abnormal. Lectures at the College de France 1974-1975, ed. Valerio Marchetti and Antonella Salomoni, English series ed. Arnold I. Davidson, trans. Graham Burchell (New York: Picador, 2003) pp. 16-21 and pp. 154 156.
13. "Les rapports de pouvoir passent a l'interieur des corps" Dits et Ecrits, vol. 3, p. 229-
14. "Entretien avec Michel Foucault" p. 140; "Truth and Power" p. 111.
15. See above, "Course Summary. "
16. L. Bonnafe, "Sources du desalienisme" in Desaliener? Folie(s) et Societe(s) (Toulouse: Presses universitaires du Mirail/Privat, 1991) p. 221.
17. Esprit, 20th year, December 1952, "Misere de la psychiatric La vie asilaire. Attitudes de la societe (Textes de malades, de medecins, d'un infirmier, denoncanl la vie asilaire chroni- cisante, la surpopulation, le reglement modele de 1838). " Foucault refers to this "remarkable number of Esprit" in Maladie mentale et Personnalite, p. 109, n. 1.
? 18. An allusion to the cases of arbitrary confinement, the most famous cases of which arc those
of General Gngorenko, arrested in February 1964 under the charge of anti Soviet activi- ties and confined in the Serbski Institute in Moscow, and Vladimir Borissov, confined in the special psychiatric hospital of Leningrad--for the liberation of whom a campaign was led by Victor Fainberg, supported by some intellectuals including David Cooper and Michel Foucault. See, "Enlermement, psychiatrie, prison" Dits et Ecrits, vol. 3, pp. 332 360. There was also the confinement ol the dissident Wladimir Boukovski in autumn 1971. See W. Boukovski, Une nouvc/le maladie mentale en URSS: /'opposition (Paris: Le Seuil, 1971).
19- T. Laine, "Une psychiatrie differente pour le malaise a vivre," La Nouvelle Critique, no.
