In the 1950s, three individuals, unknown to one another and from different countries, were engaged in what seem, looking back, to have been remarkably similar projects vis-à-vis those whom society designates as mad. One was a philosophy student: ‘I used to work in a psychiatric hospital in the 1950s. After having studied philosophy, I wanted to see what madness was: I had been mad enough to study reason; I was reasonable enough to study madness. I was free to move from the patients to the attendants, for I had no precise role . . . I was actually in a position between the staff and the patients.’
Another was an American sociologist, reporting on fieldwork he had undertaken at a psychiatric institution with more than seven thousand inmates. ‘My immediate object . . . was to try to learn about the social world of the hospital inmate, as this world is subjectively experienced by him. I started out in the role of an assistant to the athletic director, when pressed avowing to be a student of recreation and community life, and I passed the day with patients, avoiding sociable contact with the staff and the carrying of a key.’
The third was a young British psychiatrist who, during his National Service, was assigned to a psychiatric unit at a military hospital, where he openly flouted the rules forbidding the staff from talking to patients, and ‘hung out’ with a manic patient in a padded cell at night, just listening to what he was saying. ‘I felt strangely at home there, lounging on the floor.’
These participatory experiments resulted in three books, all published within a year of each other in 1960 and 1961: Michel Foucault’s Folie et déraison, Erving Goffman’s Asylums and R.D. Laing’s Divided Self, which, along with Thomas Szasz’s The Myth of Mental Illness, also published in 1961, were set to become iconoclastic classics.
There is a revealing passage in History of Madness in which Foucault proposes that ‘the knowledge of madness supposes in the person who holds it an ability to distance the self from it, and to remain aloof from its perils and its charms, a certain manner of not being mad.’ The consciousness of ‘not being mad’, Foucault claims, is ‘at the heart of the positivist experience of mental illness’. This captures exactly the spirit against which these psychiatric rebels were reacting, for what they had in common was a repugnance for this ‘certain manner of not being mad’, and the whole idea of a hard and fast line being drawn between the mad and the not mad.
The coupling of Foucault’s study with the canonical texts of the so-called anti-psychiatry movement may have been fortuitous but it was to prove lasting. Folie et déraison appeared in an abridged translation in 1967 in a series on existentialism and phenomenology edited by R.D. Laing, complete with a eulogistic preface by David Cooper (the South African-born psychiatrist who coined the term ‘anti-psychiatry’). But readers who have to rely on an English translation have had to wait almost four decades to get their hands on a complete version. In important respects the new translation does not disappoint: this is a much subtler, less sensationalist Foucault of 14 chapters as against nine, with numerous other missing sections added, and a wealth of detail on a variety of topics, from the conflict between a tragic and a critical understanding of madness in the Renaissance, to the punishment of the venereally infected in the 17th century (‘sufferers from venereal diseases will only be admitted after correction has been carried out, and after they have been whipped’). All this is strangely reassuring in the face of Foucault’s more fantastic speculations and the broad sweep of his ambitious project.
Having the full text available in English undoubtedly increases one’s admiration for Foucault’s achievement, though a few irritants and some more serious problems remain. Cooper’s precious and self-serving introduction – ‘the true significance of [Foucault’s] book resides most precisely in the terror that it may produce in a significant few of us’ – has mercifully been jettisoned, but in its stead we are given as a frontispiece a reproduction of a banal commendation by R.D. Laing to the publishers of the original translation, as though this were a comic routine in which one partner vacates the scene only for his double to re-enter by another door. Nor is the title quite right. The book’s 1961 title was Folie et déraison: histoire de la folie à l’âge classique, but over the years, the subtitle clambered into first place and usurped the incumbent. As Ian Hacking remarks in a witty and astute foreword, this is rather like the Cheshire Cat leaving behind only its grin. Hacking suggests that the disappearance or suppression of the déraison is a sign that Foucault had changed his mind about madness. Unquestionably he had, but even so all this shuffling has done little to alter the substance of the work. A new reader will soon discover that the cat still stalks the text in full vigour.
Déraison is the organising, or perhaps more accurately subverting, metaphor throughout the book, a disconcerting presence with identifiable links to epochs familiar to us from mainstream history, but given to abrupt points of departure. Until the end of the Renaissance unreason was simply a ‘natural dimension of the adventures of reason’, ‘an experience in the adventure that any human reason is’. The figure of the madman had taken on a special importance as testifying to the ‘vertiginous unreason of the world’, the uncontrollable rollercoaster of fate and destiny, but equally to ‘the shallow ridiculousness of men’. Madness mocks the pretensions of those who take themselves too seriously; it is the ‘being-already-there’ of death. Slowly, there develops a conflict between this tragic experience of madness and a critical understanding of it. Where Hieronymus Bosch and his contemporaries were drawn into the madness they saw all about them, Erasmus maintained an ironic, critical distance.
The 17th century, however, saw the onset of Foucault’s Great Confinement, and with it a dramatic shift. Unreason had become a dark force, a focus of intense dread, to be contained and confined. A diverse population of deviants were now banished en masse and placed in houses of confinement, creating ‘a uniform world of Unreason’, where ‘madness rubbed shoulders with unreason in all its forms’ – the criminal, the heretical and the dissolute – and the ‘pains of madness and the punishment of debauchery’ were intermingled. For all its diversity, the condition of this population could be summed up in the single word ‘frenzy’ (fureur); subjects were confined not necessarily as being ill or criminal, but simply as being ‘frenzied’. An ambiguous realm had come into being, halfway between the sacred and the morbid, abandoned by the sacred but not yet invested by medical concepts of the pathological. In it unreason could ‘no longer feed into the secret life of the spirit, nor accompany it as a constant threat’, but instead ‘was made into an object and thrown into an exile where it was to remain mute for centuries’. In the classical age, Foucault asserts, ‘unreason had the value of a noun and had a substantive function. It was in relation to unreason alone that madness could be understood.’
Yet, paradoxically, madness turned out after all to be the beneficiary of the classical dread of unreason. There is an ironic sense in which, in Foucault’s account of it, madness in the classical age is once again spiritualised, acquiring a special status in the universe of confinement by pointing beyond itself to the overall human predicament, revealing the backdrop of unreason that ‘menaced man and enveloped from afar each form of his natural existence’. The scandal of madness served to show ‘men how close to the animal world their fall could bring them’. Spiritualised and also free: we may now view madness as the outcome of a faulty human mechanism, but in the experience of the classical age it was ‘a freedom to roam amongst the monstrous forms of animality’, ‘a space of unpredictable liberty where frenzy was unleashed’, summing up the ‘whole of unreason in a single point – the guilt of day and the innocence of the night’. The time would come when this animality would be considered a sign of sickness, but for the moment it demonstrated ‘with singular power that a madman was not sick’.
There is also a contrasting register – more conspicuous in this new translation – in which Foucault introduces numerous qualifications into his picture of classical unreason. Alongside the correctional institutions in which there was no pretence at medical treatment, there were, as he acknowledges, medical establishments that aimed to treat and cure the mad, such as the Hôtel-Dieu in Paris and the Bethlem Royal in London. There were also developments in therapeutics: not only did doctors enter into a dialogue with patients, but the doctor-patient relationship became the constitutive element in the cure. At one point, Foucault castigates historians for associating the classical period with undiagnosed disease or for putting madmen in chains, when in reality the experience of madness was more varied and involved two different types of hospitality, one in hospitals proper, the other in places of confinement. So is this juxtaposition a sign that some progress was after all being made in what was otherwise a dark period? No, he answers vehemently: the inmates of the hospitals were a throwback to the Middle Ages and the early Renaissance; the true vanguardists were the mad of the Hôpital Général.
Yet in the mutation that took place in the late 18th and 19th centuries it was the doctor-patient relationship, or more precisely the subordination of the madman to the will of the doctor, that came to the fore. The 19th century heralded not the end of confinement but its transformation, and the emergence of institutions in which confined madness and medically treated madness were systematically brought face to face, in a double movement of liberation and enslavement. Classical madness belonged to the realms of silence; it is only in Romantic literature – the poetry of Hölderlin, for example – that the mad found their voice and that for the first time since the Renaissance the language of madness was reborn as a lyrical explosion. As if this was not epiphany enough, in the original French text there was a footnote, deleted from subsequent editions, lending it an additional Nietzschean zest: ‘It is in Zarathustra that this laughter will finally come together, in a single midday intoxication . . . Shimmering noon promises tragic man the lyrical return of the world.’
Alas, shimmering noon was unable to deliver on its promise. Though the mad and the non-mad, for so long separated, were to meet face to face in the new space of confinement, madness was made to ‘shed all the prestige that had made it until recently a figure banished on sight; it became an object of investigation, a thing invested with language, a known reality: it became, in short, an object.’ And this ‘fall into objectivity’, as Foucault styles it, was ‘a far more effective means of mastering madness than its previous enslavement to the forms of unreason’. Classical unreason was now bathed in a more benign, not to say nostalgic, light. ‘The great experience of unreason,’ Foucault asserts in a telling phrase, ‘whose unity was characteristic of the classical age, would come apart’ and madness was now ‘nothing more than a sickness’.
Unreason plays a multifaceted, haunting role in Foucault’s text, variously a prevailing cultural condition, a dark force, or a mental domain rather like the unconscious in psychoanalysis, but under every guise a force essential to human life and thus to the life of reason. Madness may be set alongside unreason, contrasted to it, set within it or made synonymous with it, but it never loses its relationship to it. The worst fate for the madman is to be separated from, or deprived of, unreason. Indeed, a cultural epoch that disparages or punishes unreason may in itself be a cause of madness. After the ‘great unity of unreason’ had briefly been illuminated in the mid-18th century by Diderot’s Le Neveu de Rameau, ‘it was more than half a century again before anyone dared revisit such a region.’ Not just Hölderlin, but Nerval, Nietzsche, Van Gogh, Raymond Roussel and Antonin Artaud ‘ventured there with tragic consequences . . . to the point at which the alienation of the experience of unreason pushed them into the abandonment of madness’.
Here we come to the difficulty at the heart of this work: its mistaken insistence on the purity of a domain of unreason, beyond reach and understanding, and outside history. Given this insistence, exactly what kind of history is History of Madness? Insanity in European culture has never presented itself, Foucault maintains, as ‘an obvious and monolithic fact’; indeed, its meaning for any age is always fractured and lies instead in its ‘torn presence’. ‘There is no certainty,’ he remarks earlier, ‘that madness was content to sit locked up in its immutable identity, waiting for psychiatry to perfect its art, before it emerged blinking from the shadows into the blinding light of truth.’ In writing the history of the mad he has not been describing a psychological type, the madman, across 150 years of his history. What he has been doing is to write the ‘history of the things that made possible the very appearance of a psychology’, a psychology that can speak only the language of alienation.
Even if we are not persuaded by all the talk of alienation, much of this is now relatively uncontroversial. Indeed, it is perhaps part of Foucault’s legacy that very few contemporary historians of psychiatry (and by no means all psychiatrists) would collude in the ‘objectivist conspiracy’ between the psychiatrist and the historian, as Mikkel Borch-Jacobsen has termed it. Madness is necessarily embedded in a moral universe, and hence can be perceived and assessed only in a context of moral relationships. Even so, the inquiry in History of Madness does not sit comfortably within the world of madness and morals, largely because madness is a captive of unreason and hence of the idea that madness itself is something pure and inaccessible.
Ironically, Foucault lends encouragement to the same idea he lambasts: that there is an essential madness lying outside the various historical discourses that have attempted to account for it. In an important sense, History of Madness is an anti-historical work that sets its face against studying the social relations of madness or of real madmen in history. For what could such a study amount to but another kind of confinement? In the 19th century, Foucault writes, in an exemplary expression of counter-historical yearning, madness was ‘firmly installed in the time of chronicles and history, stripped of all the elements that would have made the deep presence of unreason irreducible’.
For readers less disquieted by the ‘time of chronicles and history’ there is a wealth of detail here, mostly missing from the abridged translation, in which Foucault unpacks with obvious relish his discoveries from the archives. The difficulty lies in what he does with them. From 1650 to the time of Tuke and Pinel, he informs us, the guardians of Bethlem, Bicêtre, the Zuchthäuser and other institutions recited litanies of reasons for confinement in their registers: ‘debauched’, ‘imbecile’, ‘infirm’, ‘of unsound mind’, ‘libertine’, ‘ungrateful son’, ‘dissolute father’, ‘prostitute’, ‘insane’ and so forth. These, he claims, derived from the promiscuous mixing of human types and categories typical of classical confinement, in which ‘all were cast into the same abstract dishonour.’ It is impossible, he goes on (still speaking of the Great Confinement), to ‘draw up a coherent nosological map from the descriptions that were used to confine the insane’. He gives as examples, taken at random from the registers: ‘obstinate plaintiff’, ‘has obsessive recourse to legal procedures’, ‘wicked cheat’, ‘man who spends days and nights deafening others with his songs and shocking their ears with horrible blasphemy’, ‘bill poster’, ‘great liar’, ‘gruff, sad, unquiet spirit’. ‘What these formulae indicate,’ Foucault proposes, ‘are not so much sicknesses as forms of madness perceived as character faults taken to an extreme degree.’ Indeed so, but in the British case at least it would be a mistake to attribute this heterogeneous moral typography to an official consciousness, medical or otherwise, for it derives to a considerable extent from the variety of actors involved in the committal process (relieving officers, family members, workhouse infirmary attendants and so on), each of whom may have added their contribution to the asylum register.
But was this type of moral mixing specific to Foucault’s Great Confinement? The historical record scarcely suggests so. In Britain, there was in any case no ‘great confinement’ in Foucault’s classical age, and comparable lists are to be found in any asylum register at least up until the 1920s. A similar question hangs over his remarks about general paralysis, where his rage is palpable: ‘Culpability, its condemnation and its recognition, acknowledged and hidden in equal parts in an organic objectivity: this was the most felicitous expression of everything that the 19th century understood and wanted to understand about madness. Everything that was “philistine” in its attitude towards mental illness can be found there perfectly represented.’ Yet the idea that general paralysis might be related to syphilis was generally resisted until the discoveries of the first decade of the 20th century. Asylum case-notes show that as late as the 1880s general paralysis was frequently put down to hard luck or adversity, and the type or degree of condemnation that Foucault identifies only surfaced some years later. In this, as in other instances, his chronologies are unconvincing, oscillating between the vague and general and a rhetoric of exaggerated specificity. The repeated refrain, ‘for the first time’, comes to sound like a music hall compère introducing a new act. He ridicules the crudity of a dualist pathology that divides everything into antinomies – normal/abnormal, healthy/sick etc – but then indulges in such antinomies himself. He describes Samuel Tuke, for example, as having ‘created an asylum where he substituted the stifling responsibility of anguish for the free terror of madness’. Really? Are those the only two choices open to us; are there no stopping points between them?
The new translation is workmanlike, though it contains occasional peculiarities, as when Voltaire is made to remark on a madman sent to Colney Hatch asylum (founded in 1851). Some of Foucault’s errors go uncorrected: Richard III still sits on the throne of England in 1342. Famously, the translation of a sentence describing the life of the mad in the Middle Ages – ‘les fous alors avaient une existence facilement errante’ – as ‘madmen then led an easy wandering existence’ provoked a prolonged assault on Foucault’s poor scholarship, so I looked eagerly to see how it was translated here. ‘An itinerant existence,’ we read, ‘was often the lot of the mad,’ which is certainly an improvement, even if a residual tension has now been glossed over. For, as Foucault remarks some pages on, the mad were wandering ‘on the road of a strange pilgrimage’, and there was indeed something special about this medieval wandering – it was not just an itinerant existence.
Welcome though the appearance of this full translation surely is, the notion that much of the carping about the work was a product of a flawed and abridged translation is false. Indeed, the opposite is the case: a reading of the full text, far from resolving or dissolving the difficulties, seems only to confirm them, and historians are unlikely to prove any less carping in the future. Its historical shortcomings are patent, but it should not be forgotten that when Foucault set out in the 1950s the history of psychiatry was almost entirely terra incognita: Richard Hunter and Ida Macalpine’s vintage Three Hundred Years of Psychiatry did not appear until 1963. Significantly, in his later lectures and writings, Foucault revised many of the youthful ‘excesses’ of his first major work, such as the claim that Pinel’s therapeutics were ‘violent’, or that 19th-century asylums were modelled on the family, and he reconfigured much of his analysis of psychiatric institutions and practices within his emerging reflections on the micro-physics of power. In his lectures at the Collège de France in 1973-74 he dissociated the book from the anti-psychiatric movement of the 1960s, in order to give the anti-psychiatric impulse greater historical depth. It was now Charcot, not even mentioned in History of Madness, who unwittingly inaugurated the age of anti-psychiatry through his fabrication of illnesses that he claimed to have discovered, and hysterics who were saluted as the true militants of the age. ‘Fundamentally, the whole of modern psychiatry is permeated by anti-psychiatry,’ he insists, ‘if by that we understand everything that calls into question the role of the psychiatrist’ and the ‘absolute right of non-madness over madness’.
Some of the best passages in History of Madness are those where non-madness, far from lording it over its subordinate, displays a more companionable spirit. If the madman ‘is an object to be appropriated, then it must be that reason has need of him’. Unreason is integral to reason: ‘Reason cannot report the presence of madness without compromising itself in a relationship of ownership. Unreason is not outside reason, but precisely in it, invested and possessed by it.’ Foucault is ambivalent about psychoanalysis (the patient once more subjected to the will of the doctor), but he does acknowledge Freud’s innovative and subversive role in taking up madness at the level of language with the aim of restoring ‘the possibility of a dialogue with unreason to medical thought’. Psychoanalysis, declares Foucault, is not about psychology, but about ‘an experience of unreason that psychology, in the modern world, was meant to disguise’.
There are also some intriguing passages that echo the views of psychoanalytic theorists such as D.W. Winnicott, who was writing about the interplay between sanity and madness at much the same time that Foucault was working on History of Madness, rehabilitating a largely forgotten tradition of thought in which unreason was cast as a natural dimension of the adventures of reason. Foucault himself cites Montaigne: ‘The natural, original distemper of Man is presumption . . . This creature knows and sees that he is lodged down here, among the mire and shit of the world . . . yet, in thought, he sets himself above the circle of the moon, bringing the very heavens under his feet.’ As Foucault glosses, ‘turning his back on unreason is a sure sign of [man’s] condition, in that it prevents him from ever using his reason in a reasonable manner.’ From Erasmus and Pascal we get the idea ‘of a form of madness immanent within reason’ and of a divergence between a ‘mad madness’ that ‘turns its back on the madness that properly belongs to reason’; and a ‘“wise madness” which welcomes the madness of reason, listens to it, recognises its right of abode and allows itself to be penetrated by all its vivid power, thereby protecting itself from madness in a manner far more effective than any obstinate refusal, which is condemned to failure in advance’.
History of Madness is no longer, perhaps, an inspirational work, yet for all its limitations there is a dazzling fluidity of ideas here, not least in underscoring the arbitrariness and fragility of the whole psychiatric enterprise. Its relevance persists, even if we are frequently left uneasy by the way in which Foucault packages the ideas and ties the conceptual knot. It’s one of those books about which any conclusion we may reach, no matter how considered, never seems quite adequate, never quite explains the hold it continues to have on us.