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.