Madness and Civilization
Doctors and Patients
The therapeutics of madness do not work in a hospital, which attempts to "correct". But cures for madness developed in the classical period; they aimed to cure the entire individual, body and soul. Physical cures developed from moral perception and a therapeutics of the body. Foucault lists these cures and their philosophies. 1) Consolidation. Madness has elements of secret weakness, a lack of resistance. A force needs to be found in nature to reinforce nature. 2) Purification. Madness elicits a series of therapeutics that are intended to purify. The ideal is total purification. 3) Immersion. Two themes are present; ablution (washing) and immersion, which modify liquids and solids. Plunging madmen into water offers a chance to return to purity. 4) Regulation of movement. Madness is the irregular agitation of spirits, and also the immobility of limbs and ideas. Walking, running and sea voyages all help to restore movement. The subject must be returned to his original purity and initiated back into the world from pure subjectivity. These techniques lasted longer than their efficacy; when madness received psychological and moral meaning, they remained. The meanings of treatment were impoverished; medicine was now content to regulate and punish. Cures change direction, and start to act on the body or the soul; they are addressed to the various elements that make up a disease. Passion is still used in curing madmen. It represents the acceptance of a reciprocal symbolism of body and soul. Fear is a particularly useful tool. The difference between physical and psychological treatments becomes valid only when fear is no longer used, when the nineteenth century has brought madness and it cure into the arena of guilt. Psychology as a tool for curing becomes organized around punishment. A difference exists between the physical and the moral in modern medical thought.
A psychological element seems to be present in classical techniques. The idea exists that language and ethical ideas can affect the body. A difference exists between techniques that modify qualities common to body and soul and those which treat madness by discourse. The first is a technique of metaphors; the second is a technique of language. Two technical universes always existed in the treatment of madness; addressing madness as passion and seeing madness as a mistake of language and image, or delirium. Three essential configurations exist: 1) Awakening. A need existed to tear the delirious from waking sleep. Descartes tried to achieve absolute awakening, but in madness it is medicine that intervenes to awaken. The physician reproduces the moment of the Cogito in relation to madness. Awakening can be violent, or proceed from wisdom. Slowly, authoritarian awakening became only a return to the good or moral law. 2)Theatrical representation. This is opposed to awakening. Here, therapy operates in the imagination. It continues the delirious discourse, and maintains the grammar and meaning of hallucination. Theatrical representation drives out the madness of delirium. 3)The return to the immediate. If madness is an illusion, the cure of madness can also be brought about by its suppression. To give madness to a nature that cannot deceive because it does not acknowledge non-being is to give it to its own truth. Delirium is contradicted by nature. But the return to the immediate is not absolute or simple; because madness is the experience of the most basic human desires, it is rooted in bestiality. Nature has a fundamental power in the suppression of madness; it can force man from his freedom. In nature man is freed from social constraints and passion, but he is bound by a system of natural obligations. A liberation of madness is possible in which madness is opened to the constraints of nature. But the return to the immediate is effective only if the immediate is controlled.
The classical perception of madness is reduced to the moral perception of madness, which is the core of nineteenth century positive, scientific and experimental concepts. This change began in the techniques of cure but spread generally, reorganizing the experience of madness. Psychology was born as a sign that madness was detached from its truth (unreason) and was adrift. What belonged to disease became organic and what pertained to unreason became psychological.
Freud studied madness at the level of its language. He restored the possibility of dialogue with unreason. Psychology was not involved with psychoanalysis; rather, it was the experience of unreason that psychology was supposed to mask.
After his discussion of the various aspects and conditions that form madness, Foucault examines their treatments. He analyzes a central part of the process of confinement, and the development of the idea of curing or treating madness. Initially, madness was not seen as an illness or something that could be treated. But Foucault suggests that even when the idea of a cure developed, it was not a medical development. Madness was still seen in terms of morality and the links between body and soul that come from a theory of the passions.
The initial cures that he discusses (consolidation, purification, immersion and regulation of movement) all relate to the body, but affect both body and soul, such as purification. There is a great difference between this and nineteenth century techniques which center on the moral improvement of the madman. These techniques force the madman to face up to his abnormal or "bad" behavior. The doctor or warder encourages the madman's conscience to operate; he is made to fear both his captors and the consequences of bad behavior. Earlier, Foucault discussed the idea of madness as a punishment for immoral behavior; here, immoral behavior provoked by madness is punished. The introduction of punishment and guilt into the treatment of the madman represents a more sophisticated kind of confinement. Valuing and using the madman's guilt indicates a certain ideal of sanity and good behavior—the "normal" person observes recognized standards of good behavior and obeys his conscience.
Foucault associates nineteenth-century treatments for madness with punishment and the regulation of behavior. They also split up an earlier whole. Nineteenth century treatments relate to different diseases, which have a specific location, rather than to the patient's entire body and soul.
The idea of madness as moral evil is still a central theme. The relationship between madness and morality is characteristic of nineteenth century psychology. Psychology for Foucault is more about morality than science. Only when morality and madness are completely linked is psychology possible. Although classical physicians may talk to or reason with their patients, and appear to treat their minds, this is not a truly psychological approach. Reasoning is not enough; only moral judgment and an attempt to use guilt as a treatment represents a truly psychological approach.
After making this key distinction, Foucault analyzes specific methods of treatment. Most cures center on the concept of delirium. They attempt to alter or reconfigure the discourse of delirium. They therefore work with language and idea rather than with the body. In its classical form, delirium essentially means a movement away from the correct path of reason. These treatments try to direct it back onto the right track.
The various cures differ in their attitude to the discourse of delirium. "Awakening" moves the patient back towards reason by reasoning with him. Foucault's reference to Descartes is important here; he refers to a another aspect of the Cogito this time. Foucault uses the idea that Descartes confirms his own existence by reasoning. The physician does not literally make the madman recite Descartes' arguments, but he does attempt to lead him towards reason and an awareness of sanity by means of reason.
Theatrical representation is very different because it involves continuing delirium. By agreeing with the patient and even acting out insane fantasies, the physician hopes to reestablish rationality. Playing along with a madman who believes himself to be Louis XIV, then slowly directing him away from this belief is a good example of this approach. It is a concerted attempt to manipulate madness back into reason from within.
The return to the immediate is the most complex of all these techniques. It draws upon earlier ideas of the animal quality of madness, and of "anti-nature". The madman can be like a beast, and is opposed to the rational order of nature. But by confronting him with the order of nature, the physician can make him rational again. "Natural obligations" like the need for food and sleep, and the rhythm of the seasons can restrain madness through their own inner logic. Ultimately, this kind of treatment supposes that the doctor can control and shape nature as well as his patient.
Finally, Foucault's discussion of Sigmund Freud's psychoanalysis is important. Foucault sees psychoanalysis, which involves the idea of deciphering the symbols and language of madness and mental disease in a dialogue with the patient as a way of restoring contact with unreason. The absence of moral judgment and punishment in psychoanalysis means that it can access areas closed to nineteenth century psychology.
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