Tuesday, October 14, 2008

Review: Psychiatric Power

[Michel Foucault. Psychiatric Power: Lectures at the College de France, 1973-1974. New York: Picador, 2006. (Originally published in French in 2003.)]

Every year, the teaching obligations of the professors at the College de France consisted in large part of a series of lectures open to the public about their research over the preceding year. Foucault, being a superstar, attracted huge numbers to his lectures. And since this was the dawn of the age of the portable recording device, lots of those in attendance would record his words, and the lectures have thereby been preserved. This book is the lectures for 1973-1974 transcribed and translated into English.

I recently read and reviewed Madness and Civilization, an English translation of parts of Foucault's much earlier work looking at the shifting meanings of madness between about 1500 and 1800 in Europe. Psychiatric Power is a much different book. I think I got a lot more out of Psychiatric Power, both in terms of my preparation to write a chapter on anti-psychiatry for my book project and in terms of my general political education. The earlier work is, to oversimplify, sort of an intellectual or cultural history of madness. It draws a great deal on references to landmarks of French and broader European culture in the era of its focus. I don't have a lot of background in that sort of material and don't feel it worth my while to invest time in becoming familiar with it, so it did not feel as relevant to my needs and was at times difficult for me to read. This volume, however, focuses on the evolution of -- wait for it -- psychiatric power over much the 19th century. Both the era and the focus on power relations integrated into a developing capitalism mean that the current volume is closer to things that I know at least a little more about.

Part of this difference has to do with Foucault's own trajectory. He is best known for an understanding of power that focuses on the tactics, strategies, and technologies by which it functions in social relations in very practical ways at a micro level. Important aspects of this analysis had not yet begun to take shaped when he wrote Madness & Civilization. From what I gather -- and I don't know for sure because I haven't read it -- the most complete presentation of this analysis is in his History of Sexuality, Volume I, which was published a few years after these lectures, but that approach already appears here in quite a developed form. Starting from that basis, Foucault rejects the approach of focusing on the asylum as a discrete institution, which was the approach taken by a number of other writers who were critically investigating psychiatry in those years. By beginning from the technologies of the power relationships involved, it is possible to reach a more fundamental critique of the problems with psychiatry and to avoid having the very boundary of the institution prevent an analysis of the interconnection of psychiatry with broader social relations.

At least temporally, Foucault begins here where he left off in Madness & Civilization. For a period before 1800, and in contrast with earlier eras, people understood as "mad" were locked up as part of a larger social processes of confinement. At the beginning of the 19th century, however, people in France understood as "mad" were at least symbollically released from their chains, though as Foucault points out it was really more of a change in the character of their confinement than an end to it. There were a couple of crucial transitions at this time. Before that time, madness was understood as being primarily about truth and error, and so curing it could be accomplished by leading the mad person back to truth via getting them close to nature (which was thought to be inherently "true") or via theatrical interventions that kind of played along with madness to bring it to its conclusion. Confinement, in this era, was not at all about treatment. In the early 19th century, however, madness began to be understood as being about reality and about needing to be brought back to reality. Treatment ceased to be about leading a person to truth, and became entirely about forcing the person understood as "mad" to reenter "reality" by imposing the doctor's will on the patient.

The psychiatry of this era had a strange relationship to broader medical practices. On the one hand, the confinement of those thought to be "mad" became clearly understood to be a medical act presided over by a doctor, which had not been true in earlier years. Medicine more broadly was being transformed at this time through the introduction of systematic pathological studies that allowed for the development of differential diagnosis. In some ways, psychiatry participated in this -- it was not able to ground itself in the body through pathology, but it did elaborate schemes of categorization for different sorts of "madness" and it did spend lots of time making observations about patients. The unique thing about psychiatry in the early 19th century was that, unlike the rest of medicine, these categories and observations had nothing to do with how individuals in asylums were treated. The specialized knowledge that developed helped to legitimize the authority of the psychiatrist as genuinely medical in nature, but had nothing to do with how treatment was conducted. As well, the definitive question that psychiatrists had to answer as the functional prerequisite to treatment was not a differential diagnosis to link a particular treatment to a given condition, but an absolute diagnosis -- that is, is the person before me mad or not? If the answer was yes, then even though the way the patient was treated had little basixs in medicine, the power of the doctor over the patient was acceptably medical in nature.

The treatment of all psychiatric inmates was based on asylum discipline. Foucault situates this in a longer history in which a transition occurred in Western societies between two different forms of power, which he describes as sovereignty and discipline. The former is a power of direct command. It takes on different forms that cannot be reduced to each other, but has a single individual at its pinnacle in the form of the sovereign. Those who are subjected to it are never individuals, however, just classes of people who must obey when receiving an order from above. Discipline is a very different form of power. It evolved in isolated areas starting early in the middle ages and with the rise of industrial capitalism came to encompass all of society. Discipline is very much a result of regulation grounded in texts. Dominance is not focused on a single body at the top as in sovereignty, but those who are regulated by discipline -- who are, in many ways, created by discipline -- are controlled by dynamic responses to individual, micro-level behaviours. In addition, all manifestations of disciplinary power are ultimately reducible to the same sorts of processes. (Though I'm sure others could tell me the important differences between their approaches, reading his description of this broad process of transition made me think of a similar account given by Dorothy Smith, I think in Writing the Social, about her understanding of the emergence of what she calls ruling regimes.)

Given all of this -- the understanding of madness as an assertion of the will in defiance of reality, and the disciplinary nature of power within the asylum -- the entire mechanism of "treatment" of people understood as "mad" in the asylum was based on what Foucault characterizes as an "intensification of reality" such that it was imposed over the patient's defiance. The commencement of treatment was a meeting between patient and doctor that, in the manuals of the day, was quite openly about asserting the doctor's dominance. The entire physical and social functioning of the asylum was organized around observing and punishing those incarcerated, and every minute of their time was precisely regulated. They were also controlled through the manipulation of needs, both with simple disciplinary intent and also with more complex functions, such as inculcating habits of relying on earning a wage in order to meet needs. Forms of questioning and confession were used to force people to accept particular identities defined by others, to get people to see themselves in those ways or at least act as if they did.

In all of this, along with the focus on disciplining the patient, where success meant not so much any positive understanding of health but an erasure of all symptoms, there was also the establishment of the person in charge of the asylum as a medical figure despite the lack of input from medical knowledge into the functioning of the asylum.

There is also a fascinating discussion of the role of the family more generally in disciplinary forms of power. Foucault argues that the functioning of power within the family, even once disciplinary power has become generalized in society, is really more like sovereignty. Even once some disciplinary approaches do seep into the family later in the 19th century, there is still something fundamentally different between how power works there and, say, the factory or the asylum or the prison. And this, he says, is because the key function of the family is to attach its subordinate members to disciplinary regimes of power, initially the school, later the workplace, and if necessary the asylum. Disciplinary power in society as a whole, after extracting the nuclear family from its extended origins, maintains the family as a privileged site. The family, in turn, reproduces the attachment of individuals to the disciplines of institutions. This whole description, which I am sure I have not done justice to, gave what felt like a much more practical, functional picture of the role of the family within social relations than the sometimes more abstracted sorts of descriptions one sometimes encounters on the left. It was also quite disturbing, as the parent of someone who is in early stages of being attached to disciplinary power in the school system.

Foucault goes on to an interesting discussion of the difusion of psychiatric power through other areas in society via attention to children labelled "abnormal" and to people labelled "idiots." He also gives some extended attention to different ideas about "truth." This is relevant to early 19th century psychiatry because of the centrality of determining whether a particular person is, indeed, mad. Questioning, drugs, and hypnosis were the central technologies in this determination, though not functioning in the ways one might initially think these would relate to a search for a particular "truth." The question of the "truth" of madness reached a sort of culmination (as does this book) in the great attention to hysteria in the 1870s and 1880s, most famously by a French doctor called Charcot. Foucault traces out an intricate battle between hysterics and their doctors within the web of power relations of the asylum with the reality of madness as a kind of focus, which ultimately resulted in a crisis in psychiatry when it became clear that whatever might or might not be wrong with the hysterical patients, their symptoms had been produced in significant part by a collaborative/competitive process between patients and doctors rather than as some sort of direct product of organic illness. This crisis lead to a couple of different responses from the mind doctors, including psychoanalysis. Foucault characterizes this as a partial victory for those subjected to psychiatric power -- they were "ceasing to be mad so as to become patients, by finally getting through to a true doctor." Throughout the book he emphasizes great continuities between psychiatric power in the 19th century and today, but by forcing greater connection between psychiatric power and the medical knowledge which gave it legitimacy, hysterics eroded some of the absolute disciplinary power of the asylum of the early 19th century.

So. Interesting stuff. Very relevant to the anti-psychiatry of the '60s through the '80s, which is what I'm most focused on at the moment. At one point, Foucault had intended to continue his examination of psychiatric power beyond the 1880s and up to the then-current moment, but his interests and scholarship moved in other directions.

I'm not sure how much I can say about shortcomings of the text. Certainly, as I have heard is more generally true about Foucault, there is little consideration of things like racialized and gendered specificities of experiences of oppression. This is particularly notable given the quite gendered experience of hysteria and his focus on that condition. There is also relatively little attention to any possible relationship between this encounter with the Other within Europe and encounters with the Other in colonial circumstances. At the very end he does point in the direction of the connection with sexual regulation in the 20th century, but does not get to explore it. In general, the arguments pass my "gut test", for whatever that is worth, but there are places, usually where the arguments are more complex, that I do feel a little suspicious. I am not entirely convinced by all of the details of the analysis of the "battle" between hysterics and doctors, for example.

Nonetheless, this is important stuff.

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