Madness and Civilization
The Birth of the Asylum
Positive images of the asylum are familiar from histories of psychiatry. Asylums act as evidence that madness was finally treated properly. Pinel's liberation of the insane from Bicetre and Tuke's asylum, are also famous. They reveal a series of operations that organized the asylum. Tuke is not a philanthropist; in fact, his Retreat shows the moral and religious segregation of a Quaker community. Tuke saw the exercise of religious principles over the insane as a cure. Religion controlled and confined madness. Religious segregation created an environment in which the individual was constantly anxious, threatened by law and transgression. In such an environment, the madman became afraid and morally responsible for disturbing society. It was claimed that Tuke's work liberated the insane, abolished constraint and created a human milieu. In fact, he replaced free terror by anguished responsibility. The asylum organized the madman's guilt and conscience in an attempt to make him free.
Work was important in Tuke's Quaker asylum. Work rescued the worker from dangerous liberty. In the asylum, work was deprived of productive value; it was imposed only as a constraint and a moral rule. The need for esteem was also important. At Tuke's Retreat, self-restraint replaces physical constraint. Madness passed from a world of censure to a universe of judgment. A psychology of madness became possible, in which madness was judged only by its acts. Madness exists only as it is seen. The science of mental disease that developed in the asylum was always about observation. It could not be a dialogue until the development of psychoanalysis.
In the section, "Surveillance and Judgment," Foucault describes the emergence of a new authority figure. Until the eighteenth century, the world of the mad contained only madness and the faceless power that confined it. Tuke created a mediating element between reason and madness. The asylum keepers confronted madness with madness and reason alone. The absence of constraint in the nineteenth century asylum was not the liberation of unreason, but evidence that madness had been long since confronted. Madness became childhood, grafted onto the world of reason. The community of the asylum became a family. The family is important in the reorganization of madness; it appeared as the norm in the asylum, a structure in which madness is located. The discourse of unreason was now associated with the family. What had been a conflict of reason with unreason became a revolt against family institutions. Tuke substitutes an artificial family for a real family. In a way, Tuke isolated the bourgeois family, located it in the asylum and separated it from history.
Pinel did not advocate religious segregation. Rather, religion was a potential cause of madness for him. A neutralized asylum was created, free of dangerous religious passions. Pinel aimed to preserve the positive moral content of religion. The asylum was a place of pure morality without religion. The social values of family and work reigned in the asylum. The asylum under Pinel became an instrument of moral uniformity and social denunciation. Pinel's asylum aimed to create an ethical continuity between the world of madness and the world of reason. This combination allowed bourgeois morality to be imposed as law, and linked madness to social failure.
Fifty years later, mental disease became degeneracy. Pinel's asylum was a place where insanity as social deviancy was eliminated. The life of inmates was organized so that moral syntheses could operate, in three ways. First, keeping the madman in silence confines him and shames him before others. The Renaissance dialogue with madness and the eighteenth century dialogue of struggle had ended. Second, Pinel allowed madness to see itself. By causing the mad to recognize their condition, he felt he could cure their madness. After Pinel, madness was seen as an impulse by which the individual ignores moral limits. For the nineteenth century, the model of madness was to believe that you were God; in preceding centuries, to be mad was to deny God's existence. Thirdly, madness was called upon to judge itself and was judged constantly by an invisible tribunal. Pinel converted eighteenth century therapeutic techniques into justice and repression. The madman would recognize himself in a world of judgment; those who resisted this new justice were set apart and confined. The great bourgeois offenses of theft, religious fanaticism and resistance to work were punished even amongst the mad. Now unreason was caught in perpetual judgment. The asylum was a juridical space in which the insane were judged and condemned. The medical personage, which altered the relationship between madness and medical thought, was equally important. Mental disease was made possible by this development. The physician now became a key figure; he was in charge of entry to the asylum. But the physician was more important as a wise man. The medical enterprise was part of a moral project. Tuke and Pinel opened the asylum to medical knowledge. The physician became father, judge, law and family. The presence and words of the doctor were often enough to effect a cure. Various relations were created between the doctor and patient: family-child, transgression-punishment, madness-disorder. But from the nineteenth century onwards, the psychiatrist no longer knew what the nature of his power was.
Psychiatry assumed priority for the first time. Psychiatrists would increasingly confine themselves in positivism the more they felt their practice slipped into moral areas. Positivism imposed itself more on medicine; the doctor became more powerful in the patient's eyes. Structures of objectivity in psychiatry from Pinel to Freud were a reification of magic, achieved through the patient himself. Psychiatric practice was in fact a moral tactic of the late eighteenth century, preserved in the asylum and overlaid with positivism.
Behind positivist thought and concrete reality remains the couple of doctor- patient, in which the doctor does not know where his power comes from or the patient's role in it. All of nineteenth century psychiatry converges on Freud because he attempts to recognize the importance of the doctor-patient couple. Freud demystified all the other asylum structures, but exploited the magical powers of the doctor. He turned the doctor into all the powers of the asylum: observation, science and judgment.
Freud transferred Tuke and Pinel's structures to the doctor. The doctor was the key to psychoanalysis. This was perhaps why psychoanalysis was unable to hear the voices of unreason. Psychoanalysis can decipher some of madness, but unreason is foreign to it. Since the end of the nineteenth century, unreason is evident only in the works of Hoderlin, Nerval, Nietzsche and Artaud. It resists the moral imprisonment that we call the liberation of the insane.
Foucault suggests that the images of lunatic asylums that he discusses are a strategy aimed at showing psychiatry as a positive, developing force that could understand and resolve the problem of madness. But he tries to see beneath this facade to examine what is really happening.
Characteristically, Foucault chooses only two people to represent the development of the asylum system: Philippe Pinel (1745–1826) and Samuel Tuke. Tuke founded the York Retreat as a rural, Quaker institution to take an enlightened attitude to madness. The Quakers, a Protestant sect, stress the principles of self-examination and internal dialogue. This is what Foucault means by replacing terror with repression. Patients at the Retreat were not locked up, chained or shut in dungeons. Instead, their warders rebuked them for bad behavior, reasoned with them and talked to them. This aimed to awaken the individual madman's conscience. A combination of guilt and observation makes the madman behave in a normal way.
Foucault again proposes the idea that observation is a form of control. The knowledge that he is being watched restrains the madman. Observation is related to judgment. Those in charge of the asylum looked at behavior and decided what was good, bad and abnormal. This combination of observation and judgment made the modern science of psychiatry possible. Judgment and observation replaced earlier ideas of talking with madmen. Psychoanalysis was later to offer the hope of dialogue with madness, but this hope was not realized.
Tuke represents other changes, especially in the conception of the family. The family is a way of locating and controlling the madman, who was formerly set apart from society. The nineteenth century family represents society in miniature, and also a standard against which the mad were judged. The family became "normal" and reasonable. Foucault sees this as an insidious move that excludes groups other than the mad. The "bourgeois family" was a creation of eighteenth and nineteenth century Europe. Foucault's charge against the asylum is that it preserves this social structure after it ceased to exist in the world.
Pinel is the second representative of the development of the asylum. In 1794, Pinel freed the madmen confined in the Bicetre prison. This move initially had political overtones. Separating madmen from political criminals was necessary for the French government of the time. After this famous act, Pinel went on to develop a system of treatment for madness based on conscience.
Pinel's asylum condemned religion as a dangerous irritant, but aimed to instill a kind of non-religious morality in madmen. He aimed to enforce moral standards drawn from the outside world on the madman. Ignoring or exceeding the world's morality became madness. But to enforce this morality, madness had to be recognized. Madmen were allowed, indeed forced, to speak in order to recognize their madness. But it could not speak freely. Delirious discourse was silenced.
The idea of judgment was powerful and chilling. The madman was observed, judged and condemned as an abnormal phenomenon. In his later work, Discipline and Punish, Foucault analyzes how this system was extended to other modern institutions such as the hospital and the school. The imposition of a moral code onto madness was not an irreversible change, but it was a powerful one.
The system of judgment and observation was supported by the appearance of the doctor-figure. Madness now becomes a medical complaint, in the sense that the authority of science and medicine justifies the treatment of madmen in asylums. The doctor is a wise man because he has the authority of science behind him. He guarantees the value and correctness of what goes on in the asylum. The doctor's power does not end with this validation, however. He also develops a great power over his patients. He gets this power from structures developed by Pinel and other asylum-builders. The development of science covers up the source of this power of this new father-figure. Doctors no longer examine the origins of their power and its moral character.
In a way, Foucault reduces the complexity of asylum to the unequal and misunderstood relationship between doctor and patient. Neither side has any clear idea of how it develops, or works. The doctor's power is almost magical, because the patient has great faith in it without any understanding. Foucault returns to psychoanalysis. He almost sees it as the ultimate form of psychiatry or medicine, because it centers on a dialogue with the therapist. It is separate from the kind of judgment and morality that medicine involves. However, Foucault is not sure that psychoanalysis can really engage with unreason. That kind of engagement is possible only through art. The final paradox of this section is that, in freeing madmen from physical constraint, Pinel and others make them prisoners of their own consciences. Foucault argues that this is not real freedom.
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