Madness and Civilzation ( A History of Madness)

by Foucault, Michel -

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  is the decisive point, if we remember that this letter was written in the middle of the Revolution, long before the reports of Georges Cabanis, and several months after Pinel, according to tradition, had "liberated" the insane of Bicetre:

  "We could perhaps in this latter case leave the madmen there, another class of unfortunates who cause horrible suffering to humanity. . . . Make haste, then, citizens who cherish humanity, to realize such a beautiful dream, and be persuaded in advance that you will thereupon have deserved well of it." So great was the confusion of those years; so difficult was it, at the moment when "humanity" was being re-evaluated, to determine the place madness was to occupy within it; so difficult was it to situate madness in a social sphere that was being restructured.

  IX

  THE BIRTH OF THE ASYLUM

  we know the images. They are familiar in all histories of psychiatry, where their function is to illustrate that happy age when madness was finally recognized and treated ac­cording to a truth to which we had too long remained blind.

  "The worthy Society of Friends . . . sought to assure those of its members who might have the misfortune to lose their reason without a sufficient fortune to resort to expen­sive establishments all the resources of medicine and all the comforts of life compatible with their state; a voluntary subscription furnished the funds, and for the last two years, an establishment that seems to unite many advantages with all possible economy has been founded near the city of York. If the soul momentarily quails at the sight of that dread disease which seems created to humiliate human rea­son, it subsequently experiences gender emotions when it

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  considers all that an ingenious benevolence has been able to invent for its care and cure.

  "This house is situated a mile from York, in the midst of a fertile and smiling countryside; it is not at all the idea of a prison that it suggests, but rather that of a large farm; it is surrounded by a great, walled garden. No bars, no grilles on the windows."1

  As for the liberation of the insane at Bicetre, the story is famous: the decision to remove the chains from the pris­oners in the dungeons; Couthon visiting the hospital to find out whether any suspects were being hidden; Pinel cou­rageously going to meet him, while everyone trembled at the sight of the "invalid carried in men's arms." The con­frontation of the wise, firm philanthropist and the paralytic monster. "Pinel immediately led him to the section for the deranged, where the sight of the cells made a painful im­pression on him. He asked to interrogate all the patients. From most, he received only insults and obscene apostro­phes. It was useless to prolong the interview. Turning to Pinel: 'Now, citizen, are you mad yourself to seek to un­chain such beasts?' Pinel replied calmly: 'Citizen, I am convinced that these madmen are so intractable only be­cause they have been deprived of air and liberty.'

  "'Well, do as you like with them, but I fear you may become the victim of your own presumption.' Whereupon, Couthon was taken to his carriage. His departure was a relief; everyone breathed again; the great philanthropist immediately set to work."2

  These are images, at least insofar as each of the stories derives the essence of its power from imaginary forms: the patriarchal calm of Tuke's home, where the heart's passions and the mind's disorders slowly subside; the lucid firmness of Pinel, who masters in a word and a gesture the two animal frenzies that roar against him as they hunt him down; and the wisdom that could distinguish, between the

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  raving madman and the bloodthirsty member of the Con­vention, which was the true danger: images that will carry far—to our own day—their weight of legend.

  The legends of Pinel and Tuke transmit mythical values, which nineteenth-century psychiatry would accept as ob­vious in nature. But beneath the myths themselves, there was an operation, or rather a series of operations, which silently organized the world of the asylum, the methods of cure, and at the same time the concrete experience of mad­ness.

  Tuke's gesture, first of all. Because it is contemporary with Pinel's, because he is known to have been borne along by a whole current of "philanthropy," this gesture is re­garded as an act of "liberation." The truth was quite differ­ent:" ... there has also been particular occasion to ob­serve the great loss, which individuals of our society have sustained, by being put under the care of those who are not only strangers to our principles, but by whom they are frequently mixed with other patients, who may indulge themselves in ill language, and other exceptionable prac­tices. This often seems to leave an unprofitable effect upon the patients' minds after they are restored to the use of their reason, alienating them from those religious attach­ments which they had before experienced; and sometimes, even corrupting them with vicious habits to which they had been strangers."3 The Retreat would serve as an in­strument of segregation: a moral and religious segregation which sought to reconstruct around madness a milieu as much as possible like that of the Community of Quakers. And this for two reasons: first, the sight of evil is for every sensitive soul the cause of suffering, the origin of all those strong and untoward passions such as horror, hate, and digust which engender or perpetuate madness: "It was thought, very justly, that the indiscriminate mixture, which

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  must occur in large public establishments, of persons of opposite religious sentiments and practices; of the profligate and the virtuous; the profane and the serious; was calcu­lated to check the progress of returning reason, and to fix, still deeper, the melancholy and misanthropic train of ideas ..."4 But the principal reason lies elsewhere: it is that religion can play the double role of nature and of rule, since it has assumed the depth of nature in ancestral habit, in education, in everyday exercise, and since it is at the same time a constant principle of coercion. It is both spon­taneity and constraint, and to this degree it controls the only forces that can, in reason's eclipse, counterbalance the measureless violence of madness; its precepts, "where these have been strongly imbued in early life . . . become little less than principles of our nature; and their restraining power is frequently felt, even under the delirious excite­ment of insanity. To encourage the influence of religious principles over the mind of the insane is considered of great consequence, as a means of cure."5 In the dialectic of in­sanity where reason hides without abolishing itself, religion constitutes the concrete form of what cannot go mad; it bears what is invincible in reason, it bears what subsists be­neath madness as quasi-nature and around it as the constant solicitation of a milieu "where, during lucid intervals, or the state of convalescence, the patient might enjoy the so­ciety of those who were of similar habits and opinions." Religion safeguards the old secret of reason in the presence of madness, thus making closer, more immediate, the con­straint that was already rampant in classical confinement. There, the religious and moral milieu was imposed from without, in such a way that madness was controlled, not cured. At the Retreat, religion was part of the movement which indicated in spite of everything the presence of rea­son in madness, and which led from insanity to health. Re­ligious segregation has a very precise meaning: it does not

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  attempt to preserve the sufferers from the profane presence of non-Quakers, but to place the insane individual within a moral element where he will be in debate with himself and his surroundings: to constitute for him a milieu where, far from being protected, he will be kept in a perpetual anxi­ety, ceaselessly threatened by Law and Transgression.

  "The principle of fear, which is rarely decreased by in­sanity, is considered as of great importance in the manage­ment of the patients."6 Fear appears as an essential presence in the asylum. Already an ancient figure, no doubt, if we think of the terrors of confinement. But these terrors sur­rounded madness from the outside, marking the boundary of reason and unreason, and enjoying a double power: over the violence of fury in order to contain it, and over reason itself to hold it at a distance; such fear was entirely on the surface. The fear instituted at the Retreat is of g
reat depth;

  it passes between reason and madness like a mediation, like an evocation of a common nature they still share, and by which it could link them together. The terror that once reigned was the most visible sign of the alienation of mad­ness in the classical period; fear was now endowed with a power of disalienation, which permitted it to restore a primitive complicity between the madman and the man of reason. It re-established a solidarity between them. Now madness would never—could never—cause fear again; it would be afraid, without recourse or return, thus entirely in the hands of the pedagogy of good sense, of truth, and of morality.

  Samuel Tuke tells how he received at the Retreat a maniac, young and prodigiously strong, whose seizures caused panic in those around him and even among his guards. When he entered the Retreat he was loaded with chains; he wore handcuffs; his clothes were attached by ropes. He had no sooner arrived than all his shackles were removed, and he was permitted to dine with the keepers;

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  his agitation immediately ceased; "his attention appeared to be arrested by his new situation." He was taken to his room; the keeper explained that the entire house was organized in terms of the greatest liberty and the greatest comfort for all, and that he would not be subject to any constraint so long as he did nothing against the rules of the house or the general principles of human morality. For his part, the keeper declared he had no desire to use the means of coer­cion at his disposal. "The maniac was sensible of the kind­ness of his treatment. He promised to restrain himself." He sometimes still raged, shouted, and frightened his compan­ions. The keeper reminded him of the threats and promises of the first day; if he did not control himself, it would be necessary to go back to the old ways. The patient's agita­tion would then increase for a while, and then rapidly de­cline. "He would listen with attention to the persuasions and arguments of his friendly visitor. After such conversa­tions, the patient was generally better for some days or a week." At the end of four months, he left the Retreat, entirely cured. Here fear is addressed to the invalid di­rectly, not by instruments but in speech; there is no ques­tion of limiting a liberty that rages beyond its bounds, but of marking out and glorifying a region of simple responsi­bility where any manifestation of madness will be linked to punishment. The obscure guilt that once linked transgres­sion and unreason is thus shifted; the madman, as a human being originally endowed with reason, is no longer guilty of being mad; but the madman, as a madman, and in the interior of that disease of which he is no longer guilty, must feel morally responsible for everything within him that may disturb morality and society, and must hold no one but himself responsible for the punishment he receives. The assignation of guilt is no longer the mode of relation that obtains between the madman and the sane man in their generality; it becomes both the concrete form of coexist-

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  ence of each madman with his keeper, and the form of awareness that the madman must have of his own madness.

  We must therefore re-evaluate the meanings assigned to Tuke's work: liberation of the insane, abolition of con­straint, constitution of a human milieu—these are only justifications. The real operations were different. In fact Tuke created an asylum where he substituted for the free terror of madness the stifling anguish of responsibility; fear no longer reigned on the other side of the prison gates, it now raged under the seals of conscience. Tuke now trans­ferred the age-old terrors in which the insane had been trapped to the very heart of madness. The asylum no longer punished the madman's guilt, it is true; but it did more, it organized that guilt; it organized it for the madman as a consciousness of himself, and as a non-reciprocal rela­tion to the keeper; it organized it for the man of reason as an awareness of the Other, a therapeutic intervention in the madman's existence. In other words, by this guilt the mad­man became an object of punishment always vulnerable to himself and to the Other; and, from the acknowledgment of his status as object, from the awareness of his guilt, the madman was to return to his awareness of himself as a free and responsible subject, and consequently to reason. This movement by which, objectifying himself for the Other, the madman thus returned to his liberty, was to be found as much in Work as in Observation.

  Let us not forget that we are in a Quaker world where God blesses men in the signs of their prosperity. Work comes first in "moral treatment" as practiced at the Retreat. In itself, work possesses a constraining power superior to all forms of physical coercion, in that the regularity of the hours, the requirements of attention, the obligation to pro­duce a result detach the sufferer from a liberty of mind that would be fatal and engage him in a system of responsibili­ties: "Regular employment is perhaps the most generally

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  efficacious; and those kinds of employment are doubtless to be preferred, both on a moral and physical account, which are accompanied by considerable bodily action; that are most agreeable to the patient and which are most opposite to the illusions of his disease."7 Through work, man re­turns to the order of God's commandments; he submits his liberty to laws that are those of both morality and reality. Hence mental work is not to be rejected; yet with absolute rigor, all exercises of the imagination must be excluded as being in complicity with the passions, the desires, or all delirious illusions. On the contrary, the study of what is eternal in nature and most in accord with the wisdom and goodness of Providence has the greatest efficacity in reduc­ing the madman's immoderate liberties and bringing him to discover the forms of his responsibility. "The various branches of the mathematics and natural science furnish the most useful class of subjects on which to employ the minds of the insane." In the asylum, work is deprived of any productive value; it is imposed only as a moral rule; a lim­itation of liberty, a submission to order, an engagement of responsibility, with the single aim of disalienating the mind lost in the excess of a liberty which physical constraint limits only in appearance.

  Even more efficacious than work, than the observation of others, is what Tuke calls "the need for esteem": "This principle in the human mind, which doubtless influences in a great degree, though often secretly, our general manners;

  and which operates with peculiar force on our introduction into a new circle of acquaintance." In classical confinement, the madman was also vulnerable to observation, but such observation did not, basically, involve him; it involved only his monstrous surface, his visible animality; and it included at least one form of reciprocity, since the sane man could read in the madman, as in a mirror, the imminent movement of his downfall. The observation Tuke now instituted as

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  one of the great elements of asylum existence was both deeper and less reciprocal. It pursued in the madman the least perceptible signs of his madness, in the place where madness becomes secretly distinct from reason, begins to detach itself from it; and the madman cannot return this observation in any form, since he is merely observed; he is a kind of new arrival, a latecomer in the world of reason. Tuke organized an entire ceremonial around these observa­tions. There were social occasions in the English manner, where everyone was obliged to imitate all the formal re­quirements of social existence; nothing else circulated ex­cept the observation that would spy out any incongruity, any disorder, any awkwardness where madness might be­tray itself. The directors and staff of the Retreat thus regu­larly invited several patients to "tea-parties"; the guests "dress in their best clothes, and vie with each other in po­liteness and propriety. The best fare is provided, and the visitors are treated with all the attention of strangers. The evening generally passes with the greatest harmony and enjoyment. It rarely happens that any unpleasant circum­stance occurs; the patients control, to a wonderful degree, their different propensities; and the scene is at once curious and affectingly gratifying." Curiously, this rite is not one of intimacy, of dialogue, of mutual acquaintance; it is the or­ganization around the madman of a world where every­thing would be like and near him, but in which he himself would remain a stranger, the Stranger par excellence w
ho is judged not only by appearances but by all that they may betray and reveal in spite of themselves. Incessantly cast in this empty role of unknown visitor, and challenged in everything that can be known about him, drawn to the surface of himself by a social personality silently imposed by observation, by form and mask, the madman is obliged to objectify himself in the eyes of reason as the perfect stranger, that is, as the man whose strangeness does not

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  reveal itself. The city of reason welcomes him only with this qualification and at the price of this surrender to anonymity.

  We see that at the Retreat the partial suppression of physical constraint was part of a system whose essential element was the constitution of a "self-restraint" in which the patient's freedom, engaged by work and the observa­tion of others, was ceaselessly threatened by the recogni­tion of guilt. Instead of submitting to a simple negative operation that loosened bonds and delivered one's deepest nature from madness, it must be recognized that one was in the grip of a positive operation that confined madness in a system of rewards and punishments, and included it in the movement of moral consciousness. A passage from a world of Censure to a universe of Judgment. But thereby a psy­chology of madness becomes possible, for under observa­tion madness is constantly required, at the surface of itself, to deny its dissimulation. It is judged only by its acts; it is not accused of intentions, nor are its secrets to be fath­omed. Madness is responsible only for that part of itself which is visible. All the rest is reduced to silence. Madness no longer exists except as seen. The proximity instituted by the asylum, an intimacy neither chains nor bars would ever violate again, does not allow reciprocity: only the nearness of observation that watches, that spies, that comes closer in order to see better, but moves ever farther away, since it accepts and acknowledges only the values of the Stranger. The science of mental disease, as it would develop in the asy­lum, would always be only of the order of observation and classification. It would not be a dialogue. It could not be that until psychoanalysis had exorcised this phenomenon of observation, essential to the nineteenth-century asylum, and substituted for its silent magic the powers of language. It would be fairer to say that psychoanalysis doubled the absolute observation of the watcher with the endless mono-