3

Foucault’s Epistemology: Subjectivity, Truth, Reason and the History of Madness

Foucault’s critique of phenomenology dismantles the notion of the smooth and linear progression of knowledge based on lived experience. Phenomenology claims to be able to focus on the subjective experience of mental illness, to rigorously describe it and to offer its understanding. By recording the history of forms of rationality and of truthful discourse, Foucault shows that social structures and practices frame and classify the subjective experience of mental illness on the basis of true and false statements. At the limits of diagnostic taxonomy, reason reflects on the conditions of impossibility for existence, transforming limit experiences into objects of medical perception. This is how madness gave way to the birth of the asylum near the end of the eighteenth century.

Critiquing the phenomenological universality of subjective experience amounts to rejecting the fundamental character of the subject and its transcendental functions. Foucault uses his critical-historical method in order not to relativize the subject, which is still part of the phenomenological project, but to show how the subject is constructed and transformed throughout history. Social practices generate domains of knowledge and cognition and inside these domains the subject can relate to its objects of perception in a meaningful way. There is no pre-existent subject of representation, as the point of origin from which knowledge is possible and truth appears. Subjects and objects emerge simultaneously as a result of truth procedures specific to a given historical period.1 The compatibility between subject and object is not necessary but contingent: it is the product of precise and identifiable rules of truth telling which bring about the construction of the knowing subject as much as the object, which is known.2

This is Foucault’s step towards the conversion of phenomenology into epistemology, as Deleuze points out.3 In this chapter, we aim to show how the epistemological account of Enlightenment critique is the point of convergence of Foucault’s historical and philosophical considerations. His epistemological analyses indicate the central position that truth occupies in his system.4 His position vis-à-vis truth, however, is, as we have shown, thoroughly historical and political. He therefore seems to be a relativist who denounces the stability of truth and its universal validity. Moreover, notwithstanding the logical rigour of his analyses, by reducing the construction of truth and subjectivity to a primordial set of practices and forms of rationality, he appears to be advocating the inevitable mixture of elements foreign to scientific truth. This is why, as we shall discuss at length in the next chapter, he has been labelled an anti-psychiatrist.

Strictly speaking, however, Foucault is not an epistemologist. Or rather, his epistemology does not measure the objective value of a science or the degree of its universal validity. It does not start with an abstract, universal knowing subject, focusing on the structure and principles of scientific statements themselves, examining their ability to yield true knowledge.5 This type of epistemology is what he calls ‘the analytics of truth’. Foucault’s domain of research, on the other hand, belongs to the critical tradition, from the ancient Greeks and its revival through Kant’s Enlightenment critique, exploring the way a subject is constituted as truth-telling and how it can be recognized as such.6 This mode of epistemological analysis investigates the questions: ‘Who is able to tell the truth? What are the moral, the ethical, and the spiritual conditions which entitle someone to present himself as, and to be considered as, a truth-teller? About what topics is it important to tell the truth? (About the world? About nature? About the city? About behavior? About man?).’7 For the analytics of truth, such questions are meaningless insofar as the subject of science is a priori considered timeless and universal, it is de jure the sole possessor of truth on account of its ability to demonstrate the evidence of the world, and the truth that it utters is de facto determined by the degree of understanding it has achieved in relation to an equally stable and preconceived universal object of knowledge. If these are the conditions that make up the scientific subject, then scientific knowledge is based on a series of tautologies. Consistent with Western ‘logocentricism’, the analytics of truth presupposes a pre-established harmony, a circularity between subject and object, placing truth in the perpetual feedback between a transhistorical subject of knowledge that wills the truth and the natural object always awaiting to give up its internal laws and reveal its inner structure. The critical tradition, on the other hand, disputes the spontaneous existence of this circularity and considers truth as the condition that makes it possible in the first place. A prior truth demand belonging not only to science but also to politics and ethics, is required for the construction of the subject capable of uttering scientific statements, through which it recognizes itself as scientific and its correspondent object as pertinent to a specific domain of perception.8

In psychiatry two major forms of medical subjectivity – the anthropological and the psychological – have existed, thus the task of this type of (critical) epistemology is to recurrently ask the questions: what were the truth demands which created the anthropological subject of medicine in the late eighteenth century? What forms of rationality, which governmental, legal, medical and philosophical forces constructed it? Why and how was the anthropological subject asked to turn the philosophical idea of madness into an object of medical knowledge? Why did it bear radically different characteristics and follow a unique line of reasoning; and was its object of knowledge completely different from what it had been only a few decades before, or what it is today? How and why, under which new political or ethical truth demands and forms of logic did this subject become the medical-psychological subject with which we are familiar today? Has this transformation been a sign of progress, or is it just an illusory sophistication of psychiatry?

The answer to these questions requires a close examination of the political and ethical forces affecting the psychiatric subject and the truth which it articulates. This examination is not Foucault’s invention. The ethico-political implications of psychiatric discourse have not escaped the attention of psychiatry, from its most devoted proponents to its most hostile enemies. Many mainstream psychiatrists have been able to spot the existence of extra-psychiatric factors that presumably threaten the neutrality of psychiatric discourse with bias, distortion or falsification. The moderate or fierce critics of psychiatry, on the other hand, consider the intrinsic ‘impurity’ of psychiatric truth as inevitable, seeking either to protect the patients from the endogenous powers of psychiatric abuse or to ensure the correct and humane way of implementing this impure psychiatric knowledge. Both trends share the same belief in a stable and universal psychiatric subject and assume that its truth-telling is vulnerable to political or ethical judgements, either because it is inherently value laden, or because it falls victim to scientific megalomania or crypto-totalitarian prejudices.9

Foucault’s position differs radically. In agreement with the analytics of truth, he argues that science, politics and ethics are not to be confused, as they are in a relationship of heterogeneity, always remaining foreign to each other. Nevertheless, and herein lies Foucault’s unique contribution, they are in a mutual antagonism and endless confrontation with each other and the psychiatric subject is the origin but also the very product of this agonistic relationship.10 Politically motivated extra-scientific factors, even when they play no distorting or falsifying role, constitute the organizing principle around which the psychiatric subject becomes recognizable as a truthful agency capable of producing valid statements. Once formulated, these same statements have deep ethical consequences for the individuals and the institutions to which they are addressed, whatever the claim to scientific validity and neutrality. In psychiatric discourse, ethics and politics coexist in a state of strict separation and mutual reinforcement. When Foucault states that psychiatric discourse is at once ‘a discourse of truth because [it is] a discourse with a scientific status’, a ‘discourse expressed exclusively by qualified people within a scientific institution’ and a discourse which ‘concerns a person’s freedom or detention’, he highlights the ethico-political overtones of psychiatric scientificity, without contesting this scientificity.11 Psychiatric discourse is political only to the extent that the legitimate scientific responses that it provides to social truth demands qualify the psychiatric subject as a truth-teller and it is an ethical discourse only insofar as the scientific statements which it produces inevitably exclude, include, marginalize, encompass, train or guide individuals in their conduct and behaviour.12 It is this dynamic relationship between these three modalities of truth (politics, science, ethics) which permeates Foucault’s epistemological studies in the field of psychiatry. For Foucault, truth is not an endpoint for knowledge, but an activity of establishing differences, the axis around which governmental practices, scientific knowledge and ethical modes of subjectivity revolve.13

The ethico-political components of scientific knowledge are present in every type of scientific endeavour, but in psychiatry they are more pronounced, because it is the very object of its research which constitutes a major ethico-political problem for society. Madness challenges the social conception of normality, provokes measures for the protection of public hygiene and requires subjects capable of identifying it and tackling it therapeutically. Kant had sensed this triple – scientific, political and ethical – challenge that madness poses to the rational subject, when he constructed his Anthropology. Surprisingly, however, it is in Descartes that this process takes on full theoretical force. This assertion may at first seem odd since Descartes is generally known as the theorist of the founding subject of scientific knowledge, which, free of any political or ethical determinations, seeks the rational fulfilment of the world. Foucault, however, overturns this misconception, to show how Descartes questions the authority of the scientific subject as a guarantor of self-evidence, the moment it becomes entangled in an ethico-political web of problems raised by the very impossibility of thought, the experience of irrationality. Foucault uses the philosophical analogon of Descartes to show how in its origins psychiatry had established a fundamental relationship with the otherness of madness, a relationship that became epistemological only to the extent that it was simultaneously a juridico-political concern and an ethical requirement for the definition of the norm in the late eighteenth century. It was later, with the advent of positivism that psychiatry employed Cartesianism as a model of rationalism in order to disengage its scientific knowledge from non-scientific elements. This Cartesianism, in spite of Descartes himself, has eliminated madness from philosophy. It has obfuscated the historically contingent relationship between the psychiatrist as a subject of knowledge and the mentally ill as recently formed medical object of study, creating the illusory image of a necessary and timeless affinity between the two poles. It overlooks truth as a historical factor bringing together subject and object, placing it at the end of a linear path toward more complete knowledge. It is a positivist effort that has sought to crystallize the rational psychiatric subject into a transhistorical, universal source of knowledge and madness into a reality susceptible to objective medical observation. It has permeated phenomenology, psychology and biology that have encompassed all fields of human behaviour, laying claim to a universal understanding of all possible experience. It is for all these reasons that it has been fully incorporated into today’s evidence-based medicine which claims to be able to discover the nature of mental illness through an allegedly Cartesian ‘clear and distinct’ method of demonstration and proof.

Foucault challenges this model of linear progress, not because he contests the epistemological validity of psychiatry, but because it is precisely this validity that creates the illusion of a necessary, scientifically grounded ethico-political unity. He argues that this unity is contingent, fragile and precarious. Psychiatric knowledge cannot dispense with madness and the philosophical, social and cultural issues that it raises. Radicalizing Descartes, it is Nietzsche who helps show how madness itself emerges from the edges of diagnosis, the psychiatric regime of truth par excellence, to destabilize the image of a politically and ethically neutral psychiatric subject. Since the nineteenth-century phenomena of monstrosity and hysteria, there have been cases where the mentally ill re-emerge as others, as agents of simulation who alter the game of truth imposed by psychiatric discourse. They introduce splits inside diagnosis, depriving the ethico-political unity of its epistemological foundation while renewing at the same time previously silent and unquestionable political and ethical problems that bring about crises, ruptures and breaks.

Foucault’s Scepticism

Foucault’s epistemological method is a form of scepticism.14 The notion that what appears as timeless scientific truth involves non-scientific components which participate in its construction, situates Foucault firmly within the sceptical trend of thought. On several occasions Foucault himself declares that his method is sceptical, placing himself within the Western sceptical tradition of Descartes, Kant and Husserl.15 He does not, however, share the common-sensical epistemological use of Cartesian and Kantian scepticism in the study of the relationship between the structure of cognition and the demand for truth. He does not look for the threshold of scientificity in a supposedly cognitive Cartesian – and Kantian – sceptical framework which foregrounds the limitations of knowledge in the inaccessibility of the knowing subject, as well as in the unattainable in-itself, ‘truth or a reality in itself’.16 For Foucault, Kantian and Cartesian scepticism are singular in the history of Western epistemology insofar as they are not restricted to establishing the internal rules of cognition, but scrutinize its external limitations and its relation to irrationality. We saw Kant’s and Husserl’s scepticism with regard to the notion of finitude and the phenomena of consciousness in the previous chapters. We shall now discuss Cartesian scepticism and its relevance to the History of Madness. Descartes, Foucault argues, does not question the representational function of scientific propositions but introduces external – political and ethical – elements constituting the matrix for the emergence of propositions that can have a representational function. He does not even advocate the primacy of the subject, but shows how subjectivity undergoes transformations when it confronts radical alterity: madness. Madness is not merely the limit of knowledge, but an alien experience that introduces a political and ethical context for the formation of scientific knowledge.

Foucault’s scepticism therefore challenges the view that scientific discourse is an autonomous, self-sufficient mode of truth-telling. He illustrates its dynamic interaction, reciprocity and reversible relationship with truth demands imposed externally on science by the practices of government within which it is born and with the ethical truth requirements that it produces in turn. This interaction between politics, science and ethics had already been an area of concern for the ancient thinkers. For the ancient Stoics and Cynics, the knowledge of the self and the world did not concern the discovery of causal connections and the secrets of nature, but it was a relational knowledge, a form of knowledge preoccupied with the relations between politics, institutions and laws and the possibility of rational discourse. This same knowledge had an effect on the subject, as an ‘ethopoetic’ knowledge, producing a specific relationship of the subject to itself.17 The problematic was the same for the ancient Sceptics themselves, for whom the production of self-knowledge constituted a rigorous examination of the subject’s consciousness closely linked to its political role and the creation of ethical principles.18

According to the usual epistemological interpretation, the spiritual epistemology of the ancient tradition became marginalized since the famous ‘Cartesian moment’ and the beginning of modern philosophy, when a strict separation between politics, science and ethics took place.19 The assumption is that Descartes’ Meditations introduce a radical break with ancient spirituality, insofar as in them Descartes detaches the thinking subject from the political or ethical conditions needed for the transformation of the subject’s mode of being in order for that subject to gain access to the truth. The Meditations posit objective knowledge based on sound reasoning as the sole condition for the truth. It is enough for the subject to follow a method whereby it will deduce the law of its representations, never letting go of the line of self-evidence, for truth to be attained. Descartes’ subject is, then, a transcendental, immutable agent whose freedom from the constraints of interest, passion or morality constitutes the very possibility for the discovery of truth in the form of objective, neutral knowledge. Through systematic doubt of his senses, the same interpretation continues, Descartes aims to reach a state of certainty which only pure thinking can provide, in the manner that mathematics provides clear and distinct ideas. The obvious truth definitively attained is the only requirement for the subject, which thereby becomes the impersonal, universal subject, the agent and origin of a new scientific era, marking the historical point when the institutionalization of modern science became possible.20

Our contention is, rather, that for Foucault the ‘Cartesian moment’ is not a point of rupture but, on the contrary, a moment of revival of ancient scepticism which paved the way for a type of philosophical reflection that would later permeate the critical spirit of the Enlightenment. In an original reading of the Meditations, Foucault shows how Descartes in many ways renews the ancient problematic of spiritual knowledge – hence the appearance of Foucault’s discussion of Descartes in a brief but crucial analysis in the History of Madness. Descartes, Foucault shows, is not merely seeking the foundations of knowledge, nor a foundational relationship of knowledge and philosophy. Descartes is not even performing the usual sceptical exercise which consists of thinking about everything in the world that could be doubted, directing his search towards indubitable knowledge.21 If we read Descartes’ thought experiment not as an intellectual method defining the law of representations, but as a meditation, as its title suggests, it will become clear that Descartes performs a test on himself as a subject, a test of truth through which his subjectivity emerges transformed.22 Descartes is not concerned with the relation between his ideas and reality or with the relationship between his mind and the external world. He does not simply look for a ground for his beliefs and convictions, but primarily sets as the task of his meditation to respond to the question: ‘how could I discover the truth?’23 As the meditation proceeds, this search for truth transfigures the subject conducting the meditation.24 Descartes’ will to truth is an ethical demand, a desire to avoid deception so that the lucidity of self-examination and self-scrutiny can guide moral decisions and the establishment of codes of personal conduct. It is also a political demand, a demand of power placing truth itself in the privileged position of determining the terms in which Descartes can constitute himself as a legitimate scientific subject. This double demand, therefore, precedes and conditions the constitution of scientific knowledge: it does not arise from it. Foucault demonstrates that the Meditations do not merely proclaim the foundations of scientific theory, or the ground of political or ethical principles based on scientific knowledge. They constitute a spiritual exercise that tests the political and ethical effects that the truth may have on subjectivity:

If Descartes’ Meditations are in fact an enterprise to found a scientific discourse in truth, [they are] also an enterprise of parrhesia in the sense that it is actually the philosopher as such who speaks in saying ‘I’, and in affirming his parrhesia in that precisely scientifically founded form of evidence, and he does this in order first of all to play a particular role in relation to the structures of power of ecclesiastical, scientific, and political authority in the name of which he will be able to conduct men’s conduct.25

Crucially, Descartes centres his ethical and politically pertinent project around a singular moment overlooked by conventional epistemology: the exclusion of madness. In the series of tests to which he submits his thought, Descartes performs the ultimate test, the most extreme hypothesis his rationality can endure. He hypothesizes that there is one case in which simulation, the absolute condition of self-delusion, can take on the form of perfect clarity, and where doubt ceases to exist. This case is madness. The mad subject, Descartes argues, firmly and clearly believes that everything around it, the sky, the air, the earth, colours, figures and sounds are illusory; it believes that its body is made of glass, or it has no hands, or eyes. Whereas for the rational subject this identification is submitted to doubt, for the mad subject it is an unequivocal reality, a distinct and clear conviction free of the possibility of deception. Whereas for the rational subject this state of absolute certainty is merely an extreme hypothesis, a limit case suggested by an evil genius which introduces the possibility of deception, for the mad subject it is a state of absolute and unconditional truth.26 It is on account of this unconditionality, this impossibility and this exteriority with regard to all hypotheses, that madness is excluded: madness is not a defect intrinsic to knowledge itself. It is not endogenous to reason, a product of its excess. It is not a property of the object, of its structure and essence. It is postulated by reason as an external condition for the attainment of truth, as a limit beyond which truth becomes unconditional and therefore absurd.27 Madness must therefore be excluded if the doubting subject is to exert an ethical and political role based on truth.

Descartes’ breakthrough, therefore, consists of excluding madness in a threefold manner. Madness is not excluded as a formal or objective condition of knowledge, but as an external, spiritual and ethical condition of truth: ‘In order to know the truth I must not be mad.’28 The rational subject may well be impure or immoral and still know the truth, but self-delusion is the sole extra-ethical condition. It is a state of mind governed by a private, incommensurable truth, which cannot be communicated; it cannot be transformed into ethos. Secondly, madness is excluded politically; employing the term demens, Descartes disqualifies the mad subject as a legal category incapable of certain religious, civil and legal acts. Insofar as the mad subject represents the impossibility of thought itself, legal rights do not apply to it.29 It stands outside juridical rules, the possibility of rational punishment and correction. It is therefore marginalized with respect to rational norms. Finally, after this political and ethical exclusion has taken place, the mechanisms responsible for the disordered reason inside the mind of the mad person can be made intelligible. Only after madness is conceived as an impossibility of thought, an exteriority and even a threat to reason, can it be contemplated as a rectifiable disease, an object of a constituted knowledge. It is then that the mad subject can become an object of medical reflection and not only an ethically and politically disqualified subject. It can be problematized medically as an effect of truth. This, as we shall show, is crucial for the emergence of psychiatry as a scientific enterprise. There is no pre-existent ‘mad’ object that calls for a rational investigation of its nature. Nor is there a rational subject that creates the object ‘madman’ ex nihilo. Both emerge in a reciprocal relation, as a result of the effects of truth, when the truth is taken to its limits, to simulation.

Thus Descartes does not posit an abstract, universal knowing subject which grounds the structure and principles of scientific statements.30 Starting with this assumption, current mainstream epistemology studies the scientific rules which stem from the relationship of an originary subject with an equally fixed and transparent object, a relationship irreducible to political categories. The ‘Cartesian moment’ is the founding instance for this epistemology which regards social relations and political forms as elements foreign to the knowledge relation, setting for itself the task of defining the strict separation, incommensurability and heterogeneity between politics, science and ethics. Any confusion and interdependence between these domains is regarded as a negative component clouding and obscuring the knowledge relation and it is the duty of epistemology to restrict as much as possible the obfuscating influence of political and social conditions on the subject of knowledge ‘who rightfully should be open to the truth’.31 Foucault, on the other hand, argues that in Descartes, political and ethical conditions do not constitute an obstacle or a veil for the subject of knowledge, but play a positive role in the production of this subject and its correspondent object. The subject of knowledge is not given but is transformed the more it seeks the truth, by way of the effect upon it occasioned by the articulation of truth. This transformation entails prohibitions, interdictions and restrictions that the scientific subject must follow in order to remain scientific. Cartesian epistemology, Foucault shows, is essentially an ascetic practice, a process whereby the subject explores the part of itself that must be renounced if it wants to behave rationally and regulate its behaviour on true principles. The Cartesian scientist submits to the ascetic price of reason, accepting the necessity of excluding its irrational side as a condition for the modification of its mode of being in order to ensure access to the truth.

From Descartes to the History of Madness

Let us now look at how Foucault applies his critical reading of Descartes to the History of Madness. The Meditations constitute a valuable supplement to Kant’s Anthropology insofar as they share a common problematic, the dichotomy between reason with madness, but with one important addition: the study of the historical and local interaction between subjectivity and truth, which determines each time the form of this dichotomy, its terms, its epistemological coordinates and its possible reversals. This addition will enable Foucault to show why and how the triple Cartesian exclusion (political, epistemological and ethical) of the mad subject took place on a social level at a specific point in history and in specific spatial settings. He will use it to demonstrate that the anthropological subject of the late eighteenth century was not a pre-given rational subject seeking to exclude madness in order to assert the autonomy and sovereignty of its rationality, but was formed as reasonable through the exclusion of madness. Foucault will set out to illustrate that the Cartesian methodical path of doubt from which madness must be excluded is not a transhistorical, transcendental condition of a universal subject, but it was the product of specific political, scientific and ethical distinctions and decisions made by the medical subject in the late eighteenth century. The result of these distinctions was the exclusion of madness and its problematization for the first time in Western history as a domain of political reflection, institutional transformation, establishment of normality and medical attention.

Foucault does not argue that madness was outside the sphere of medical concern until its medicalization in the eighteenth century and the advent of modern psychiatry. On the contrary, he demonstrates that in the sixteenth and seventeenth centuries the medicine of madness was entirely within the corpus of general medicine, in terms of aetiology and therapy. ‘Maladies of the spirit’ existed and theories of humours were used to explain mental disorder. Somatic and mental treatments, baths and theatrical performances were medical remedies for insanity. Also, Foucault does not ignore the fact that certain places inside hospitals or private institutions were reserved especially for the mad, such as the Hôtel-Dieu in Paris or the Bethlem hospital in England. By the end of the eighteenth century, however, the newly born asylum bore completely different medical and institutional characteristics. Madness became an object of knowledge as a separate and marginalized topic, not as a condition requiring medical attention like other somatic illnesses. ‘It was a matter of understanding how, in the Western world, madness had become a precise object of analysis and scientific investigation only starting in the eighteenth century, even though there had previously been medical treatises concerning (in brief chapters) ‘‘maladies of the spirit’’.’32 Alienism replaced the theories of humours and medical treatises and taxonomic systems differed radically from the medical theories written only one generation before.33 The architectural design of the asylum in no way resembled the general hospitals where the mentally disordered had until then been treated.34 There was a sudden rupture, a clear discontinuity in the care of the mentally ill from the moment madness became the object of specific medical and anthropological reflection in the late eighteenth and early nineteenth centuries: a discontinuity which Foucault sets out to analyse.

If Foucault were an Enlightenment optimist, he would have claimed that the rationality of Descartes and the political rationality that culminated in the French Revolution, reached a stage of maturity during this period, that scientists and politicians had become ‘enlightened’ enough to be able to identify mental illness and offer the mad a humane treatment for the first time. If, on the contrary, his work were an anti-Enlightenment project, he would have attributed the birth of psychiatry to an intensification of social control. The social order of the rational state would place madmen under close surveillance to ensure the safety of the path towards reason and progress. Foucault takes neither of these two sides. He refuses the ‘blackmail’ of the Enlightenment. Instead, he speaks of two new elements that introduce a break in relation to the allegedly smooth progress of seventeenth century rationality. He speaks of fear and division.

A central feature of the late eighteenth century rationality, fear was a result of urbanization and the new disciplinary governmentality. The fear was of the crowding together of the population, the fear of epidemics, the excessive height of the buildings, the fear of the cohabitation of the rich and the poor in an undifferentiated urban environment.35 This fear gave rise to the need for an administrative division which became possible with the emergence of a new type of knowledge during this period. In the Order of Things Foucault notes an important mutation that took place in the eighteenth century scientific rationality. In the eighteenth century, the plethora of information gathered called for a classification of data. Whereas previously mathesis was an ontology, a precise quantitative measurement of the world, and taxonomy simply a mode of ordering of things measured, in the eighteenth century there was a Taxinomia universalis, a priority of specifying identities and differences, which would direct measurement. Kant’s analysis was crucial in this respect.36 Amidst this fear, a new technology of truth arose, a call for a division and establishment of differences: How could the madman be recognized? How could he be singled out without error? Things no longer stood as they did in the Renaissance where madness had appeared with clear signs, threatening reason with contradiction. Confusion now emerged as there was no clear-cut way of distinguishing between those who are really mad and those who were arbitrarily mingled with them. Diagnosis was crucial in order to prevent chaos and the generation of even greater fear. It was important for the arrangement of spaces and the clarification of forensic issues. For Foucault, the primacy of differentiation at this historical point took place even before the scientific theories about the mentally ill had been constructed: ‘working at the limits of the resources that we have at our disposal, we can still partially trace the evolution of a long, painstaking process of classification that moved in parallel to the theoretical model but was entirely independent from it’.37 Diagnostic thinking in the late eighteenth century established for the first time a truth regime which called for differences and sought to authenticate mental disorder. This truth regime came to pick out the mad as the genuinely ill among those indiscriminately confined. Mad were not considered the evil, the mystics or the destitute, the dreamers or the mentally deficient. They were those who were incapable of doubting and therefore incapable of verifying what they thought. They displayed a capacity to use arguments according to the rules of logic, but they lacked judgement: they were unable to see through their mental images because they gave absolute truth-value to them. They never questioned the validity of what they perceived. Their delirious convictions were unshakable:

the act of a reasonable man who, rightly or wrongly, judges an image to be true or false, goes beyond the image, and measures it against that which is not. The madman, by contrast, never steps over the image that appears. He allows himself instead to be totally caught up in its immediate vivacity, and only gives his approval in so far as he is entirely absorbed in it […] Whereas error is simply non-truth, and dreams neither affirm nor judge, madness fills the void of error with images, and binds fantasies together through affirmation of falsehood.38

Thus for late eighteenth-century rationality the insane belonged to Descartes’ category of demens, which is why their exclusion was primarily a juridico-political act. The law posed specific demands on doctors to distinguish rigorously between what will count as true and false illness. So as not to punish unjustly the one whose crime was caused by madness rather than an act of choice, it was necessary for the law to differentiate as clearly as possible between authentic and inauthentic madness. Doctors were asked to perform a diagnosis, a differentiation and classification of irrational behaviours, in order to ensure that justice could be administered to the legally responsible, and urban fear could be lessened. Crucially, as it will be shown in greater detail in the next chapter, jurisprudence did not forcibly dictate diagnostic procedures: it did not interfere with medical knowledge, but prompted the distinction of true and false phenomena of illness, rendering doctors capable of producing for the first time knowledge concerning the insane. Jurisprudence was an external factor, which set up the truth conditions for the reciprocal formation of madness as an object susceptible of being understood and determined and of the rational subject of mental medicine. This is why Foucault considers the law as the most fundamental political component in the genesis and development of psychiatric discourse.

The second type of exclusion was ethical. The newly born psychiatric knowledge was obliged to legitimate and delineate the norm scientifically. The psychiatric decision to treat and correct medically influenced and generated a whole field of education and pedagogy. In the late eighteenth century, doctors intervened diagnostically in matters of morality, as a result of the bifurcation and close kinship between medical psychology and the institutionalization of ethical behaviour. For the late eighteenth-century doctor there was a fundamental separation between those delirious individuals who could not doubt their experiences and those who were simply law breakers, social outcasts or sexually promiscuous. For the first time since the classical age, the libertines, the vagabonds and the poor were left outside the medical milieu. They fell outside psychiatric and legal jurisdiction as they were indeed unreasonable but in the sense that they were the manifestation of a form of reason ‘alienated in the unreason of the heart’ and therefore not legally incompetent or politically irresponsible.39 Theirs was a reason that served the desires of the heart and its use was indistinguishable from disorder resulting from immorality, but it was clearly not madness. In an important passage in the History of Madness, Foucault mentions a letter sent by Marquis de Sade’s doctor, Royer-Collard, to the chief of police in 1808. Royer-Collard wished to discharge Sade from Charenton in order to turn it into a hospital. In his letter, he states that he does not believe that Sade is mad, but simply a man of vice who cannot be treated medically but is in need of imprisonment. His diagnosis, like many others that separated the world of unreason from that of madness, was decisive:

Royer-Collard no longer understood correctional existence. Having looked for its meaning in illness, and failing to find it there, he reverts to an idea of pure evil, which has no reason for existence other than its own unreason, which he terms the delirium of vice. The day of that letter to Fouché, classical reason ended, leaving its own enigma, and that strange unity that grouped together so many diverse faces was definitely lost to us.40

With the insertion of the new type of diagnosis, the absolute diagnosis between madness and reason, the doctor had to give an account of this division, in order to determine how these patients would be treated, how many of them deserved and could benefit from internment and to what extent they posed a danger to society. So the doctor employed the theory of alienism to identify and explain the behaviour of these individuals. The madman was now an object which was isolated physically, observed daily and explained medically. At the same time, the rational subject of the psychiatrist was formed. He was an alienist whose role was to define, explain and manage his new object of study within a specified location – the mental hospital. He became responsible for all the production of knowledge relating to this new field of medicine. The anthropological subject emerged – psychiatry was born.

The Death and Return of the Other

This analysis of Foucault’s reading of Descartes has attempted to refute the one-dimensional interpretation of the History of Madness as either a historical document, inaccurate in many respects, or a structuralist endeavour devoid of epistemological validity.41 It is closer to readings such as Derrida’s, who has drawn special attention to the simultaneous historical and philosophical originality of Foucault’s work which is closely linked to his reflections on Descartes.42 Unlike Derrida, however, greater emphasis has been placed on the history of truth as it operates in the background of the exclusion of the insane, showing how this background constitutes an essential component of Enlightenment critique. Thus, it has been illustrated that a particular game of truth in the late eighteenth century focused on madness as the impossibility for thought. Diagnosis was the truth regime that satisfied the double requirement of responding to the needs of the late eighteenth-century universe of taxonomy and of conforming to the rules of medical theory and juridical practice. This diagnostic regime of veridiction simultaneously generated madness as the outside of reason and constructed the rational subject who supervised spaces of confinement such as the asylum in which madness was isolated and studied. It established madness firmly as a marginal and borderline experience foreign to morality and normality.

It is therefore obvious that it is in diagnosis, the truth regime of psychiatry par excellence, where politics, epistemology and ethics meet. Diagnosis, as it was indicated in the previous chapter, is not a neutral epistemological endeavour operating in a strict phenomenological field. It is a metalinguistic discourse, a discursive practice through which the elements and rules of construction of a language, one that can be called psychiatric, are defined.43 But it is not value laden; it is not permeated by extra-scientific, ideological or moral categories, at least not by definition.44 On the contrary, in order for these categories to have a political effect, they have to rely on the ability of diagnosis to establish a domain in which truth and falsity can be made pertinent. As it has been shown, forms of rationality set up programmes, lay down collective values and goals, and dictate codes of governing and ways of doing things. These programmes, goals and regulations are not free floating but are attached to the production of true and false. They rely on true discourses, which ‘found, justify and provide reasons and principles for these ways of doing things’.45 Rationality does not exert power through the imposition of truthful discourse that is accepted blindly. It ‘wills the truth’; that is, it poses a demand for a distinction, the strict separation between true and false statements; the legitimacy and acceptability that this division provides constitutes the power of rationality, creating what will count as real and valid for scientific research.46 This was precisely the function of psychiatric diagnosis as it was constructed in the late eighteenth century: a set of true and false propositions which offered scientific legitimacy to the political and ethical pretensions of a specific form of rationality. These propositions did not represent the reality of mental illness; they established a differential diagnosis, a basic distinction, a dual field between madness and sanity, conditioning any subsequent investigation of mental illness, its ontology, the modes of being connected to it, the institutional structures supporting it, and the cultural norms emanating from it.47

It was from the late nineteenth century when psychiatry sought to become a normed, regulated, established medical science embodied in institutions, that psychiatric diagnosis was divorced from its inherent political and ethical implications, presenting itself as an objective and rigorous activity equivalent and strictly continuous with the rest of medicine. In order to achieve this equivalence, psychiatry sought to dispense with the otherness of madness and its political and ethical bearings, so that a rigorous epistemology could provide objective access to illness and valid methods of its cure. From the middle nineteenth century onwards, biology, genetics, psychology and degeneration served as the aetiological factors of mental disorder. Madness ceased to be the ‘absolute other’ of reason and psychiatry would look for natural factors that would differentiate types of mental illness. There was no longer a dividing line between madness and reason, but a spectrum of illnesses with a biological reality that should be uncovered using medical means of investigation. Doctors ceased to be alienists and became psychiatrists-psychologists, armed with medical knowledge. This was the dawn of the age of the transformation of psychiatry into a medical specialism. It was and still is characterized, not by the exclusion of madness as other, but by the incorporation of otherness itself. It paved the way for a narrative according to which the psychiatric subject has always followed the model of a medical science, capable of discovering the reality of mental illness in a linear progressive fashion, supported by neuroscience and advanced technology.

Foucault’s scepticism critiques psychiatric truth precisely for this supposed level of neutrality and scientific sophistication. He insists that non-scientific elements have not been abolished, but have merely been obfuscated by the ‘whiggish-march-of-progress’ view of psychiatry. He shows how the linear progress of positivism merely appears to be independent from the political and ethical truth demands, which are nevertheless still imposed on psychiatric knowledge. Thus, it is not the rationalization of psychiatric knowledge but the political imperative of security, which has extended the diagnostic and therapeutic powers of twentieth-century positivist psychiatry and has increased its preventive role to the scientific protection of society through heredity, familial sexuality, education and detection of crime. Also, it is not the humanization of psychiatric practice but the social pressure of the ethic of public hygiene and socialization, which has created the conditions for the abolition of the asylum through a massive deinstitutionalization and the generalization of psychological therapy and medical care. It is not only because psychiatry has adopted the advances of medicine and technological development (neuroscience, psychopharmacology), but also because there is a consistent ethico-political desire for global medicalization and normalization, that psychiatry has achieved the discovery of biological and psychosocial abnormalities to explain mental disorder.

However, anthropological critique is not content to simply unearth the ethico-political forces that the positivist truth of neurobiological and social psychiatry masks. It must be kept in mind that these forces, these values and metaphysical prejudices hidden in rationality, do not determine the emergence of psychiatric truth according to a certain causality. The truth that they seek to produce no longer belongs to them. This is why it is ineffective to perform an ethical or political critique of psychiatry, to simply deny the validity of psychiatric truth, or to attach this truth to systems of arbitrary (political and ethical) values that need to be overthrown. On the contrary, it is necessary to study truth in its autonomy and its capacity to reverse power relations and values, to silence certain behaviours or give voice and expression to others.

It is in this vein that Foucault scrutinizes post-anthropological psychiatric truth and the fixed subject-object relation, which it has staged since its birth. In it, he does not discover the smooth compatibility between the two terms under the aegis of a rational psychiatric subject. He rather sees a fundamental discord, a tension provoked by the object of knowledge, which unsettles not only the metaphysical illusion of the psychiatric subject, but also the political and ethical coordinates of rationality and the established values sustaining this illusion. Since the dawn of positivist psychiatry, it has been the assimilated, reified forms of insanity, which have shuttered the false image of a neutral diagnostic truth, precisely at those instances when positivism has claimed to have entirely dispensed with alterity. Madness has resisted its integration, not by refuting the biological or psychological model of psychiatry, but, on the contrary, by conforming perfectly to it, while renewing the political and ethical problems which lie behind it.48

As Foucault’s Cartesian analysis has demonstrated, in the age of proto-psychiatry madness was an alterity, which harboured its own evil genius, its own private simulacrum, the absolute and unquestionable truth of delirium, which resisted meaning and prompted exclusion. In the present age of an all-inclusive, globalizing psychiatric rationality, on the other hand, an interesting reversal is taking place: insanity no longer asserts its difference, it no longer evokes its own truth, but inserts its evil genius into the truth criteria claiming to comprehend it; it ‘contaminates’ the clarity of psychiatric truth with simulation. Madness does not refute the truth model on which psychiatric discourse is based, but it insidiously affirms it and simultaneously deprives it of any referentiality, aetiology, meaning or anatomical localization. It puts on the mask of sameness and familiarity, while withholding its secrets, forcing psychiatric rationality into a vacuous, virtual and self-deluded state of absolute truth. Thus, just at the moment when psychiatric truth appears to have irreversibly included madness into the universe of rationality, it is madness that excludes itself, and it is psychiatric rationality that loses its anchoring points and becomes irrational.

This has been the case, as it will be shown in the following chapters, with monstrosity and hysteria, two forms of madness with no delirium, which, since the late nineteenth century have given the impression of being ordinary clinical syndromes, while losing nothing of their capacity to overturn power relations. Monstrosity was for eighteenth-century psychiatry the most singular and exceptional form of criminal insanity. Since that time, psychiatric positivism has strove to cancel its terrifying singularity, integrating the human monster into the abstract equivalence of dangerous abnormalities. However, it can nowadays be observed that it is precisely in its most unsuspected, ordinary forms of social danger that the human monster disturbs this equivalence, forcing current forensic rationality to exclude it and to recognize its exceptionality. Monstrosity is nowadays a dubious clinical category; it oscillates between legal and psychiatric truth, it defies its legitimate placement either in prison or in a mental hospital and provokes an administrative rather than a strictly juridical or medical reaction. Similarly, since the nineteenth century, hysteria (and its contemporary derivatives) has adapted fully to the neurological and psychotropic truth models which claim to comprehend madness, while simultaneously falsifying them and giving them an empty content. From an originally harmless neurological syndrome, hysteria has turned out to be unsuitable for a general hospital, a psychiatric institution or even the psychoanalytic couch; it is a singular mode of subjectivity irreducible to medical or psychological norms. Both these clinical cases disrupt the truth of psychiatric discourse, occupying an epistemological void, a non-space where psychiatrists are forced to exert a political and moral, rather than strictly scientific role. They are both monsters, not only because they provoke fear, danger or bewilderment, nor because they appear as inhuman, other, but mainly because they are epistemologically exterior to the field of normality created by psychiatric theory. They show how psychiatry, like ‘each discipline recognizes true and false propositions; but it pushes back a whole teratology of knowledge beyond its margins’.49

Increasing the rationalization of psychiatric practice will not abolish but will only accentuate the confrontation with the political and ethical implications of madness inside psychiatric practice. This is because truth is not a property of the object or an achievement of rationality. It is a product of political, ethical and scientific disputes. Truth does not only produce the compatibility between subject and object, but it can also create their distance, irreconcilability, and asymmetry, generating crises.50 Inside the illusory unity, homogeneity, peace and continuity which positivism seeks to achieve through the rejection of otherness, madness reveals its truth violently through fear, false proximity and division. It is the mad, the patients themselves, who dismantle the positivist continuity between the two poles of the knowledge relationship51 in a process which reverses the Cartesian epistemological problematic by taking it to its Nietzschean extreme. While Descartes would accept the necessity of excluding madness as a price that the psychiatric subject must pay in order to remain the master of meaning, representation and causality, Nietzsche would celebrate the strategies of counterfeit, evasion and disguise through which madness disturbs the diagnostic truth game, challenging the hegemonic position of the subject in the field of representation.52 For Nietzsche, as Foucault reads him, it would not be the exclusion but the inclusion of madness which costs the psychiatric subject its authority in the field of knowledge. The more the psychiatric subject aspires to transgress the limits of its knowledge, the more it sacrifices itself as an agent of knowledge, ethics and political power. Confronting madness, the psychiatric subject loses its status as the origin of knowledge, meaning and truth and it is no longer the universal agent of knowledge and morality.53 On the contrary, it loses its unity and becomes multiple, facing the fact that it is ‘not one but split, not sovereign but dependent, not an absolute origin but a function ceaselessly modified’.54

Conclusion

Foucault resists the epistemological claims to a general theory of all science or of every possible scientific statement. Contrary to the epistemological discourse which investigates the rules and forms, the conditions and structures of truth-telling, Foucault analyses truthful discourse in close relation to the political structures within which it can arise and become possible and to the forms of subjectivity to which it is linked. In other words, he explores the political and institutional conditions under which a scientist can acquire the ability to articulate true psychiatric discourse and the modes of subjectification, which this discourse generates. Thus, Foucault’s area of concern is the domain that combines the history of science (the political forces, power relations and institutional framework which determine the formation of specific modes of scientific knowledge) and epistemology (the distinction between truth and falsity governing knowledge).55 In this field of research, Foucault explores the interdependence between truth, power, and ethics, without seeking their identification, underlying unity or strict separation. Instead, he shows that Enlightenment critique consists in bringing these aspects together, raising the question of each with constant reference to the others, without confusing them, relativizing them, or denying their specificity: ‘It is the discourse of the irreducibility of truth, power and ēthos, and at the same time the discourse of their necessary relationship, of the impossibility of thinking truth (alētheia), power (politeia), and ēthos without their essential, fundamental relationship to each other.’56 Power relations, epistemological structures and ethical issues find their locus of interaction, mutual dependence or even antagonism in the activity of articulating truthful discourse. The role of critique, however, is not to suspend political and ethical issues so that it can ensure that the process of reasoning that a psychiatrist follows is correct in determining whether his statements are true. It rather challenges the truth which endows the psychiatrist with the position of a valid speaker of scientific discourse, questioning the self-evidence of his status and his indispensability and foregrounding the effects of his discourse on the object which it addresses and about which he is qualified to speak (the mad, the mentally ill, the psychoanalytic subject).

Foucault’s critique is not a form of nihilism.57 He tackles truth as a perspective, not in the sense of being relative on account of limitations inherent in human nature, but because it is strategic and polemic.58 Truth involves incessant struggles, rivalry and disputes. We should not, Foucault points out, look to philosophers but to politicians, if we really want to grasp the root of truth and its manufacture.59 Truth is not the exclusive possession of an inventive mind nor the product and ownership of reason, but an effect of relationships of domination, conflict and debate: ‘devotion to truth and the precision of scientific methods arose from the passion of scholars, their reciprocal hatred, their fanatical and unending discussions, and their spirit of competition — their personal conflicts that slowly forged the weapons of reason’.60 Critical psychiatry illustrates that every diagnostic statement made by the psychiatrist opens up a battlefield, an agonistic space. However neutral and objective the utterances of the psychiatrist may be, they define, organize and distribute the whole set of power relations of his institution, posing at the same time the question of the ethos to which his institutional structure will give space. Inversely, no moral or pedagogical values, no partial goals or ideological forms will ever prevail, insofar as they will never find full and absolute legitimacy in truth to which they will always remain foreign and irreducible.