On 31 December
1819, Jean Pierre Falret (1794-1870) defended his thesis: Observations et propositions medico-chirurgicales, Medical Thesis, Paris, no.
1819, Jean Pierre Falret (1794-1870) defended his thesis: Observations et propositions medico-chirurgicales, Medical Thesis, Paris, no.
Foucault-Psychiatric-Power-1973-74
20
By simulation I do not mean the way in which someone who is not mad could pretend to be mad, because this does not really call psychiatric power into question. Pretending to be mad when one is sane is not some thing like an essential limit, boundary, or defect of psychiatric practice and psychiatric power, because, after all, this happens in other realms of knowledge, and in medicine in particular. We can always deceive a doctor by getting him to believe that we have this or that illness or symptom-- anyone who has done military service knows this--and medical practice is not thereby called into question. On the other hand, and this is the sim- ulation I want to talk to you about, the simulation that was the historical problem of psychiatry in the nineteenth century is simulation internal to madness, that is to say, that simulation that madness exercises with regard to itself, the way in which hysteria simulates hysteria, the way in which a true symptom is a certain way of lying and the way in which a false symptom is a way of being truly ill. All this constituted the insoluble problem, the limit and, ultimately, the failure of nineteenth century psychiatry that brought about a number of sudden developments.
If you like, psychiatry said more or less: I will not pose the problem of truth with you who are mad, because I possess the truth myself in terms of my knowledge, on the basis of my categories, and if I have a
12 December 7973 135
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power in relation to you, the mad person, it is because I possess this truth. At this point madness replied: If you claim to possess the truth once and for all in terms of an already fully constituted knowledge, well, for my part, I will install falsehood in myself. And so, when you handle my symptoms, when you are dealing with what you call illness, you will find yourself caught in a trap, for at the heart of my symptoms there will be this small kernel of night, of falsehood, through which I will confront you with the question of truth. Consequently, I won't deceive you when your knowledge is limited--that would be pure and simple simulation-- but rather, if one day you want really to have a hold on me, you will have to accept the game of truth and falsehood that I ofier you.
Simulation: the whole history of psychiatry can be said to be perme- ated by this problem ol simulation, from the two simulators at Salpetriere in 1821, when it looms up before Georget, one of the leading psychiatrists of the period, until the 1880s and the important episode with Charcot. And when I say this problem, I am not talking about the theoretical problem of simulation, but the processes by which those who were mad actually responded with the question of falsehood to this psychiatric power that refused to pose the question of truth. The untruthfulness of simulation, madness simulating madness, was the anti-power of the mad confronted with psychiatric power.
I think the historical importance of this problem of both simulation and hysteria derives from this. It also enables us to understand the col- lective character of this phenomenon of simulation. We see it emerge around 1821 in the behavior of the two hysterics called "Petronille" and "Braguette. "21 I think these two patients founded an immense historical process in psychiatry; they were imitated in all the asylums in France because ultimately it was their weapon in the struggle with psychiatric power. And with the serious crisis of asylum psychiatry, which broke out at the end of the nineteenth century, around 1880, the problem of truth really was imposed by the mad on psychiatry when, in front of Charcot the great miracle worker, it became evident that all the symp toms he was studying were aroused by him on the basis of his patients' simulation.
I emphasize this history for a number of reasons. The first is that it is not a matter of symptoms. It is often said that hysteria has
? disappeared, or that it was the great illness of the nineteenth century. But it was not the great illness of the nineteenth century; it was, to use medical terminology, a typical asylum syndrome, or a syndrome correl- ative to asylum power or medical power. But I don't even like the word syndrome. It was actually the process by which patients tried to evade psychiatric power; it was a phenomenon of struggle, and not a patho- logical phenomenon. At any rate, that is how I think it should be viewed.
Second, we should not forget that if there was so much simulation within asylums after Braguette and Petronille, this was not only because it was made possible by the coexistence of patients withm the asylums, but also because of sometimes spontaneous and sometimes involuntary, sometimes explicit and sometimes implicit complicity with the patients on the part of the personnel, of warders, asylum doctors, and medical subordinates. We should not forget that Charcot practically never exam ined a single one of these hysterics, and that all his observations, falsi- lied by simulation, were actually given to him by the personnel surrounding the patients, and who, together with the patients, with greater or lesser degrees of complicity, constructed this world of simula- tion as resistance to psychiatric power that, m 1880 at Salpetnere, was incarnated in someone who, precisely, was not even a psychiatrist, but a neurologist, and so someone most able to base himself on the best constituted discourse ol truth.
The trap of falsehood, then, was set for the person who came armed with the highest medical knowledge. So the general phenomenon of simulation in the nineteenth century should be understood not only as a process of the patients' struggle against psychiatric power, but as a process of struggle at the heart of the psychiatric system, of the asylum system. And I think we arrive here at the episode that must be the aim of my course, which is the moment when, precisely, the question of truth, put aside after Pinel and Mason Cox by the disciplinary system ol the asylum and by the type of functioning of psychiatric power, was lorcibly reintroduced through all these processes. *
* The manuscript adds: "We can, then, call antipsychiatry any movement by which the question ol l ruth is put back in play within the relationship between the mad person and the psychiatrist. "
12 December 7 9 7 3 137
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We may say that psychoanalysis can be interpreted as psychiatry's first great retreat, as the moment when the question of the truth ol what is expressed in the symptoms, or, in any case, the game of truth and lie in the symptom, was forcibly imposed on psychiatric power; the prob- lem being whether psychoanalysis has not responded to this first defeat by setting up a first line of defense. At any rate, credit should not be given to Freud for the first depsychiatrization. We owe the first depsy chiatrization, the first moment that made psychiatric power totter on the question of truth, to this band of simulators. They are the ones who, with their falsehoods, trapped a psychiatric power which, in order to be the agent ol reality, claimed to be the possessor of truth and, within psychiatric practice and cure, refused to pose the question of the truth that madness might contain.
There was what could be called a great simulator's insurrection that spread through the whole of the asylum world in the nineteenth century, and the constant and endlessly rekindled source of which was Salpetnere, an asylum for women. This is why I don't think we can make hysteria, the question ol hysteria, the way in which psychiatrists got bogged down in hysteria in the nineteenth century, a kind of minor scientific error, a sort of epistemological blockage. It is clearly very reas suring to do this, because it makes it possible to write the history ol psychiatry and the birth of psychoanalysis in the same style as the expla nation of Copernicus, Kepler, or Einstein. That is to say, there is a sci entific blockage, an inability to get free from the excessive number oi spheres of the "Ptolemaic" world, or from Maxwell's equations, etcetera. We find secure footing in this scientific knowledge and, starting from this kind of dead-end, see an epistemological break and then the sudden appearance of Copernicus or Einstein. By posing the question in these terms, and by making the history of hysteria the analogon of these kinds of episodes, the history of psychoanalysis can be placed in the calm tradition ol the history of the sciences. However, if, as I would like to do, we make simulation--and so not hysteria--the militant underside ol psychiatric power rather than an epistemological problem of a dead end, if we accept that simulation was the insidious way lor the mad to pose the question of truth forcibly on a psychiatric power that only wanted to impose reality on them, then I think that we could write a
? history of psychiatry that would no longer revolve around psychiatry and its knowledge, but which finally would revolve around the mad.
And you can see that if we take up the history of psychiatry in this way, then it can be seen that what we can call the institutional perspec tive, which poses the problem of whether or not the institution is the site of violence, is in danger of suppressing something. It seems to me that it delineates the historical problem of psychiatry--that is to say, the problem of this power of reality that it was the psychiatrist's task to re-impose and which was trapped by the questioning falsehood of the simulators--in an extraordinarily narrow way.
This is the kind of general background I would like to give to the lollowing lectures. So, next week, I will try to resume this history, which I have suggested to you in a sketchy way, by taking up the problem of how psychiatric power functioned as a surplus-power of reality.
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1. In 1861 the asylum received 1227 insane persons, 561 men and 666 women, divided into 215 paying and 1212 destitute residents. See the work by the asylum's director, Guslave L a b i t t e , De la colonie de Fit^-James, succursale de I'asile prive de Clermont (Oise), considered au
point de vue de son organisation administrative el medicale (Paris: J. B. Bailliere, 1861) p. 15. On the history of the Clermont asylum, see E. J. Woillez, Essai hislorique, descriplif el slatislique sur la maison d'alienes de Clermont (Oise) (Clermont: V. Danicourt, 1839).
2. The Fitz James colony was created in 1847.
3. "In creating the Fitz James colony, first of all we wanted the patients to be in a completely
different environment than that ol Clermont" G. Labitte, De la colonie de Fit^-James, p. 13.
4. In 1861, the larm comprised "170 patients," ibid. p. 15.
5. According to G. Labilte's description: "1. The management section allocated to living
quarters for the director and male residents. 2. The Farm section, where the colonists stay. 3. The Petit Chateau section, inhabited by resident women. /|. The Bevrel section, occupied by women employed in laundering the linen" ibid. p. 6.
6. "On the larm . . . work in the fields and workshops, looking alter and managing animals and plowing tools, are the remit ol maniacs, monomaniacs and the demented" ibid. p. 15.
7. Ibid.
8. Ibid. p. V\. 9. Ibid.
10. P. Pinel, Traite medico-philosophique, section VI, ? iv: "Essai lente pour guerir une melancolie profonde produile par une cause morale" pp. 233 237; A Treatise on Insanity, "An attempt to cure a case ol melancholia produced by a moral cause" pp. 227i 227.
11. Joseph Mason Cox, Practical Observations on Insanity, Case II, p. 51; Observations sur la de? nence,(^06), p. 77.
12. Ibid. p. 51; ibid. p. 78.
13. Ibid. p. 52; ibid. pp. 78 79.
V\. F. Leuret, Fragments psychologiques sur la folie (Paris: Crochard, 1837|) ch. 2: "Delirium ol
intelligence": "The chair hirer of a Parisian parish, treated by Monsieur Esquirol,. . . said he had bishops in his belly who were holding a council. . . Descartes thought it an established tact that the pineal gland is a mirror which reflected the image ol external bodies . . . Is one of these assertions better proved than the other? " p. 7i3. Leuret is referring to Descartes' analysis of the role ol the pineal gland in the lormation of ideas ol objects which strike the senses: R. Descartes, Traite de VFlomme (Paris: Clerselier, 1667|) in Descartes, CEuvrcs el Lettres, ed. A. Bridoux, pp. 8 5 0 853; English translation, "Treatise on Man," trans. Robert Slootholl, in The Philosophical Writings oj Descartes, trans. John Cottingham, Robert Slootholl, Dugald Murdoch (Cambridge: Cambridge University Press, 1985) vol. 1, p. 106.
15. In this conception, "Judging is the action in which the mind, bringing together dillerent ideas, aflirms ol one that it is the other, or denies ol one that it is the other. This occurs when, for example, having the idea ol the earth and the idea ol round, I affirm or deny ol the earth that it is round" A. Arnauld and P. Nicole, La Logique, ou VArl depenser, contcnanl, outre les regies communes, plusieurs observations nouvelles propres a former le jugemenl ( 1 6 6 2 ) (Paris: Desprez, 1683, 51'1 edition) p. 36; English translation, Logic, or, The art of thinking, trans. J. V. Buroker (Cambridge: Cambridge University Press, 1996) p. 23. See, L. Mann, La Critique du discours. Sur la "Logique de Port-Royal" et les "Pensees de Pascal" ( P a r i s : E d . d e Minuit, 1975) pp. 275 299; and Foucault's comments in Les Mots et let Choses, Part One, "Representer," pp. 72 81; The Order oj Things, pp. 58 67; and, "Introduction" to A. Arnauld and C. Lancelot, Grammaire generale et raisonnee conlenanl lesJondements de Part de
parler expliques d'une maniere claire et nalurelle (Paris: Republications Paulet, 1969),
reprinted in Dits el Ecrits, vol. 1, pp. 732 752.
16. On this theatrical production, see Michel Foucault, Histoirc de lafolie, pp. 350 354; Madness
and Civilisation, pp. 187 191. The second lecture ol the College de France course of 1970 1971, "The Will to Knowledge," speaks of this "theatricalization" of madness as an "ordeal test" which involves "seeing which oi the two, patient or doctor, would keep up the game of truth the longest, all this theater of madness by which the doctor objectively real- ized as it were the patient's delirium and, on the basis ol this feigned truth, reached the patient's truth" (personal notes;J. L. ).
? 17. Whereas paralytic disorders were considered to be intercurrent affections ol the develop ment of dementia or, as Esquirol said, a "complication" of the illness (sec the article " D e m e n c e " in Dictiotmairc des sciences medicates, par unc sociele de medecins et de chirurgiens | Paris: C. L. F. Panckoucke, 1814] vol. VIII, p. 283, and the article "Folie" vol. XVI, 1816), in 1822, Antoine Laurent Jesse Bayle (1799-1858), on the basis of six observations lol lowed by anatomical checks, gathered in the department ol Royer Collard at Salpetnere, identified a morbid entity which, following the anatomical cause to which he attributed it, he called "chronic arachnitis," using the tact that "in all the periods ol the illness, there is a constant relationship between the paralysis and the delirium . . . we therelore could not reluse to accept that these two orders ol phenomena are the symptoms ol a single illness, that is to say of a chronic arachnitis," to which he devotes a first part ol his thesis defended on 21 November 1822 (Recherches sur les maladies mentales, Medical Thesis, Paris, no. 1/|7 [Paris: Didot Jean, 1822j): Recherches sur /'arachnitis chronique, la gastrile, la gaslro-enterite, et la goutle, considerees comme causes de {'alienation menlale (Pans: Gabon, 1822; centenary repub licalion Paris: Masson, 1922) vol. 1, p. 32. Bayle later extended his conception to most men tal tllnesses: "Most mental illnesses are the symptoms of an original chronic phlegmasia ol the 'membranes of the brain' " Traitc des maladies et de scs membranes (Paris: Gabon, 1826) p. xxiv. See also his text, "De la cause orgamque de l'alienation mentale accompagnee de paralysie generale" (read at the Imperial Academy ol Medicine) Annales medico-
psychologiques, 3rJ series, vol. 1,July 1855, pp. 409 425.
18. In the 1820s, a group ol young doctors turned to pathological anatomy on which it tried to graft clinical psychiatry. Felix Voisin set out the programme: "Given the symptoms, how can the seat ol the disease be determined. This is the problem that medicine illuminated by physiology can address today" Des causes morales et physiques des maladies mentales, et de quelcjues aulres afjeclions telles que I'hyslerie, la nymphomanie el le salyriasis ( Paris: J. B. Bailliere, 1826) p. 329. In 1821, two students of Leon Rostan (1791 1866), Achille |de| Foville (1799 1878) and Jean Baptiste Delaye (1789 1879), presented a paper for the Prix Esquirol: "Considerations sur les causes de la folie et de leur mode d'action, suivies de recherches sur la nature et le siege special de cette maladie" (Paris: 1821).
On 31 December
1819, Jean Pierre Falret (1794-1870) defended his thesis: Observations et propositions medico-chirurgicales, Medical Thesis, Paris, no. 296 (Paris: Didot, 1919) belore publishing his, De rhypocondrie el du suicide. Considerations sur les causes, sur le siege el le traitemenl du ces maladies, sur les moyens d'en arrctcr les progres et d'en prevoir les developpements ( P a n s : Croullebois, 1822). On 6 December 1823, Falret gave a lecture to the Athenee de Medecine: "Inductions ttrees de Pouverture des corps des alienes pour servir an diagnostic et an traitemenl des maladies mentales" (Paris: Bibliotheque Medicale, 182/|).
In 1830 a debate on the organic causes ol madness was started on the occasion ol the thesis ol one ol Esquirol's students, Etienne Georget (who entered Salpetriere in 1816 and in 1819 won the Prix Esquirol with his paper: "Des ouvertures du corps des alienes") which was defended on 8 February 1820, Dissertation sur les causes de la folie, Medical Thesis, Paris, no. 31 (Pans: Didot Jeune, 1820), and in which he criticizes Pinel and Esquirol lor being satisfied with observation of the phenomena of madness without seeking to connect them to a productive cause. In his work, De lafolie, p. 72, Georget declares: "I must not tear linding mysell in opposition to my teachers . . . by demonstrating that madness is a cerebral
idiopathic allection. "
19. It was Jean Pierre Falret who asserted that, thanks to isolation, "the lamily, in the silence
ol a positive law, overcoming the fear of committing an arbitrary act, and making use of the imprescriptible right of reason over delirium, subscribes to the teachings ol science in order to obtain the benefit of the cure of the insane. " J. -P. Falret, Observations sur le projel de loi relalij aux alienes, presented le 6 Janvier 1837 a la Chambrc des deputes par le ministre de Vlnterieur (Paris: Everal, 1837) p. 6.
20. The problem of simulation was raised in 1800 by P. Pinel who devoted a chapter to it in his Traile medico-philosophique section VI, ? xxii: "Mania simulee; moyens de la reconnoitre" pp. 297 302; A Treatise on Insanity, "Feigned mania: the method of ascertaining it," pp. 282 287. See also, A. Laurent, Etude medico-Iegalc sur la simulation de lafolie. Considerations cliniques et
pratiques a I'usage des medecins experts, des magistrals el desjurisconsulles (Paris: Masson, 1866); H. Bayard, "Memoire sur les maladies simulees," Annales d'hygiene publique et de medecine
72 December 7973 141
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PSYCHIATRIC POWER
21.
legate, lsl series, vol. XXXVIII, 1867, p. 277; E. Boisseau, "Maladies simulees" in A. Dechambre and others, eds. Diclionnaire encyclopedic/ue des sciences medicates, 2,H series, vol. 2 (Paris: Masson/Asselin, 1876) pp. 266-281; G. Tourcles, "Simulation" ibid. pp. 681 715. Charcot dealt with the question on several occasions: ( l ) "Ataxie locomotnce, forme anormale" (20 March 1888) in Lecons du mardi a la Salpelriere. Policlinique 1887-1888, notes of the course of M. Blin,J. Charcot, and H. Colin (Paris: Lecrosnier & Babe, 1889) vol. 1, pp. 281-284; (2) Lecture IX: "De 1'ischurie hyslerique," (1873) in Lecons sur les maladies du systeme nervcux, vol. 1, collected and published by D. M. Bourneville (Pans: Delahaye et Lecroisner, 1884, 5th edition) pp. 281 283; English translation, J. M. Charcot, Clinical Lectures on Diseases of the Nervous System, vol. 1, trans. George Sigerson (London: New Sydcnham Society, 1877) Lecture 10, "Hysterical ischuria" pp. 230-232; (}) Lecture 1: "Lec,on d'ouverture de la chaire de clinique des maladies du systeme nerveux" (23 April 1882), and Lecture XXVI: "Cas du mutisme hystenque chez l'homme," both in Lecons sur les maladies du systeme nerveux, vol. 3, collected and published by Babinski, Bernard, Fere, Guinon, Marie and Gilles de La Tourcttc (1887) (Paris: Lecroisner & Babe, 1890), pp. 17 22 and 452-433; English translation, J. M. Charcot, Clinical Lectures on Diseases of the Nervous System, trans. Thomas Savill (London and New York: Tavistock/Routledge, 1991) vol. 3, Lecture I, "Introductory," pp. 14 19, and Lecture 26, "A Case ot Hysterical Mutism in a man," pp. 368 570.
In 1821, at Salpetnere, Etienne Georget, attracted by the experiments conducted by the Baron Jules Dupotet de Sennevoy in October 1820 at the Hotel Dieu in the department ol Hussun, with the help of Leon Rostan, converted two patients into somnambulistic experimental subjects: Petronille and Manoury, the widow Brouillard, called "Braguette. " See A. Dechambre, "Nouvelles experiences sur le magnetisme animal" Gazette medicale de Paris, 12 September 1835, p. 585- Georget reports these experiments, without revealing the identity ol the patients, in De la physiologie du systeme nerveux, et specialement du ccrveau, vol. 1, ch. 3: "Somnambulisme magnetique" (Paris:J. B. Bailliere, 1821) p. 404. See also, A. Gauthier, Histoire du somnambulisme: che^ tous les peuples, sous les noms divers d'extases, songes, oracles, visions, etc. (Paris: F. Maltese, 1842) vol. 2, p. 324; A. Dechambre, "Deuxieme lettre sur le magnetisme animal," Gazette medicale de Paris, 1840, pp. 13-14, and "Mesmensme," in Diclionnaire encyclopedique des sciences medicates, 2ml series (Paris: Masson/Asselin, 1877) vol. VII, pp. 164 165.
? se^en
19 DECEMBER 1973*
Psychiatric power. ^ A treatment by Francois Leuret and its strategic elements: 1-creating an imbalance of power; 2-the reuse of language; 3-the management of needs; 4-the statement of truth. ^ The pleasure of the illness. ^ The asylum apparatus
(dispositif).
THE ESSENTIAL FUNCTION OF psychiatric power is to be an effective agent of reality, a sort of mtensifier of reality to madness. In what respect can this power be defined as a surplus-power of reality?
To begin to sort out this question a little, I would like to take the example ot a psychiatric treatment of around the years 1838-1840. How did psychiatric treatment take place at this time?
At first sight, at the time of the establishment, the organization, of the asylum world, there was no treatment, because recovery was expected as a sort of, if not spontaneous, at least automatic process of reaction to the combination of four elements. These were: first, isolation in the asylum; second, physical or physiological medication with opiates,1 laudanum,2 etcetera; third, a series of restraints peculiar to asylum life, such as discipline, obedience to a regulation,3 a precise diet/1 times of sleep and of work,5 and physical instruments of constraint; and then, finally, a sort of psychophysical, both punitive and therapeutic medication,
* In the manuscript this lecture is given the title: "The psychiatric cure. "
? 144 PSYCHIATRIC POWER
like the shower,6 the rotary swing,7 etcetera. These combined elements defined the framework oi treatment from which recovery was expected without any theory or explanation ever being given for this recovery*
Despite this initial appearance, I think psychiatric treatment devel- oped in terms of a number of plans, tactical procedures, and strategic elements that can be defined and are, I believe, very important for the constitution of psychiatric knowledge, maybe up until our own time.
I will take one cure as an example that, to my knowledge, is the most developed example in the French psychiatric literature. Sadly the psy chiatrist who provided this example has an unfortunate reputation: Leuret, the man of moral treatment, who for a long time was reproached for his abuse of punishment and the shower, and other such methods. 8 He is certainly the person who not only defined the classical psychiatric cure in the most precise, meticulous way, and who left the most docu ments concerning his treatments, but I think he is also the person who developed his practices, his strategies of treatment, and pushed them to a point of perlection which makes it possible both to understand the general mechanisms which were put to work by other psychiatrists, his contemporaries, and to see them in slow motion, as it were, m detail and in terms of their subtle mechanisms.
The treatment is that of a M. Dupre and is reported in the final chapter of the Traitement moral de lafolie in I87i0. 9 "M. Dupre is a short, fat man, given to stoutness; he walks alone and never addresses a word to anyone. His gaze is uncertain, his countenance vacant. He is con stantly belching and farting, and he frequently makes a very disagreeable little grunt with the aim of ridding himself of the emanations that have entered his body by means of necromancy. He is insensitive to the kind- nesses he may be shown and even seeks to avoid them. If one insists it puts him in a bad mood, but without him ever becoming violent, and he says to the supervisor, if one is there: 'Make these madmen who come to torment me go away' He never looks anyone in the face, and if one suc- ceeds in drawing him out from uncertainty and daydreaming for an instant, he immediately falls back into it (. . . ). There are three families
* The manuscript adds: "A code, in short, not a linguistic code of signifying conventions, but a tactical code enabling the establishment and definitive inscription of a certain relationship ol force. "
? on Earth whose nobility makes them pre-eminent over all others; these are the families of the Tartar princes, of Nigritie, and of the Congo. One particular race, the most illustrious of the family of Tartar princes, is that of the Halcyons, of which he is the head, Dupre so-called, but in reality born in Corsica, descendant of Cosroes: he is Napoleon, Delavigne, Picard, Audnent, Destouches, Bernardin de Saint-Pierre, all at the same time. The distinctive sign of his Halcyon status is his con stant ability to enjoy the pleasures of love. Beneath him are degenerate, less favored beings of his race, called three quarters, one quarter, or one hfth Halcyons, according to their amorous abilities. As a result of his excesses, he fell into a state of chronic illness, for the treatment of which his adviser sent him to his Saint-Maur chateau (this is what he calls Charenton), then to Saint-Yon, then to Bicetre. The Bicetre in which he hnds himself is not the one near Paris, and the town one points out to him, some distance from the home, is none other than the town of Langres, in which, in order to deceive him, there are representations ol monuments which bear some resemblance to those of the true Pans. He is the only man in the home; all the others are women, or rather combi- nations of several women, wearing well arranged masks provided with beards and side-whiskers. He positively recognizes the doctor who looks alter him as a cook who was once in his service. The house in which he slept, when coming from Saint-Yon to Bicetre, vanished when he left it. He never reads a newspaper and would not touch one for anything in the world; the newspapers he is given are false, they do not speak of him, Napoleon, and those who read them are accomplices in league with those who produce them. Money has no value; there is nothing but counterfeit money. He often hears the bears and apes talking in the jardm des Plantes. He remembers his stay in his Saint Maur chateau, and even some of the people he met there (. . . ). The multiplicity of his lalse ideas is no less remarkable than the confidence with which he
spouts them. "10
In the subsequent analysis of the lengthy treatment I think we can distinguish a number of game plans or maneuvers, which Leuret never theorizes and for which he provides no explanation founded on an eti ology of mental illness, or on a physiology of the nervous system, or even, more generally, on a physiology of madness. He merely dissects the
79 December 7973 145
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PSYCHIA TRIC POWER
different operations he tried out and these maneuvers can, I think, be divided into four or five major types.
First, there is the maneuver of creating an imbalance of power, that is to say, right from the start or, anyway, as quickly as possible, making power flow in one and only one direction, that is to say, from the doctor. And this is what Leuret hastens to do; his first contact with Dupre consists in creating an imbalance of power: "The first time I approach M. Dupre in order to treat him, I find him in a huge room filled with the supposedly incurably insane. He is sitting, waiting for his meal with his stupid look, indifferent to everything going on around him, completely unaffected by the dirtiness of his neighbors and him self, and seeming to have only the instinct to eat. How to bring him out of his torpor, to give him some real sensations, to make him a bit attentive? Kind words do nothing; would severity be better? I pretend to be unhappy with his words and conduct; I accuse him of laziness, vanity and untruthfulness, and I demand that he stand upright and bareheaded before me. "11
I think this first meeting fully reveals what we could call the general ritual of the asylum. Basically, and Leuret is in no way different from his contemporaries in this respect, in all the asylums of this period, the first episode of contact between the doctor and his patient is indeed this cer- emony, this initial show of force; that is to say, the demonstration that the field of forces in which the patient finds himself in the asylum is unbalanced, that there is no sharing out, reciprocity, or exchange, that language will not pass freely and neutrally from one to the other, that all possible reciprocity or transparency between the different characters inhabiting the asylum must be banished. Right from the start one must be in a different world in which there is a break, an imbalance, between doctor and patient, a world in which there is a slope one can never reascend: at the top of the slope is the doctor; and at the bottom, the patient.
It is on the basis of this absolutely statutory difference of level, of potential, which will never disappear in asylum life, that the process of treatment can unfold. It is a commonplace of the advice given by alienists concerning different treatments that one should always begin by marking power in this way. Power is all on one side, Pinel said when
? he recommended approaching the patient with "a sort ol ceremony ol lear, an imposing air, which can act strongly on the imagination [ol the maniac; J. L. ] and convince him that all resistance is pointless. "12 Esquirol said the same: "In a home for the insane there must be one and only one chief to whom everything is subordinate. "H
Clearly, it is the "principle ol the foreign will" again, which we can call Falret's principle, which is the substitution ol a "loreign will" lor the patient's will. 11 The patient must leel himsell immediately con lronted by something in which all the reality he will lace in the asylum is summed up and concentrated in the doctor's foreign and omnipotent will. By this I do not mean that every other reality is suppressed to the advantage ol the single will ol the doctor, but that the element which carries all the reality that will be imposed on the patient, the support lor this reality the task of which is to get a hold on the illness, must be the doctor's will as a foreign will that is oflicially superior to the patient's will and so inaccessible to any relationship ol exchange, reciprocity, or equality.
This principle has basically two objectives. Its lirst objective is to establish a sort of state of docility that is necessary for the treatment: the patient, in fact, must accept the doctor's prescriptions. But it is not just a question ol subjecting the patient's wish to recover to the doctor's knowledge and power; establishing an absolute difference of power involves above all breaking down the fundamental assertion of omnipo tence in madness. In every madness, whatever its content, there is always an assertion of omnipotence, and this is the target ol the first ritual ol the assertion ol a loreign and absolutely superior will.
In the psychiatry of this time, the omnipotence of madness may man ilest itself in two ways. In some cases it will be expressed within the delirium in the lorm ol ideas of grandeur for example: thinking one is a king. In M. Dupre's case, believing he is Napoleon,'"^ that he is sexually superior to all humanity,16 that he is the only man and all the others are women,1' are all so many assertions, within the delirium itself, of a sort ol sovereignty or omnipotence. But clearly this only applies to cases of delusions of grandeur. Outside of this, when there is no delusion ol grandeur, there is still an assertion of omnipotence, not in the way the delirium is expressed, but in the way it is exercised.
79 December 7973 V\l
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Whatever the content of the delirium, even when one thinks one is persecuted, the fact of asserting one's delirium, that is to say refusing all discussion, reasoning, and proof, is in itself an assertion of omnipotence, and this is absolutely coextensive with all madness, whereas expressing omnipotence within the delirium is only the fact of having delusions of grandeur.
Asserting one's omnipotence in the delirium simply by the fact of being delirious is typical ol all madness.
Consequently, you can see how and why this first move, this first maneuver of the psychiatric operation is justified: it is a matter of break- ing down the omnipotence of madness, ol reducing it by demonstrating a different, more vigorous will endowed with greater power. Georget advises doctors: "Instead of. . . refusing to accord a lunatic the status ol king that he claims, prove to him that he is powerless and that you, who are anything but powerless, can do anything to him; perhaps he will reflect that actually, it may well be that he was in error. "18
So, this lirst contact, which I illustrated with the case ol M. Dupre, is inserted in the general context of asylum practice of this time, obvi- ously with many variants, in the form ol the delirium's omnipotence countered by the doctor's reality and omnipotence, which is accorded him by, precisely, the statutory imbalance ol the asylum. And all the internal discussions ol psychiatric discourse take place around this: some doctors think the doctor's power should be marked (rom time to time with violence, but also, on occasion, with the demand lor esteem and trust, in a compromise mode, with a sort of pact imposed on the patient. Then, on the other hand, there are psychiatrists who recom mend lear, violence, and threats in every case. Some see the fundamen- tal imbalance of power as sufficiently assured by the asylum system itself, its system of surveillance, internal hierarchy, and the arrangement of the buildings, the asylum walls themselves, carrying and defining the network and gradient of power. And then other psychiatrists consider rather that the doctor's own person, his prestige, presence, aggressive- ness, and polemical vigor all give him this mark. All these variants do not seem to me to be important with regard to the basic ritual, which I will show you that Leuret then develops throughout the treatment by clearly opting for the solution of the medical individualization of this
? surplus power conferred by the asylum, and by giving it the very direct lorm of aggression and violence.
One of the themes ol Dupre's delirium was belief m his sexual omnipotence, and that those around him in the asylum were women. Leuret asks Dupre if all the people around him really are women: "Yes" says Dupre. "Me too" asks Leuret. "Ol course, you too. " At this point Leuret takes hold ol Dupre and, "shaking him vigorously, asks him if this is a woman's arm. "19 Dupre is not very convinced, so to convince him more Leuret puts some "grains ol calomel" in his evening food and the unfortunate Dupre sullers violent diarrhea during the night. This enables Leuret to say to Dupre the next morning: "The only man in the asylum is so afraid ol the night that it's given him the runs. "20 This is how he marked his virile and physical supremacy, by producing this artificial sign of fear in Dupre.
We could cite a series ol elements like this throughout the treatment. Leuret puts Dupre in the shower. Dupre struggles, comes out with his delirious themes again, and says: "A woman is insulting me! " "A woman? " says Leuret, and directs the shower on him violently, deep in his throat, until the struggling Dupre recognizes that this really is a man's behavior, and "ends by agreeing that it is a man. "21 So, there is a ritual imbalance of power.
A second maneuver is what could be called the reuse of language. In Iact, Dupre did not recognize people for what they were, believed his doctor was his cook, and gave himsell a series of successive and simulta- neous identities, since he was "Destouches, Napoleon, Delavigne, Picard, Audrieux, Bernardin de Saint-Pierre, all at the same time. "22 Therefore--and this is what characterizes the second maneuver, which, with some overlap, more or less lollows the first chronologically-- Dupre must first of all relearn the names and be able to give each per- son his correct name: "As a result of being pestered, he becomes attentive and obeys. "2* He is made to repeat them until he knows them: "He must learn my name, those of the students, supervisors, and nurses. He must name all of us. "
Leuret makes him read books, recite verse, and forces him to speak the Latin he learned at school; he forces him to speak in Italian, which he had learned when he was in the army; he makes him "tell a story. "24
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Finally, on another occasion, he puts him in the bath, puts him under the shower as usual and, having done this, contrary to the usual practice, orders him to empty the bath. Now Dupre is not accustomed to obey ing orders.
By simulation I do not mean the way in which someone who is not mad could pretend to be mad, because this does not really call psychiatric power into question. Pretending to be mad when one is sane is not some thing like an essential limit, boundary, or defect of psychiatric practice and psychiatric power, because, after all, this happens in other realms of knowledge, and in medicine in particular. We can always deceive a doctor by getting him to believe that we have this or that illness or symptom-- anyone who has done military service knows this--and medical practice is not thereby called into question. On the other hand, and this is the sim- ulation I want to talk to you about, the simulation that was the historical problem of psychiatry in the nineteenth century is simulation internal to madness, that is to say, that simulation that madness exercises with regard to itself, the way in which hysteria simulates hysteria, the way in which a true symptom is a certain way of lying and the way in which a false symptom is a way of being truly ill. All this constituted the insoluble problem, the limit and, ultimately, the failure of nineteenth century psychiatry that brought about a number of sudden developments.
If you like, psychiatry said more or less: I will not pose the problem of truth with you who are mad, because I possess the truth myself in terms of my knowledge, on the basis of my categories, and if I have a
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power in relation to you, the mad person, it is because I possess this truth. At this point madness replied: If you claim to possess the truth once and for all in terms of an already fully constituted knowledge, well, for my part, I will install falsehood in myself. And so, when you handle my symptoms, when you are dealing with what you call illness, you will find yourself caught in a trap, for at the heart of my symptoms there will be this small kernel of night, of falsehood, through which I will confront you with the question of truth. Consequently, I won't deceive you when your knowledge is limited--that would be pure and simple simulation-- but rather, if one day you want really to have a hold on me, you will have to accept the game of truth and falsehood that I ofier you.
Simulation: the whole history of psychiatry can be said to be perme- ated by this problem ol simulation, from the two simulators at Salpetriere in 1821, when it looms up before Georget, one of the leading psychiatrists of the period, until the 1880s and the important episode with Charcot. And when I say this problem, I am not talking about the theoretical problem of simulation, but the processes by which those who were mad actually responded with the question of falsehood to this psychiatric power that refused to pose the question of truth. The untruthfulness of simulation, madness simulating madness, was the anti-power of the mad confronted with psychiatric power.
I think the historical importance of this problem of both simulation and hysteria derives from this. It also enables us to understand the col- lective character of this phenomenon of simulation. We see it emerge around 1821 in the behavior of the two hysterics called "Petronille" and "Braguette. "21 I think these two patients founded an immense historical process in psychiatry; they were imitated in all the asylums in France because ultimately it was their weapon in the struggle with psychiatric power. And with the serious crisis of asylum psychiatry, which broke out at the end of the nineteenth century, around 1880, the problem of truth really was imposed by the mad on psychiatry when, in front of Charcot the great miracle worker, it became evident that all the symp toms he was studying were aroused by him on the basis of his patients' simulation.
I emphasize this history for a number of reasons. The first is that it is not a matter of symptoms. It is often said that hysteria has
? disappeared, or that it was the great illness of the nineteenth century. But it was not the great illness of the nineteenth century; it was, to use medical terminology, a typical asylum syndrome, or a syndrome correl- ative to asylum power or medical power. But I don't even like the word syndrome. It was actually the process by which patients tried to evade psychiatric power; it was a phenomenon of struggle, and not a patho- logical phenomenon. At any rate, that is how I think it should be viewed.
Second, we should not forget that if there was so much simulation within asylums after Braguette and Petronille, this was not only because it was made possible by the coexistence of patients withm the asylums, but also because of sometimes spontaneous and sometimes involuntary, sometimes explicit and sometimes implicit complicity with the patients on the part of the personnel, of warders, asylum doctors, and medical subordinates. We should not forget that Charcot practically never exam ined a single one of these hysterics, and that all his observations, falsi- lied by simulation, were actually given to him by the personnel surrounding the patients, and who, together with the patients, with greater or lesser degrees of complicity, constructed this world of simula- tion as resistance to psychiatric power that, m 1880 at Salpetnere, was incarnated in someone who, precisely, was not even a psychiatrist, but a neurologist, and so someone most able to base himself on the best constituted discourse ol truth.
The trap of falsehood, then, was set for the person who came armed with the highest medical knowledge. So the general phenomenon of simulation in the nineteenth century should be understood not only as a process of the patients' struggle against psychiatric power, but as a process of struggle at the heart of the psychiatric system, of the asylum system. And I think we arrive here at the episode that must be the aim of my course, which is the moment when, precisely, the question of truth, put aside after Pinel and Mason Cox by the disciplinary system ol the asylum and by the type of functioning of psychiatric power, was lorcibly reintroduced through all these processes. *
* The manuscript adds: "We can, then, call antipsychiatry any movement by which the question ol l ruth is put back in play within the relationship between the mad person and the psychiatrist. "
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? 138 PSYCHIATRIC POWER
We may say that psychoanalysis can be interpreted as psychiatry's first great retreat, as the moment when the question of the truth ol what is expressed in the symptoms, or, in any case, the game of truth and lie in the symptom, was forcibly imposed on psychiatric power; the prob- lem being whether psychoanalysis has not responded to this first defeat by setting up a first line of defense. At any rate, credit should not be given to Freud for the first depsychiatrization. We owe the first depsy chiatrization, the first moment that made psychiatric power totter on the question of truth, to this band of simulators. They are the ones who, with their falsehoods, trapped a psychiatric power which, in order to be the agent ol reality, claimed to be the possessor of truth and, within psychiatric practice and cure, refused to pose the question of the truth that madness might contain.
There was what could be called a great simulator's insurrection that spread through the whole of the asylum world in the nineteenth century, and the constant and endlessly rekindled source of which was Salpetnere, an asylum for women. This is why I don't think we can make hysteria, the question ol hysteria, the way in which psychiatrists got bogged down in hysteria in the nineteenth century, a kind of minor scientific error, a sort of epistemological blockage. It is clearly very reas suring to do this, because it makes it possible to write the history ol psychiatry and the birth of psychoanalysis in the same style as the expla nation of Copernicus, Kepler, or Einstein. That is to say, there is a sci entific blockage, an inability to get free from the excessive number oi spheres of the "Ptolemaic" world, or from Maxwell's equations, etcetera. We find secure footing in this scientific knowledge and, starting from this kind of dead-end, see an epistemological break and then the sudden appearance of Copernicus or Einstein. By posing the question in these terms, and by making the history of hysteria the analogon of these kinds of episodes, the history of psychoanalysis can be placed in the calm tradition ol the history of the sciences. However, if, as I would like to do, we make simulation--and so not hysteria--the militant underside ol psychiatric power rather than an epistemological problem of a dead end, if we accept that simulation was the insidious way lor the mad to pose the question of truth forcibly on a psychiatric power that only wanted to impose reality on them, then I think that we could write a
? history of psychiatry that would no longer revolve around psychiatry and its knowledge, but which finally would revolve around the mad.
And you can see that if we take up the history of psychiatry in this way, then it can be seen that what we can call the institutional perspec tive, which poses the problem of whether or not the institution is the site of violence, is in danger of suppressing something. It seems to me that it delineates the historical problem of psychiatry--that is to say, the problem of this power of reality that it was the psychiatrist's task to re-impose and which was trapped by the questioning falsehood of the simulators--in an extraordinarily narrow way.
This is the kind of general background I would like to give to the lollowing lectures. So, next week, I will try to resume this history, which I have suggested to you in a sketchy way, by taking up the problem of how psychiatric power functioned as a surplus-power of reality.
72 December 7973 139
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1. In 1861 the asylum received 1227 insane persons, 561 men and 666 women, divided into 215 paying and 1212 destitute residents. See the work by the asylum's director, Guslave L a b i t t e , De la colonie de Fit^-James, succursale de I'asile prive de Clermont (Oise), considered au
point de vue de son organisation administrative el medicale (Paris: J. B. Bailliere, 1861) p. 15. On the history of the Clermont asylum, see E. J. Woillez, Essai hislorique, descriplif el slatislique sur la maison d'alienes de Clermont (Oise) (Clermont: V. Danicourt, 1839).
2. The Fitz James colony was created in 1847.
3. "In creating the Fitz James colony, first of all we wanted the patients to be in a completely
different environment than that ol Clermont" G. Labitte, De la colonie de Fit^-James, p. 13.
4. In 1861, the larm comprised "170 patients," ibid. p. 15.
5. According to G. Labilte's description: "1. The management section allocated to living
quarters for the director and male residents. 2. The Farm section, where the colonists stay. 3. The Petit Chateau section, inhabited by resident women. /|. The Bevrel section, occupied by women employed in laundering the linen" ibid. p. 6.
6. "On the larm . . . work in the fields and workshops, looking alter and managing animals and plowing tools, are the remit ol maniacs, monomaniacs and the demented" ibid. p. 15.
7. Ibid.
8. Ibid. p. V\. 9. Ibid.
10. P. Pinel, Traite medico-philosophique, section VI, ? iv: "Essai lente pour guerir une melancolie profonde produile par une cause morale" pp. 233 237; A Treatise on Insanity, "An attempt to cure a case ol melancholia produced by a moral cause" pp. 227i 227.
11. Joseph Mason Cox, Practical Observations on Insanity, Case II, p. 51; Observations sur la de? nence,(^06), p. 77.
12. Ibid. p. 51; ibid. p. 78.
13. Ibid. p. 52; ibid. pp. 78 79.
V\. F. Leuret, Fragments psychologiques sur la folie (Paris: Crochard, 1837|) ch. 2: "Delirium ol
intelligence": "The chair hirer of a Parisian parish, treated by Monsieur Esquirol,. . . said he had bishops in his belly who were holding a council. . . Descartes thought it an established tact that the pineal gland is a mirror which reflected the image ol external bodies . . . Is one of these assertions better proved than the other? " p. 7i3. Leuret is referring to Descartes' analysis of the role ol the pineal gland in the lormation of ideas ol objects which strike the senses: R. Descartes, Traite de VFlomme (Paris: Clerselier, 1667|) in Descartes, CEuvrcs el Lettres, ed. A. Bridoux, pp. 8 5 0 853; English translation, "Treatise on Man," trans. Robert Slootholl, in The Philosophical Writings oj Descartes, trans. John Cottingham, Robert Slootholl, Dugald Murdoch (Cambridge: Cambridge University Press, 1985) vol. 1, p. 106.
15. In this conception, "Judging is the action in which the mind, bringing together dillerent ideas, aflirms ol one that it is the other, or denies ol one that it is the other. This occurs when, for example, having the idea ol the earth and the idea ol round, I affirm or deny ol the earth that it is round" A. Arnauld and P. Nicole, La Logique, ou VArl depenser, contcnanl, outre les regies communes, plusieurs observations nouvelles propres a former le jugemenl ( 1 6 6 2 ) (Paris: Desprez, 1683, 51'1 edition) p. 36; English translation, Logic, or, The art of thinking, trans. J. V. Buroker (Cambridge: Cambridge University Press, 1996) p. 23. See, L. Mann, La Critique du discours. Sur la "Logique de Port-Royal" et les "Pensees de Pascal" ( P a r i s : E d . d e Minuit, 1975) pp. 275 299; and Foucault's comments in Les Mots et let Choses, Part One, "Representer," pp. 72 81; The Order oj Things, pp. 58 67; and, "Introduction" to A. Arnauld and C. Lancelot, Grammaire generale et raisonnee conlenanl lesJondements de Part de
parler expliques d'une maniere claire et nalurelle (Paris: Republications Paulet, 1969),
reprinted in Dits el Ecrits, vol. 1, pp. 732 752.
16. On this theatrical production, see Michel Foucault, Histoirc de lafolie, pp. 350 354; Madness
and Civilisation, pp. 187 191. The second lecture ol the College de France course of 1970 1971, "The Will to Knowledge," speaks of this "theatricalization" of madness as an "ordeal test" which involves "seeing which oi the two, patient or doctor, would keep up the game of truth the longest, all this theater of madness by which the doctor objectively real- ized as it were the patient's delirium and, on the basis ol this feigned truth, reached the patient's truth" (personal notes;J. L. ).
? 17. Whereas paralytic disorders were considered to be intercurrent affections ol the develop ment of dementia or, as Esquirol said, a "complication" of the illness (sec the article " D e m e n c e " in Dictiotmairc des sciences medicates, par unc sociele de medecins et de chirurgiens | Paris: C. L. F. Panckoucke, 1814] vol. VIII, p. 283, and the article "Folie" vol. XVI, 1816), in 1822, Antoine Laurent Jesse Bayle (1799-1858), on the basis of six observations lol lowed by anatomical checks, gathered in the department ol Royer Collard at Salpetnere, identified a morbid entity which, following the anatomical cause to which he attributed it, he called "chronic arachnitis," using the tact that "in all the periods ol the illness, there is a constant relationship between the paralysis and the delirium . . . we therelore could not reluse to accept that these two orders ol phenomena are the symptoms ol a single illness, that is to say of a chronic arachnitis," to which he devotes a first part ol his thesis defended on 21 November 1822 (Recherches sur les maladies mentales, Medical Thesis, Paris, no. 1/|7 [Paris: Didot Jean, 1822j): Recherches sur /'arachnitis chronique, la gastrile, la gaslro-enterite, et la goutle, considerees comme causes de {'alienation menlale (Pans: Gabon, 1822; centenary repub licalion Paris: Masson, 1922) vol. 1, p. 32. Bayle later extended his conception to most men tal tllnesses: "Most mental illnesses are the symptoms of an original chronic phlegmasia ol the 'membranes of the brain' " Traitc des maladies et de scs membranes (Paris: Gabon, 1826) p. xxiv. See also his text, "De la cause orgamque de l'alienation mentale accompagnee de paralysie generale" (read at the Imperial Academy ol Medicine) Annales medico-
psychologiques, 3rJ series, vol. 1,July 1855, pp. 409 425.
18. In the 1820s, a group ol young doctors turned to pathological anatomy on which it tried to graft clinical psychiatry. Felix Voisin set out the programme: "Given the symptoms, how can the seat ol the disease be determined. This is the problem that medicine illuminated by physiology can address today" Des causes morales et physiques des maladies mentales, et de quelcjues aulres afjeclions telles que I'hyslerie, la nymphomanie el le salyriasis ( Paris: J. B. Bailliere, 1826) p. 329. In 1821, two students of Leon Rostan (1791 1866), Achille |de| Foville (1799 1878) and Jean Baptiste Delaye (1789 1879), presented a paper for the Prix Esquirol: "Considerations sur les causes de la folie et de leur mode d'action, suivies de recherches sur la nature et le siege special de cette maladie" (Paris: 1821).
On 31 December
1819, Jean Pierre Falret (1794-1870) defended his thesis: Observations et propositions medico-chirurgicales, Medical Thesis, Paris, no. 296 (Paris: Didot, 1919) belore publishing his, De rhypocondrie el du suicide. Considerations sur les causes, sur le siege el le traitemenl du ces maladies, sur les moyens d'en arrctcr les progres et d'en prevoir les developpements ( P a n s : Croullebois, 1822). On 6 December 1823, Falret gave a lecture to the Athenee de Medecine: "Inductions ttrees de Pouverture des corps des alienes pour servir an diagnostic et an traitemenl des maladies mentales" (Paris: Bibliotheque Medicale, 182/|).
In 1830 a debate on the organic causes ol madness was started on the occasion ol the thesis ol one ol Esquirol's students, Etienne Georget (who entered Salpetriere in 1816 and in 1819 won the Prix Esquirol with his paper: "Des ouvertures du corps des alienes") which was defended on 8 February 1820, Dissertation sur les causes de la folie, Medical Thesis, Paris, no. 31 (Pans: Didot Jeune, 1820), and in which he criticizes Pinel and Esquirol lor being satisfied with observation of the phenomena of madness without seeking to connect them to a productive cause. In his work, De lafolie, p. 72, Georget declares: "I must not tear linding mysell in opposition to my teachers . . . by demonstrating that madness is a cerebral
idiopathic allection. "
19. It was Jean Pierre Falret who asserted that, thanks to isolation, "the lamily, in the silence
ol a positive law, overcoming the fear of committing an arbitrary act, and making use of the imprescriptible right of reason over delirium, subscribes to the teachings ol science in order to obtain the benefit of the cure of the insane. " J. -P. Falret, Observations sur le projel de loi relalij aux alienes, presented le 6 Janvier 1837 a la Chambrc des deputes par le ministre de Vlnterieur (Paris: Everal, 1837) p. 6.
20. The problem of simulation was raised in 1800 by P. Pinel who devoted a chapter to it in his Traile medico-philosophique section VI, ? xxii: "Mania simulee; moyens de la reconnoitre" pp. 297 302; A Treatise on Insanity, "Feigned mania: the method of ascertaining it," pp. 282 287. See also, A. Laurent, Etude medico-Iegalc sur la simulation de lafolie. Considerations cliniques et
pratiques a I'usage des medecins experts, des magistrals el desjurisconsulles (Paris: Masson, 1866); H. Bayard, "Memoire sur les maladies simulees," Annales d'hygiene publique et de medecine
72 December 7973 141
? 142
PSYCHIATRIC POWER
21.
legate, lsl series, vol. XXXVIII, 1867, p. 277; E. Boisseau, "Maladies simulees" in A. Dechambre and others, eds. Diclionnaire encyclopedic/ue des sciences medicates, 2,H series, vol. 2 (Paris: Masson/Asselin, 1876) pp. 266-281; G. Tourcles, "Simulation" ibid. pp. 681 715. Charcot dealt with the question on several occasions: ( l ) "Ataxie locomotnce, forme anormale" (20 March 1888) in Lecons du mardi a la Salpelriere. Policlinique 1887-1888, notes of the course of M. Blin,J. Charcot, and H. Colin (Paris: Lecrosnier & Babe, 1889) vol. 1, pp. 281-284; (2) Lecture IX: "De 1'ischurie hyslerique," (1873) in Lecons sur les maladies du systeme nervcux, vol. 1, collected and published by D. M. Bourneville (Pans: Delahaye et Lecroisner, 1884, 5th edition) pp. 281 283; English translation, J. M. Charcot, Clinical Lectures on Diseases of the Nervous System, vol. 1, trans. George Sigerson (London: New Sydcnham Society, 1877) Lecture 10, "Hysterical ischuria" pp. 230-232; (}) Lecture 1: "Lec,on d'ouverture de la chaire de clinique des maladies du systeme nerveux" (23 April 1882), and Lecture XXVI: "Cas du mutisme hystenque chez l'homme," both in Lecons sur les maladies du systeme nerveux, vol. 3, collected and published by Babinski, Bernard, Fere, Guinon, Marie and Gilles de La Tourcttc (1887) (Paris: Lecroisner & Babe, 1890), pp. 17 22 and 452-433; English translation, J. M. Charcot, Clinical Lectures on Diseases of the Nervous System, trans. Thomas Savill (London and New York: Tavistock/Routledge, 1991) vol. 3, Lecture I, "Introductory," pp. 14 19, and Lecture 26, "A Case ot Hysterical Mutism in a man," pp. 368 570.
In 1821, at Salpetnere, Etienne Georget, attracted by the experiments conducted by the Baron Jules Dupotet de Sennevoy in October 1820 at the Hotel Dieu in the department ol Hussun, with the help of Leon Rostan, converted two patients into somnambulistic experimental subjects: Petronille and Manoury, the widow Brouillard, called "Braguette. " See A. Dechambre, "Nouvelles experiences sur le magnetisme animal" Gazette medicale de Paris, 12 September 1835, p. 585- Georget reports these experiments, without revealing the identity ol the patients, in De la physiologie du systeme nerveux, et specialement du ccrveau, vol. 1, ch. 3: "Somnambulisme magnetique" (Paris:J. B. Bailliere, 1821) p. 404. See also, A. Gauthier, Histoire du somnambulisme: che^ tous les peuples, sous les noms divers d'extases, songes, oracles, visions, etc. (Paris: F. Maltese, 1842) vol. 2, p. 324; A. Dechambre, "Deuxieme lettre sur le magnetisme animal," Gazette medicale de Paris, 1840, pp. 13-14, and "Mesmensme," in Diclionnaire encyclopedique des sciences medicates, 2ml series (Paris: Masson/Asselin, 1877) vol. VII, pp. 164 165.
? se^en
19 DECEMBER 1973*
Psychiatric power. ^ A treatment by Francois Leuret and its strategic elements: 1-creating an imbalance of power; 2-the reuse of language; 3-the management of needs; 4-the statement of truth. ^ The pleasure of the illness. ^ The asylum apparatus
(dispositif).
THE ESSENTIAL FUNCTION OF psychiatric power is to be an effective agent of reality, a sort of mtensifier of reality to madness. In what respect can this power be defined as a surplus-power of reality?
To begin to sort out this question a little, I would like to take the example ot a psychiatric treatment of around the years 1838-1840. How did psychiatric treatment take place at this time?
At first sight, at the time of the establishment, the organization, of the asylum world, there was no treatment, because recovery was expected as a sort of, if not spontaneous, at least automatic process of reaction to the combination of four elements. These were: first, isolation in the asylum; second, physical or physiological medication with opiates,1 laudanum,2 etcetera; third, a series of restraints peculiar to asylum life, such as discipline, obedience to a regulation,3 a precise diet/1 times of sleep and of work,5 and physical instruments of constraint; and then, finally, a sort of psychophysical, both punitive and therapeutic medication,
* In the manuscript this lecture is given the title: "The psychiatric cure. "
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like the shower,6 the rotary swing,7 etcetera. These combined elements defined the framework oi treatment from which recovery was expected without any theory or explanation ever being given for this recovery*
Despite this initial appearance, I think psychiatric treatment devel- oped in terms of a number of plans, tactical procedures, and strategic elements that can be defined and are, I believe, very important for the constitution of psychiatric knowledge, maybe up until our own time.
I will take one cure as an example that, to my knowledge, is the most developed example in the French psychiatric literature. Sadly the psy chiatrist who provided this example has an unfortunate reputation: Leuret, the man of moral treatment, who for a long time was reproached for his abuse of punishment and the shower, and other such methods. 8 He is certainly the person who not only defined the classical psychiatric cure in the most precise, meticulous way, and who left the most docu ments concerning his treatments, but I think he is also the person who developed his practices, his strategies of treatment, and pushed them to a point of perlection which makes it possible both to understand the general mechanisms which were put to work by other psychiatrists, his contemporaries, and to see them in slow motion, as it were, m detail and in terms of their subtle mechanisms.
The treatment is that of a M. Dupre and is reported in the final chapter of the Traitement moral de lafolie in I87i0. 9 "M. Dupre is a short, fat man, given to stoutness; he walks alone and never addresses a word to anyone. His gaze is uncertain, his countenance vacant. He is con stantly belching and farting, and he frequently makes a very disagreeable little grunt with the aim of ridding himself of the emanations that have entered his body by means of necromancy. He is insensitive to the kind- nesses he may be shown and even seeks to avoid them. If one insists it puts him in a bad mood, but without him ever becoming violent, and he says to the supervisor, if one is there: 'Make these madmen who come to torment me go away' He never looks anyone in the face, and if one suc- ceeds in drawing him out from uncertainty and daydreaming for an instant, he immediately falls back into it (. . . ). There are three families
* The manuscript adds: "A code, in short, not a linguistic code of signifying conventions, but a tactical code enabling the establishment and definitive inscription of a certain relationship ol force. "
? on Earth whose nobility makes them pre-eminent over all others; these are the families of the Tartar princes, of Nigritie, and of the Congo. One particular race, the most illustrious of the family of Tartar princes, is that of the Halcyons, of which he is the head, Dupre so-called, but in reality born in Corsica, descendant of Cosroes: he is Napoleon, Delavigne, Picard, Audnent, Destouches, Bernardin de Saint-Pierre, all at the same time. The distinctive sign of his Halcyon status is his con stant ability to enjoy the pleasures of love. Beneath him are degenerate, less favored beings of his race, called three quarters, one quarter, or one hfth Halcyons, according to their amorous abilities. As a result of his excesses, he fell into a state of chronic illness, for the treatment of which his adviser sent him to his Saint-Maur chateau (this is what he calls Charenton), then to Saint-Yon, then to Bicetre. The Bicetre in which he hnds himself is not the one near Paris, and the town one points out to him, some distance from the home, is none other than the town of Langres, in which, in order to deceive him, there are representations ol monuments which bear some resemblance to those of the true Pans. He is the only man in the home; all the others are women, or rather combi- nations of several women, wearing well arranged masks provided with beards and side-whiskers. He positively recognizes the doctor who looks alter him as a cook who was once in his service. The house in which he slept, when coming from Saint-Yon to Bicetre, vanished when he left it. He never reads a newspaper and would not touch one for anything in the world; the newspapers he is given are false, they do not speak of him, Napoleon, and those who read them are accomplices in league with those who produce them. Money has no value; there is nothing but counterfeit money. He often hears the bears and apes talking in the jardm des Plantes. He remembers his stay in his Saint Maur chateau, and even some of the people he met there (. . . ). The multiplicity of his lalse ideas is no less remarkable than the confidence with which he
spouts them. "10
In the subsequent analysis of the lengthy treatment I think we can distinguish a number of game plans or maneuvers, which Leuret never theorizes and for which he provides no explanation founded on an eti ology of mental illness, or on a physiology of the nervous system, or even, more generally, on a physiology of madness. He merely dissects the
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different operations he tried out and these maneuvers can, I think, be divided into four or five major types.
First, there is the maneuver of creating an imbalance of power, that is to say, right from the start or, anyway, as quickly as possible, making power flow in one and only one direction, that is to say, from the doctor. And this is what Leuret hastens to do; his first contact with Dupre consists in creating an imbalance of power: "The first time I approach M. Dupre in order to treat him, I find him in a huge room filled with the supposedly incurably insane. He is sitting, waiting for his meal with his stupid look, indifferent to everything going on around him, completely unaffected by the dirtiness of his neighbors and him self, and seeming to have only the instinct to eat. How to bring him out of his torpor, to give him some real sensations, to make him a bit attentive? Kind words do nothing; would severity be better? I pretend to be unhappy with his words and conduct; I accuse him of laziness, vanity and untruthfulness, and I demand that he stand upright and bareheaded before me. "11
I think this first meeting fully reveals what we could call the general ritual of the asylum. Basically, and Leuret is in no way different from his contemporaries in this respect, in all the asylums of this period, the first episode of contact between the doctor and his patient is indeed this cer- emony, this initial show of force; that is to say, the demonstration that the field of forces in which the patient finds himself in the asylum is unbalanced, that there is no sharing out, reciprocity, or exchange, that language will not pass freely and neutrally from one to the other, that all possible reciprocity or transparency between the different characters inhabiting the asylum must be banished. Right from the start one must be in a different world in which there is a break, an imbalance, between doctor and patient, a world in which there is a slope one can never reascend: at the top of the slope is the doctor; and at the bottom, the patient.
It is on the basis of this absolutely statutory difference of level, of potential, which will never disappear in asylum life, that the process of treatment can unfold. It is a commonplace of the advice given by alienists concerning different treatments that one should always begin by marking power in this way. Power is all on one side, Pinel said when
? he recommended approaching the patient with "a sort ol ceremony ol lear, an imposing air, which can act strongly on the imagination [ol the maniac; J. L. ] and convince him that all resistance is pointless. "12 Esquirol said the same: "In a home for the insane there must be one and only one chief to whom everything is subordinate. "H
Clearly, it is the "principle ol the foreign will" again, which we can call Falret's principle, which is the substitution ol a "loreign will" lor the patient's will. 11 The patient must leel himsell immediately con lronted by something in which all the reality he will lace in the asylum is summed up and concentrated in the doctor's foreign and omnipotent will. By this I do not mean that every other reality is suppressed to the advantage ol the single will ol the doctor, but that the element which carries all the reality that will be imposed on the patient, the support lor this reality the task of which is to get a hold on the illness, must be the doctor's will as a foreign will that is oflicially superior to the patient's will and so inaccessible to any relationship ol exchange, reciprocity, or equality.
This principle has basically two objectives. Its lirst objective is to establish a sort of state of docility that is necessary for the treatment: the patient, in fact, must accept the doctor's prescriptions. But it is not just a question ol subjecting the patient's wish to recover to the doctor's knowledge and power; establishing an absolute difference of power involves above all breaking down the fundamental assertion of omnipo tence in madness. In every madness, whatever its content, there is always an assertion of omnipotence, and this is the target ol the first ritual ol the assertion ol a loreign and absolutely superior will.
In the psychiatry of this time, the omnipotence of madness may man ilest itself in two ways. In some cases it will be expressed within the delirium in the lorm ol ideas of grandeur for example: thinking one is a king. In M. Dupre's case, believing he is Napoleon,'"^ that he is sexually superior to all humanity,16 that he is the only man and all the others are women,1' are all so many assertions, within the delirium itself, of a sort ol sovereignty or omnipotence. But clearly this only applies to cases of delusions of grandeur. Outside of this, when there is no delusion ol grandeur, there is still an assertion of omnipotence, not in the way the delirium is expressed, but in the way it is exercised.
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Whatever the content of the delirium, even when one thinks one is persecuted, the fact of asserting one's delirium, that is to say refusing all discussion, reasoning, and proof, is in itself an assertion of omnipotence, and this is absolutely coextensive with all madness, whereas expressing omnipotence within the delirium is only the fact of having delusions of grandeur.
Asserting one's omnipotence in the delirium simply by the fact of being delirious is typical ol all madness.
Consequently, you can see how and why this first move, this first maneuver of the psychiatric operation is justified: it is a matter of break- ing down the omnipotence of madness, ol reducing it by demonstrating a different, more vigorous will endowed with greater power. Georget advises doctors: "Instead of. . . refusing to accord a lunatic the status ol king that he claims, prove to him that he is powerless and that you, who are anything but powerless, can do anything to him; perhaps he will reflect that actually, it may well be that he was in error. "18
So, this lirst contact, which I illustrated with the case ol M. Dupre, is inserted in the general context of asylum practice of this time, obvi- ously with many variants, in the form ol the delirium's omnipotence countered by the doctor's reality and omnipotence, which is accorded him by, precisely, the statutory imbalance ol the asylum. And all the internal discussions ol psychiatric discourse take place around this: some doctors think the doctor's power should be marked (rom time to time with violence, but also, on occasion, with the demand lor esteem and trust, in a compromise mode, with a sort of pact imposed on the patient. Then, on the other hand, there are psychiatrists who recom mend lear, violence, and threats in every case. Some see the fundamen- tal imbalance of power as sufficiently assured by the asylum system itself, its system of surveillance, internal hierarchy, and the arrangement of the buildings, the asylum walls themselves, carrying and defining the network and gradient of power. And then other psychiatrists consider rather that the doctor's own person, his prestige, presence, aggressive- ness, and polemical vigor all give him this mark. All these variants do not seem to me to be important with regard to the basic ritual, which I will show you that Leuret then develops throughout the treatment by clearly opting for the solution of the medical individualization of this
? surplus power conferred by the asylum, and by giving it the very direct lorm of aggression and violence.
One of the themes ol Dupre's delirium was belief m his sexual omnipotence, and that those around him in the asylum were women. Leuret asks Dupre if all the people around him really are women: "Yes" says Dupre. "Me too" asks Leuret. "Ol course, you too. " At this point Leuret takes hold ol Dupre and, "shaking him vigorously, asks him if this is a woman's arm. "19 Dupre is not very convinced, so to convince him more Leuret puts some "grains ol calomel" in his evening food and the unfortunate Dupre sullers violent diarrhea during the night. This enables Leuret to say to Dupre the next morning: "The only man in the asylum is so afraid ol the night that it's given him the runs. "20 This is how he marked his virile and physical supremacy, by producing this artificial sign of fear in Dupre.
We could cite a series ol elements like this throughout the treatment. Leuret puts Dupre in the shower. Dupre struggles, comes out with his delirious themes again, and says: "A woman is insulting me! " "A woman? " says Leuret, and directs the shower on him violently, deep in his throat, until the struggling Dupre recognizes that this really is a man's behavior, and "ends by agreeing that it is a man. "21 So, there is a ritual imbalance of power.
A second maneuver is what could be called the reuse of language. In Iact, Dupre did not recognize people for what they were, believed his doctor was his cook, and gave himsell a series of successive and simulta- neous identities, since he was "Destouches, Napoleon, Delavigne, Picard, Audrieux, Bernardin de Saint-Pierre, all at the same time. "22 Therefore--and this is what characterizes the second maneuver, which, with some overlap, more or less lollows the first chronologically-- Dupre must first of all relearn the names and be able to give each per- son his correct name: "As a result of being pestered, he becomes attentive and obeys. "2* He is made to repeat them until he knows them: "He must learn my name, those of the students, supervisors, and nurses. He must name all of us. "
Leuret makes him read books, recite verse, and forces him to speak the Latin he learned at school; he forces him to speak in Italian, which he had learned when he was in the army; he makes him "tell a story. "24
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Finally, on another occasion, he puts him in the bath, puts him under the shower as usual and, having done this, contrary to the usual practice, orders him to empty the bath. Now Dupre is not accustomed to obey ing orders.
