6

Foucault and Psychoanalysis: Traversing the Enlightenment

Through our analysis of hysteria, we have shown how for Foucault the phenomenon of simulation introduces an important split inside diagnostic truth. There is on the one hand the dominant scientific truth regime, which objectifies, demonstrates and analyses mental illness. This truth regime is guided by a rationality that has become increasingly positivist since the late nineteenth century. On the other hand, there is a marginalized truth regime that tests madness. It is a regime of truth guided by reason, a type of diagnostic truth, which establishes a relationship with otherness, a truth where scepticism reaches its culmination and the presence of madness is recurrently problematized. These two truth regimes, Foucault argues, are in an antagonistic, conflictual relationship and their oppositional coexistence in the same diagnostic discourse gives rise to moments of crisis, to rupture and discontinuity.

Challenging psychiatric positivism in the late nineteenth and early twentieth century, psychoanalysis brought this uncomfortable relationship between science and otherness centre stage. Freud – and Jacques Lacan (1901–81) later more explicitly – made it visible by revisiting Kant and the alienists, renewing their anthropological reflections. The father of psychoanalysis introduced the unconscious, opposing negativity, death and madness to the calm positivism of his time. However, Freud’s method was at the same time an effort to insert madness into the domain of medical authority, grounding psychoanalysis on a fundamental paradox: while he recognized the irreducible tension between the truth regime of science and that of the test of madness, Freud tried to reconcile and modify the two truth regimes, in order to make them function harmoniously in a medical setting. Freud found the probing method of positivism and the scepticism of the truth-test too uncertain and dubious to come to terms with the obscurity of madness. His goal was to construct a new methodology, which would transform scientific discourse so as to provide direct evidence of madness itself. For this purpose, he furnished a unique diagnostic system based not on truth but on falsity and illusion, as a way of unequivocally proving its presence in the psyche of the patient. However, this methodology – this inverted scientific model of simulation and crisis, coupled with the ceremonial staging of madness, which could only take place on the analytic couch – rendered psychoanalysis an ambiguous enterprise. Psychoanalysis became both scientific and ritualistic; objective and prophetic; quasi-positivist and quasi-religious; anti-institutional and authoritative. Psychoanalysis presented itself as a type of medical and psychological practice, which nonetheless criticized the efforts of medicine to pathologize madness. It became the protagonist in the expanding system of normalization, but also a source of philosophical, political, literary and humanist critique of theories and institutions.

It is this ambiguity intrinsic to psychoanalytic practice and theory which Foucault underlined with his genealogy and which we shall attempt to reconstruct in the final chapter. Some commentators hold that Foucault treated psychoanalysis as a pseudoscience throughout his work, while psychoanalytically orientated thinkers reproach him for his inability to assess the merits of their theory from the standpoint of his historicity and his preoccupation with power.1 Foucault, however, applies his historical method and his analysis of power relations not in order to condemn psychoanalysis, but to submit it to critical scrutiny. His aim was not to invalidate its scientific status or its critical powers, but to locate the exact place that it occupies in Western rationality and to assess the type of truth that it articulates in relation to psychiatry: ‘I had attempted to account for what happened until the beginning of the 19th century; then psychiatrists took my analysis to be an attack against psychiatry. I don’t know what will happen with psychoanalysts but I am afraid they will take as “anti-psychoanalysis” something that is only meant to be a genealogy.’2 In this chapter we shall try to illustrate this genealogy in order to demonstrate the affinity of psychoanalysis with Enlightenment critique, but also to highlight the ways in which it risks contradicting the spirit of the Enlightenment. We shall show how Foucault classifies psychoanalysis as a ‘counter-science’ and a form of alienism and gives it credit for its capacity to reflect on the limits of science. He views psychoanalysis as a valuable critical enterprise, which has renewed the possibility of playing off truth, desire and limit-experiences against reality, reintroducing philosophical thought within science, into everyday practices and inside local struggles.3 He does, however, treat with scepticism the Freudian and Lacanian conceptions of Enlightenment critique, insofar as their theoretical premises and practical applications are in many ways in conformity with the psychiatric rationality, which they claim to criticize. Foucault underscores the need for psychoanalysis to recognize the limitations of its truth claims and to critique its own mechanisms of power to the extent that these renew and support rather than oppose the psychiatric institution. If it is to restore the critical potential, which it lost from the moment it laid claim to scientificity, psychoanalysis must reinstate its theoretical exteriority vis-à-vis science and as a practice it must engage in a politics of truth in order to question psychiatric rationality.

Freud and Hysteria

Freud followed closely the events surrounding the phenomenon of hysteria at the Salpêtrière. He observed and recorded carefully the efforts of the neurologists to offer medical recognition of hysteria as mental illness. As an astute and diligent clinician, Freud noticed that the hysterics posed a set of stumbling blocks to Charcot’s efforts to give madness, through neurology, the medical reality that it lacked. He became aware that the hysterics responded to the game of reality imposed by the asylum system with another peculiar game of truth and falsity. The hysterics’ game disrupted any attempt at anatomical localization that would claim to represent their madness. He thus praised Charcot’s achievement in pathologizing hysteria, while foregrounding the limitation of his methods.4 Disillusioned by the inevitable failure of the neurological approach, Freud set out to secure diagnosis in a way that would sidestep the patients’ elusive game of truth. He went on to construct a new diagnostic method, which would lead safely to the demonstration of the inner core of the hysterical symptomatology. In fact, it was more this new diagnostic thinking rather than his theories about trauma and sexuality, which distinguished Freud from his contemporaries. Charcot had already discovered a possible sexual aetiology for hysteria, which he was nonetheless hesitant to systematize, insofar as repressed sexuality had already been attributed to all simulatable neuroses in the late nineteenth century and therefore was not unique to hysteria.5 Charcot had also thematized the theory of trauma, which served as a neurological aetiological model, an epileptic equivalent, which also lacked specificity and could also be simulated.6 Freud’s great achievement, therefore, was not the supposed sophistication with which he developed sexuality and trauma.7 His innovation consisted in building a system of interpretation, which would enable the traps of hysterical symptomatology unwittingly to disclose a repressed archaic traumatic sexual experience, whether real or fantasmatic. Freud modified diagnosis in such a way as to turn the hysterics’ simulation to his own advantage; it was not the clear and unequivocal symptoms of the patient, but her most obscure and ambiguous signs which provided confirmation of his theory of sexuality. For Freud the hysterics’ game of truth and falsity posed no diagnostic problem but, on the contrary, it was revealing of a psychic reality containing a madness, which remained hidden from the patients themselves:

Freud and psychoanalysis took the historical point of their departure — their point of departure — in a phenomenon which, at the end of the nineteenth century, had a very great importance in psychiatry and even in a general way in society, and it can be said, in western culture. This singular phenomenon — almost marginal — fascinated doctors, and fascinated in a general way, let us say, the researchers who were interested in one manner or another in the very broad problems of psychology. This phenomenon was hysteria. Let us, if you will, set aside the properly medical problems of hysteria; hysteria was essentially characterized by a phenomenon of forgetfulness, a massive misunderstanding (méconnaissance) of oneself by the subject who was able, through the increase of his hysterical syndrome, to ignore an entire fragment of his past or entire part of his body. Freud showed that the subject’s misunderstanding of himself was the point of anchorage for psychoanalysis; that it was, in fact, a misunderstanding by the subject, not of himself generally, but of his desire or of his sexuality.8

Freud’s stroke of genius consisted of using the simulation of the hysterics in order to disclose their madness. Whereas in typical medical practice the demonstrative power of scientific knowledge stumbled at the ruses of the hysterical crises, which barred recognition of pathology, for Freud the lies of the patients became the very condition of possibility for this recognition. There was no longer any need to depend on the hysterics’ truth game, which blocked awareness of illness. Now misrecognition itself could unveil what is blocked from the patients’ consciousness. Moreover, there was no longer any need for the institutional power of the neurologist. All that was needed was a type of discourse, a form of confession, which sidestepped the patients’ games of truth and illusion which puzzled Charcot, in order to decipher symptoms as markers of a hidden truth which was desire. With the notion of misrecognition, Freud asserted madness as a void, a limit experience, which can only be approached negatively through the self-limitation of truth and knowledge. He thus introduced an extra-psychiatric and extra-institutional diagnostic discourse, which reversed Charcot’s observations, questioning the possibility of pathologizing madness and foregrounding its ungraspable truth, which resists its immersion into the reality of the asylum.9 He disrupted the rational hegemony of psychiatry and rendered problematic the field of the human sciences tout court as a positivist enterprise. After nearly one hundred years Freud made it possible for madness to be posited again as the excluded term, the inaccessible truth, the secret of man’s destiny and myth, and at the same time his hidden reality which could become an object of knowledge.

The Perverse Core of Psychoanalysis – A New Regime of Truth

From the moment Freud circumvented the problem of simulation, or rather used simulation itself as a tool for staging the truth of madness, he introduced a unique and unprecedented type of discourse in the history of psychiatry.10 As we have shown, simulation is the biggest epistemological obstacle for psychiatry, a diagnostic problem, which must be overcome anatomically in order for madness to be demonstrated as mental illness so that treatment can be applied and the magistrates can be convinced that the involuntary sequestration of an individual can be medically legitimized. With Freud’s approach, this difficulty is bypassed; the transformation of madness into mental illness is not the ideal end goal and therefore simulation is removed as an obstacle to its recognition. On the contrary, regardless of any proposed anatomical or psychological aetiology, for Freud, the simulation intrinsic to mental illness – the patient’s deception, his fantasies – is the highest moment of crisis, the surest path to madness, its clearest indication. With this crucial reversal, psychoanalysis not only presented itself as an epistemological break, but also as a discourse whose claim was that it could go beyond the traditional modes of veridiction governing psychiatry. Medical knowledge and testing madness are indispensable for psychiatric practice and it is the conflictual relationship between these two truth regimes that provokes crises of truth in psychiatry. In psychoanalysis, on the other hand, there is a truth regime, which does not test but stages madness and a system of knowledge which limits its own scientificity in order to allow madness to burst forth. Thus, there is a prophetic truth regime, which takes transcendence as its point of departure and produces the crises of madness itself and a scientific truth which is not strictly medical but helps these crises come to the fore. The coupling of these two types of truth is typically operative around the figure of the psychoanalyst and it is the analytic relationship, which constitutes the scene where the crises of madness are staged.

The prophetic truth at work in the analytic process is not merely a truth that foretells the patient’s future, or a truth that offers unequivocal and clear prescriptions. It is a discourse of finitude, addressing a truth to the patient, which comes from elsewhere.11 It is a truth which reveals what is hidden from the patient’s gaze and it evokes a voice which the patient cannot hear. It is a truth which unveils what the patient’s blindness prevents him from seeing and, importantly, it performs this revelation in an obscure way, in the form of riddles and enigmas. Psychoanalytic prophecy never speaks a pure, transparent truth; even when its truth is spoken, the patient has to ask himself ‘whether (he) has really understood, whether (he) may still be blind; (he) still has to question, hesitate, and interpret’.12 This prophetic truth regime is incompatible with the clear and distinct ideas of Descartes or Kant’s transparent transcendental subject. It rather follows the opposite direction; it evokes the dark side of subjectivity, the unconscious, and then sets out to investigate the possibility of studying the human subject.13 The unconscious hides behind riddles because it has its own voice for which the analyst works as an intermediary. It is a transcendental space with its own language, its own logic and its own typology.14 This is why psychoanalysis as the study of the unconscious constitutes a ‘counter-science’, not because it is an irrational, magico-religious endeavour, but because it foregrounds the unconscious, man’s double, his finitude, as no longer being the forbidden region of psychiatry, but its epistemological basis.15 Psychoanalysis does not speak the clear language of representation – hence its reliance on simulation – insofar as its object, the unconscious, lies at the limits of representation and the borders of human experience which, as Kant had shown, mark the boundaries of possible knowledge, but also its condition of possibility: ‘With its gaze turned the other way, psychoanalysis moves towards the moment — by definition inaccessible to any theoretical knowledge of man, to any continuous apprehension in terms of signification, conflict, or function — at which the contents of consciousness articulate themselves, or rather stand gaping, upon man’s finitude.’16

As a prophetic discourse, psychoanalysis is also a discourse of fate: standing between past and future, the analyst demonstrates to the patient that she is caught in an endless loop, an eternal cycle between the empirical and the transcendental. He shows to the patient how all her empirical determinations cling upon unconscious transcendental forces, which at the same time foreclose any possibility of completion and self-realization: death, desire, law. Death, as a condition of possibility for knowledge, desire as the ‘unthought at the heart of thought’ and the law-language as the origin of signification, all belong to the transcendental realm which makes possible and simultaneously annuls the patient’s efforts to achieve complete knowledge and jouissance: ‘It is indeed true that this Death, and this Desire, and this Law can never meet within the knowledge that traverses in its positivity the empirical domain of man; but the reason for this is that they designate the conditions of possibility of all knowledge about man.’17 The revelation of the most extreme aspects of existence – the limit of death, the deadlock of desire, the distant and obscure Law – lead to the recognition of an inner, inaccessible and traumatic core of the psyche which is unthought and resistant to symbolization. Here psychoanalysis reveals madness in its otherness, its truth which cannot be grasped or assimilated into our reality: ‘when Desire reigns in the wild state, as if the rigour of its rule has leveled all opposition, when Death dominates every psychological function and stands above it as its unique and devastating form, we recognize madness as it is posited in the modern experience, as its truth and its alterity’.18 For psychoanalysis madness does not exist as an autonomous entity, as the repressed reality of the inner life, but as the unbearable truth which we can never know or grasp, and whose terrifying encounter forces us to escape into reality, in order to ensure the consistency of our being. Psychoanalytic prophecy shows madness to be the radical otherness, the kernel of our psyche, which does not stand for what is excluded or silenced, but which represents a primordial state from which we protect ourselves and constantly try to avoid by constructing a reality that we can tolerate.

By asserting the Kantian, anthropological tension between the empirical and transcendental as the fundamental precondition for the production of truth, psychoanalytic prophecy presented as a challenge to orthodox psychiatric and psychological thinking, without however being anti-scientific in itself. Psychoanalytic knowledge is scientific, but in a ‘perverse’ way;19 it is a system that questions the standard Cartesian tradition governing positivism and phenomenological hermeneutics. Analytic knowledge is demonstrative and apodictic but, unlike the Cartesian tradition, it does not take the exclusion of doubt as a prerequisite for the establishment of truth. Rather, doubt is the result of a primordial traumatic experience, of an archaic truth, which the subject has repressed. This premise is based on an original reading of the Cartesian method: contrary to Foucault’s interpretation whereby the possibility of madness is excluded by the doubting subject, in psychoanalysis doubt is proof that there is a mad kernel, an absolute truth from which the subject is excluded.20 It is therefore not in certainty, but in the gaps of knowledge, in its inherent incompleteness that indications of otherness are sought. Whereas Descartes aims to discover the self-evident and is suspicious of simulation, the very being of the evil genius of madness, psychoanalysis does precisely the opposite: it is suspicious of the self-evident and accepts what is sufficiently disguised. As Foucault notes, ‘Freudian censorship is a falsehood operator through symbolization.’21 Thus, the economy of truth for psychoanalysis rests on semiology rather than hermeneutics, which is why psychoanalytic theory is to a large extent opposed to phenomenology.22 Psychoanalytic examination is not an interpretive process, which deciphers meanings until it reaches the point where the ultimate truth of madness is decoded, along with the law by which the hidden message of madness means what it means. On the contrary, it looks for the fractures of meaning, the caesuras between the signifier and its denotation, until an absolute break ensues. Symptomatology for psychoanalytic diagnosis consists of a system of signs, which do not offer access to the Real through knowledge, but enact the traumatic encounter with it. The symptom is not considered a product of the pathology of the unconscious, but the pathway to the impossible, the unrepresentable, the intolerable. Discussing Freud’s notion of the symptom, Foucault describes it as a phantasm, a unique sign belonging simultaneously to two distinct orders, the ‘irruptive figure of a signifier that is absolutely unlike the others’23 which emerges from within the symbolic chain of interpretation, bringing interpretation itself to its limit, since the symptom also belongs to the transcendental and the realm of the nonsensical: hence the psychoanalytic account of hysteria which interprets it as an ambiguous and confusing set of signs and symptoms from within the established table of nosography, revealing the inaccessible and irreducible madness which neurology strove to medicalize. With the involuntary and unconscious hyperconformity of the hysterics, psychoanalysis argues, the Real exploded in the heart of the medical system of representation, overthrowing the symbolic universe of psychiatric discourse and unsettling the reality of the asylum.

Foucault’s anthropological ethno-epistemology does not consider the perversity of psychoanalysis (its counter-scientific stance, its prophetic dimension, its attention to critical moments) to be a sign of epistemological weakness; on the contrary, the unorthodox scientificity of psychoanalysis defines it as a unique type of discourse that can critique psychology itself as well as historical analysis. Its capacity to locate symptoms, pinpoint phantasms and illusions and reflect on limits, gives it its strength of criticism in fields of application that exceed its own domain. Foucault maintains that, through psychoanalysis, psychiatry could acquire the potential to establish a self-reflective attitude in relation to its past and present reality. He openly declares that ‘it should be said that, without psychoanalysis, our criticism of psychiatry, even from a historical perspective, would not have been possible’.24

Crisis and Psychoanalysis

Psychoanalysis has been the first psychological theory since the birth of psychiatry to employ the notion of crisis, the age-old medical conception of truth which psychiatric positivism has attempted to obliterate: herein lies its critical force. In fact, in psychoanalysis crisis is no longer a marginal truth modality, but an explicit, uncensored and fundamental epistemological stance. Its epistemological framework is thus very closely connected to the critical model, which Foucault discerns in the forgotten and overlooked methodology of alienism and the anthropology. What needs to be examined is how close this connection is, that is how decisively opposed to positivism the psychoanalytically conceived notion of crisis is and how radically it touches the roots of medical rationality. Here it becomes necessary to focus on certain crucial aspects of clinical psychoanalysis, using the delirious crisis, the privileged object of anthropological epistemology, as a testing ground for the possible proximity of psychoanalytic theory to a type of clinical critique that could be called anthropological.

As a prophetic discourse, psychoanalysis regards truth as a site of revelation, with its privileged moments, its reversals and its breaks. There is no positivist proof or statistical approximation in psychoanalysis, only a preoccupation with moments of rupture, with symptoms signalling the presence of a repressed truth, with dreams pointing to an irrational world. Psychoanalytic prophecy looks for truth in places and moments where it is least expected to be found, in the occurrence of fateful (or fatal) events, where the laws of causality fall apart and knowledge is acquired in the form of a lighting flash, in spite of the subject itself. The most universal, the most fateful event par excellence is delirium, the tragic dimension of human knowledge, the universal ‘word […] uttered from afar and above’; the knowledge which ‘blinds the very ones it concerns, a knowledge which watches and whose gaze dazzles those on whom it fixes’.25 Delirium is not a momentary affliction, a disturbance of consciousness, but the very mark of man’s Oedipal fate, the unthought in the heart consciousness, the point where all human cognition inevitably faces its own defeat. Delirium is not foreign to reason, but inextricably linked to it. This is why psychoanalysis does not expect it to be captured by the categories of rational thought, but looks for it precisely in the failures and impasses of positive knowledge: in those cracks and holes, which reason tries to patch up a posteriori in order to preserve the subject’s psychic equilibrium.

A genealogy of crisis, however, reveals that the prophetic universality of psychoanalytic neo-alienism is not exactly alienist, but halfway between the anthropology and mainstream psychiatric practice. In the age of alienism, it was reason that was posited as universal, leading to the discovery of the other, the real other, precisely the one that did not fall back into universal. This other manifested the phenomenon of delirium, the exceptional and not universal form of falsity or absolute truth intruding the consciousness of specific patients. This delirium presented in the form of a deceptive idea which either affected intelligence, but not the rest of behaviour (partial madness), or it was completely absent in the patient’s discourse and did not affect intelligence, while manifesting in an ‘act of delirium’, as in the monstrous, motiveless crime (monomania). The proto-psychiatric anthropologists did not assume the role of prophets to disclose the secrets of madness in order to detect the presence of delirium in these cases and their existing bodies of knowledge were restricted to a phenomenological taxonomic system designed to allow the prophetic speech of madness to be heard. To this end, they isolated and excluded the mad subjects so as to witness the crisis of insanity and contain its sovereign power. The asylum was a space where this opportunity arose, marking the crisis of delirious truth as the hallmark of proto-psychiatric diagnosis and treatment.

With the development of positivist psychiatry, reason was annulled as limit, rationality became universal and madness was the negative instance to be warded off at all cost. The dissolution of the delirious experience became the principal medical task. Seeking to obliterate the unexpectedness, incomprehensibility and danger that the crisis of delirium posed, medicine set out to cancel the emergence of crises. It did this in two ways: one was to reconstruct and intervene in the process of the development of delirium, so that it would never reach a critical level. The notion of partial madness was rejected and it was thought that pathological instincts, predisposing factors, hereditary markers, disorders of perception and degenerative phenomena which affected the whole of the patient’s personality, produced a (preventable) generalized pathological process in which delirium constituted only the ultimate contingent, surface effect (Wilhelm Greisinger [1817–68], Valentin Magnan [1835–1916], Emil Kraepelin [1856–1926]).26 The other way to dissolve delirium was to reproduce its crisis in a way that would both reveal its ontological depth and make its management as safe as possible. This is the transition from the truth-crisis to the crisis of reality, where ‘the doctor must be able to arbitrate on the question of the reality or non-reality of the madness’.27 Medicine began to use drugs (Moreau de Tours – hashish, labdanum, opium) in order to reproduce a crisis of madness at will, in a manageable, disciplined way, permeable to biochemical analysis.28 It used hypnosis and neurological models based on epilepsy, in order to demonstrate the automatisms, signs of degeneration and pathological instincts beneath the delirious outburst (Charcot, Jules Baillarger [1809–90]).29 Medicine appropriated the crisis by simulating it, grounding it at the same time on a precise anatomy, seeking to prove that the critical moment of madness can be a controllable, immune to simulation and predictable event. This reduction of madness to an anatomical seat could ideally dispense with the need for asylums, expand the powers of psychiatry from the most insane individual to the simplest automatism, to the most everyday and non-pathological type of behaviour and establish a type of medicine which could be practiced in the community, where madness would be reduced to zero and prevention and treatment could be equally available to all.

Psychoanalysis maintains an ambiguous relationship with both trends. First, it resembles alienism in detecting the presence of delirious truth in the crises where it shines through. Unlike alienism, however, psychoanalysis does not see in this delirious truth, ‘the trace of another world; it no longer observes the wandering of a straying reason; it sees welling up that which is, perilously, nearest to us’.30 Psychoanalysis universalizes madness, considering it an intrinsic part of reason, which is why it employs the notion of delirium to the most commonplace abnormalities and not to the altered state of consciousness of specific individuals. Hence, the fact that the exclusion of the insane is a notion totally foreign to psychoanalysis.31 Psychoanalytic anthropology is the alienism of the non-pathological. Psychoanalysis accepts the alienist concept of partial madness, but as a universal aspect of the human psyche. If dreaming is so important for psychoanalysis, it is because it is the most elementary, isolated form of insanity occurring in the most normal individual. Dreaming not only constitutes the most universal form of partial insanity, but it also discloses the internal law of madness, the events and processes of delirium, to the sane observer. It enables the psychoanalyst to say: ‘I can well understand what madness is, because I can dream. With my dream, and with what I can grasp of my dream, I will end up understanding what is going in someone who is mad.’32 Likewise, psychoanalysis retains and generalizes the concept of monomania, insofar as it is possible for anyone to act incomprehensibly, to perform monstrous acts, without the overt presence of delirium. Freud’s ‘psychopathology of everyday life’ is a case in point.33

Moreover, psychoanalysis appears foreign to alienism and closer to psychiatric rationality insofar as it replaces the truth crisis with the crisis of reality. This does not mean that psychoanalysis embraces the positivist bodily ontologization of madness. On the contrary, psychoanalytic epistemology is careful enough to avoid the insertion of delirium into a causal chain. Only some vulgarized forms of Freudianism propose a strict reduction of madness to somatic aetiology (archaic forms of sexuality, actual events of sexual abuse or seduction, Wilhelm Reich’s orgone).34 The psychoanalytic relationship with delirium remains non-reductive. It is not, however, completely devoid of any determinations. For psychoanalysis delirium may not be secondary to automatisms or perceptual disorders, but it does contain libidinal forces, investments of desire, impossible pleasures and modalities of enjoyment: ‘these typologies of delirium are no longer organized around the delirious object or thematic, as in the time of Esquirol, but rather around its instinctual and affective root, around the interplay of instincts and pleasure underlying the delirium’.35 Hence the influence on psychoanalysis, not of Emil Kraepelin and Eugen Bleuler (1857–1939) who spoke of psychosis in terms of dementia and autism, that is in terms of flattened symptoms, degeneration and organic etiology, but of Gratian de Clerambault (1872–1934), Lacan’s master and his studies on affective forms of delirium (persecution delirium, erotomania).36 The truth of delirium, according to psychoanalysis, is pinned not to reality, but to the Real, the empty ontology of the abysmal, traumatic or excessively anxiety-provoking forces of the void that sustains and at the same time threatens the subject with disintegration. This Real may not be the tangible reality that neuroscience, neuropharmacology or the psychotropic body seek to uncover, but it is nevertheless present as a default in the symbolic universe shared by all humans.37

Thus, as a universalized form of alienism and a mirror image of psychiatric rationality, psychoanalysis accepts and foregrounds the crisis of delirium, while at the same time employing the prevalent psychiatric categories of normality. This is why, even if it is not always practiced by doctors, psychoanalysis functions as therapy, as an extra-asylum medical type of intervention, considering all mental illnesses as potentially curable in the analyst’s office, disregarding any de jure particular reasons why some individuals should be committed involuntarily and why in some patients madness might pose a danger to others. Thus, while today’s psychoanalytic techniques are rooted in the anthropological methodology of the early nineteenth century (‘the doctor’s power, language, money, need, identity, pleasure, reality, childhood memory’),38 the presuppositions on which they rest are in many ways foreign to the spirit and practice of alienism. Psychoanalysis considers the patient capable of establishing a free contract with the doctor, while in the years of proto-psychiatry the consciousness of madness prohibited such a possibility, hence the need for involuntary hospitalization. Confession in psychoanalysis, the famous ‘talking cure’, aims at the consensus between analyst and analysand and the mutual agreement on the identification of the patient’s fantasy and the rule of the signifier which resists confession and brings it to a halt. The confessing techniques of the early anthropologists, on the other hand, sought to make the mad person publicly avow and declare his madness, in order to formally accept his status as mad, submit to the superior power of the doctor and recognize the need for treatment.39 Therapy in psychoanalysis is restricted to discourse and the body, the sexual body, is an object of theoretical contemplation (oral, anal, genital cathexis); in the anthropology of the proto-psychiatry the body was isolated, deprived of most of its needs and even tortured, in order to make the patient adapt to the sub-reality of the asylum world. The patient’s history in psychoanalysis leads to the identification of a primordial trauma, whereas in alienism it was meant to lead to a recognition of madness (past hospitalizations, breaks and discontinuities with premorbid personality); in analysis, the restriction of needs, the economy of pleasures and the exchange of money constitute theoretical presuppositions (pathological desire, impossible jouissance) and practical conditions for the continuation of therapy (the payment of fees), whereas in the asylum they had only an instrumental value, they were strategic manoeuvres aiming to expose the patient to her illusory omnipotence. While the paranoiac model of psychoanalysis is anthropological and deeply Cartesian in considering the misrecognition of truth, the unshakable conviction of the patient’s beliefs as the core pathology of insanity, its goal is to stage unequivocally this misconstrued truth through the falsity, the simulation of the patient’s discourse, her slips and misrecognitions. Alienism, on the other hand, seeks to insert the Cartesian evil genius into the patient’s thinking, using the model of reversibility, to help the patient recognize the illusion hidden inside her most plausible convictions.

Psychoanalysis and the Strategy of Madness

Thus, there is a perverse dialectical synthesis between the scientific and the prophetic aspect of psychoanalysis, evident in its anthropological interpretation of paranoia and the quasi-medical way of tackling it on a clinical level. As it will now be shown, this synthesis is more evident in the case of hysteria, the second major anchoring point of psychoanalysis, a borderline case already occupying an ambivalent position in the theoretical and clinical context of psychiatry since the late nineteenth century. More than any other psychological theory, psychoanalysis has helped shed philosophical as well as scientific light on this limit-experience, but at the same time, this obscure medical syndrome and its contemporary equivalents have exposed the clinical limitations of psychoanalysis as a whole.

When hysteria created the first major tremors at the Salpêtrière, the mechanisms of reality were immediately set in motion. Neurologists experienced hysteria as a typical case of simulation threatening the objectivity of real illnesses. Babinski dismissed it as a fake illness and strove to invent diagnostic manoeuvres in order to disprove its existence (the famous Babinski sign). Charcot, on the other hand, accepted and enhanced the crises of hysteria in order to stabilize their atypical presentation and use them against regular simulation. The same path was followed by psychological theories as well as by Freud himself, who saw childhood trauma and disordered sexuality behind the appearance of the hysterical outbursts. This was the beginning of the ‘passion for the real,’ as Badiou would say,40 dominating psychiatry to this day, a will to factual objectivity submitting all forms of crisis, all types of simulation to the test of reality, where diagnostic truth should find its objective support and substantiation. At this point psychoanalysis made a breakthrough, evading this all-encompassing logic; instead of seeking to add one more theory to the explanations of hysteria, it marked it out as an exceptional case and as deadlock to this overproduction of knowledge concerning madness. Psychoanalysis spotted in hysteria a crisis of madness, albeit a ‘normal’ madness without delirium. Instead of considering hysteria as a type of simulation threatening reality, psychoanalysis saw hysteria as a case of the Real of madness producing effects of simulation the moment it comes too close to being grasped and assimilated. Defying the passion for the real, psychoanalysis argues, the hysterics displayed the unbridled, indifferent passion for semblance and false appearance, which is a way to resist the total transparency and vulgar objectivity of science.

At any rate, credit should not be given to Freud for the first depsychiatrization. We owe the first depsychiatrization, the first moment that made psychiatric power totter on the question of truth, to this band of simulators. They are the ones who, with their falsehoods, trapped a psychiatric power which, in order to be the agent of reality, claimed to be the possessor of truth and, within psychiatric practice and cure, refused to pose the question of the truth that madness might contain.41

The psychoanalytic description of hysteria and its effects on the medical authorities has inspired not only Foucault, but many mental health specialists. On numerous occasions since the late nineteenth century, psychoanalysis has pioneered in identifying similar cases, where patients use simulation, misrecognition and ambivalence to shatter the apparent consistency of the symbolic order and of psychiatric power. Hence the affinity of psychoanalysis with borderline disturbances.42 It is no accident that it was psychoanalysis which coined the term alexithymia to denote the inability of certain patients bordering on psychosis (somatoform patients, personality disordered) to recognize and express their emotions in the course of therapy.43 It is no coincidence that psychoanalysis described, spotted and systematized the notion of borderline personality disorder, an entity so uniformly and consistently atypical and unstable, so ambiguous and fuzzy, that it adopts, imitates and makes a mockery of today’s bio-socio-psychological model.44 Psychoanalysis not only distinguishes these ordinary and frequently undetectable syndromes from the neuroses, but goes on to treat them as limit-cases, as pre-psychotic states whose delirium finds expression almost exclusively in the body, caricaturing, exaggerating and turning the various medical models and their bodily inscriptions against the power which generated them. Psychoanalysis rightly regards these cases as descendants of hysteria, that is, as symptoms and also forms of resistance to the excessive medical desire for otherness and the surplus power of psychiatry. Recent psychoanalytic studies have helped show how, like hysteria and its manipulation of the neurological model, contemporary forms of somatoform and psychosomatic disorders (hypochondriacs, body dysmorphic patients, the psychosomatic) are products of the psychotropic model, emptying medical semiology of its content,45 and how the famous cutters and self-injurious borderline patients figure as the negative result and the symptom of the expansion of the biopsychosocial model, defying the medical and psychological means of assessment and care.46

However, although psychoanalysis has the philosophical background to identify the limit-position and the disruptive effects that these syndromes have on the framework of psychiatric theory and practice, on a clinical level it aspires to cancel these effects and master them in a thoroughly medical way. While it has recognized the force of singularity contained in the unbearable silence and bodily expression of delirium in these limit-cases, it has striven to make this silent delirium speak, accommodating it into its own spatial coordinates and its own relations of power and truth. Psychoanalysis effectively removes the patient from the asylum world where he had once become the undesirable excrescence of psychiatric power and medical transparency, transferring him to the private office of the analyst where he is submitted to the test of perpetual discourse which channels the hidden delirium out of the dangerous muteness of the body, into a form of speech guaranteeing the controlled management of crisis: ‘withdrawal outside the space of the asylum in order to get rid of the paradoxical effects of psychiatric surplus-power; but reconstitution of a truth-producing medical power in a space arranged so that that production of truth is always exactly adapted to that power’.47 So as to avoid the negative effects and ruses of psychiatric omnipotence, the analyst is not the omnipresent and omniscient asylum doctor who constantly observes and questions the subject, but a more humble, silent and invisible partner who assumes the position of a listener of the patient’s mandatory monologue, ensuring that the ‘sovereign science’ of psychoanalytic power ‘is not caught up in mechanisms that it may have unwittingly produced’.48 In his abstract power and humility, the analyst never loses control of the disembodied, discursive arrangement of the analytic process, where even the most confusing and perplexing symptoms which constitute the patient’s ‘counter-power that traps, nullifies and overturns the doctor’s power’,49 are used as unequivocal proof of the madness which these lies mask. Even if the patient unconsciously attempts to deceive the doctor, especially as the hysterics and the personality disordered are expected to do, he will not have trapped him, but will have temporarily disrupted the production of truth, adding further sessions to the therapeutic process.50 Psychoanalysis is thus at once more humble and more perverse, establishing a positivist mechanism in reverse, a mechanism which does not deny madness so as to protect the privileges of science, but which makes ‘the production of madness in its truth as intense as possible, but in such a way that the relationships of power between doctor and patient are invested exactly in this production, that they remain appropriate for it, do not let themselves be outflanked by it, and keep it under control’.51 This is why, while the theoretical insight of psychoanalysis has offered an indispensable grid of analysis of the way delirium has resisted its assimilation into the network of medical rationality, on a clinical level psychoanalysis has aligned itself with the rest of psychiatry, reproducing this same assimilation into the programmed and calculated procedures, the sophistical manipulations and prophetic enigmas of the analytic relationship. As Foucault points out, ‘if it has played a critical role, at another level, psychoanalysis plays harmoniously with psychiatry’.52

For Foucault, the crisis of delirium has deeper political ramifications. It is exactly the silence, the territoriality, the actual, physical presence of the delirious patient and the symbolic violence with which he responds to interpellation, which shakes the roots of power. Delirium challenges power only from a position of exclusion, from a relationship of exteriority with power, be it the disciplinary power of the proto-psychiatrists, the liberal, bureaucratic or ubuesque power of contemporary psychiatry, or the silent and invisible power of the analyst. This exclusion is not a natural fact, a logical necessity, but it does follow logically from the historically determined way in which medical rationality has posed madness as a problem. This problem is by definition insoluble, it can therefore exist only as a form of challenge. The early psychiatrists had intuited this fact, when, faced with the crisis of delirium, they created a phenomenological diagnostic system and a therapeutic regime based on clear distances between different forces, duality and strategy. Today, these tactics seem outmoded and unscientific and the forces of inclusion, the mechanisms of liberation and the processes of rationalization aim to preclude the possibility of a similar clash with the irrational. Under today’s logic of security, the logic of peaceful coexistence, protection and abstraction, there is no singular experience which can be called madness, either because there exist only anatomically localizable and psychologically understandable mental illnesses differing in degree, or because, as psychoanalysis asserts, everyone is mad, everyone harbours a kernel of delirium decipherable through the textual analysis of the unconscious. Nevertheless, the singularity of madness is indispensable and ineluctable, which is why we witness its spontaneous resurgence and resistance to this logic, to this ‘monopoly of consciousness, and the monopoly of the unconscious’, as Baudrillard would say.53 But it is a case of pure challenge, distance and duality, not a case of an archaic, fascist or revolutionary resistance, as Guattari’s schizoanalysis would argue;54 in the biopolitical age of global harmony and reconciliation of heterogeneous forces, the sovereignty of delirium, by definition aimless and otherworldly, does not seek to liberate itself or overturn the universe of reason by force, but excludes itself, it subtracts itself from this uniformity, imposing limits and points of subversion within what appear as stable and fixed mechanisms of power. Delirium destabilizes linearity and demarcates zones of reversal, creates sites of confrontation and forms lines of escape. It reintroduces the spectre of madness when all mental illnesses are neatly placed in the smooth spectrum of abnormalities.55 When all accounts appear settled and a uniform consciousness of security appears natural, it is the patients themselves who cancel objectives, postpone rational ends, distort or annul the goals, values and the initial programming of the globalizing rationality, constituting strategic manipulations which change the very nature of today’s governmentality.

Thus, today we are faced with a second phase of exclusion of madness, this time less generalized and more local and dispersed, but nevertheless more violent and uncontrollable than the first, altering the physiognomy of the mental institution in unforeseeable ways. The patients are nowadays engulfed in a network of inclusion, security and socialization, no more liberating or subjugating than the system of exclusion that preceded it. It is a system of infinite supply of services in which security, prophylaxis and control are offered as abundantly as the systems of overconsumption and dependence that inevitably follow. In its institutionalized form, psychoanalysis, which, ‘God knows how much it is spread throughout our culture’, is part of the same apparatus, the same psy-function infiltrating the social body.56 The patients defy the rules of this system of integration, by taking its provisions, its unconditional care and solicitude to its paroxysmal form, creating reversals of power that the system cannot tolerate, which is why these patients, this time under the cover of normality, become once again marginalized, circulating in the interstices of the saturated web of services. The incident of hysteria was the first major episode in the history of this process; official psychiatry may have assessed the confrontation with hysteria as a victory of medical rationality and truth over false illness, but, in actuality, the hysterics took Charcot and the neurologists hostage, depriving them of their absolute authority over the medicalization madness, while they became masters of the diagnostic game. When they confirmed medical truth, they simultaneously managed to conceal their madness behind it, thereby seducing power into granting them medical extra-territoriality by discharging them from the asylum space.57 The process is the same today with all the borderline cases which psychoanalysis has so diligently managed to pinpoint but is equally unable to fully contain. Somatoform and psychosomatic patients are in many ways considered unmanageable.58 Their symptomatology points to the existence of real illnesses, while lacking anatomical seat; their psychotherapeutic treatment has offered poor evidenced-based results and psychoanalytic theory has highlighted the pre-psychotic and therefore impervious to analysis, relationship that these patients have with their own body and their subjectivity. Eventually, this group of patients disregards the psychoanalytic cure, overflowing the hospital and its outpatient clinics, demanding more medical care, more and more benefits. They take the health services hostage, projecting irrational demands and their dependent attitude towards the excessive availability of psychiatric care saturates the system to the point of collapse. Overconsumption of psychotropics, numerous medical examinations and tests, insoluble problems in managing their absurd needs, all lead to economic and administrative deadlocks and overcrowding inside the hospital. Similarly, borderline personality disorder, the single most important case for which psychodynamic psychotherapy is considered today as one of the first-line treatments by the official psychiatric establishment, endlessly circulates between the analytic couch, the community and the mental hospital. Adopting all forms of major psychopathology (periodic delusional ideation, emotional instability, suicidal or self-harming behaviour), borderline personality disorder has been identified as an atypical but nevertheless distinct nosological entity. Very often, however, its existence is associated with terror and blackmail: its pre-psychotic defence mechanisms (splitting, projection, dissociation), its impulsivity, its objectless anger, its manipulative and dangerous behaviour and its proclivity to pretence and victimization distort the goals of psychoanalytic cure, force the therapist to commit the borderline patients to hospital against their will, or to administer excessive doses of psychotropics which reinforce their sense of victimhood and become tools of substance misuse and further suicide attempts.59

All these limit-cases do not constitute epistemological blockages, rebellious forces or anti-psychiatric voices inside the psychiatric institution. It is their paradoxical nature, the absence of delirium in an otherwise mad behaviour, the excessive and inexplicable hyperconformity to the diagnostic decrees and rules of the mental hospital, which render them the underside of power, its outer limit.60 It is exactly this strategic aspect of their existence which Foucault stresses. By adopting and exaggerating the regime of truth, which a specific mode of psychiatric rationality uses to explain them, by turning this same model of truth (the neurological, the sexual, the psychotropic or the psychological body) against power, they are transformed from subjects to be governed into adversaries that power is obliged to confront. They become dissidents, the frontier for the relationships of power, the ‘line at which, instead of manipulating and inducing actions in a calculated manner, one must be content with reacting to them after the event’.61 Medical rationality is already in the process of recognizing this challenge which it has striven to suppress and it is now obliged to face: it confronts the political and ethical issues arising from the requirement of dangerousness for involuntary commitment, which treats individuals as social adversaries threatening public safety and hygiene; it reconsiders the role of the asylum, which has been so easily dismissed by the anti-psychiatric movements and the proponents of deinstitutionalization; it has increased its awareness of the overwhelming social and political pressures it receives in the wake of the psycho-political phenomena of barbarism, terrorism and fundamentalism.62 Psychoanalysis has greatly contributed to this introspection especially from its extra-institutional position as an ‘exotic science’63 where it is able to speak the language of finitude, negativity and the limit, the language which best acknowledges and describes the instances of duality, the anthropological mutations, the divisions, conflicts and points of antagonism which disrupt and unsettle today’s hegemonic rationality.

Conclusion

Prophecy and science are the two modalities of truth-telling governing psychoanalysis. Whenever prophecy has dominated, psychoanalysis has functioned as an anti-psychiatric discourse, an anti-repressive discourse promising to liberate the drives and desires that have been silenced by the constraining effects of the psychiatric classificatory and therapeutic system. Whenever the scientific aspect has prevailed, psychoanalysis has provided a medical and psychotherapeutic setting where the hysteric’s symptoms are verbalized, the ‘legalistic scruples of the obsessional neurotic’ are alleviated and the denial of the paranoiacs is enacted.64 In the history of psychoanalysis, both truth modalities have functioned in a balanced and symmetrical way, constantly referring to medical knowledge and affirming medical truth. It is the proximity of the psychoanalytical discourse to medicine that Foucault sets out to critique. He does not, therefore, criticize psychoanalysis for its low level of scientificity, but, on the contrary, for its efforts to be medical and scientific. He is not sceptical of its epistemological status, its rules of construction or the validity of its concepts, but rather of the way it denounces its own critical powers as counter-science, in its bid to become a valid scientific discourse with power effects:

You know how many people have been asking themselves whether or not Marxism is a science for many years now, probably for more than a century. One might say that the same question has been asked, and is still being asked, of psychoanalysis or, worse still, of the semiology of literary texts. Genealogies’ or genealogists’ answer to the question ‘Is it a science or not?’ is: ‘Turning Marxism, or psychoanalysis, or whatever else it is, into a science is precisely what we are criticizing you for’.65

The importance of psychoanalysis, for Foucault, lies in its effective critique of today’s scientism. It has dismantled the absolute power of science, its universal legitimacy, the unanimity that it provides, and the functional coherence and formal systematization that it aims to produce. Psychoanalysis has escaped the ‘disciplinary policing of knowledges’, which scientific truth has increasingly imposed since the late eighteenth century.66 However, psychoanalytic discourse has also asserted theoretical unity, a totalizing approach and hierarchical organization. It too has drawn its pretensions to validity and universality from scientificity,67 laying claim to power effects and becoming centralizing and hegemonic. Even in its critical dimension, it is embodied in the university, has a diffuse pedagogical role, has been widely institutionalized and comprises a vast theoretico-commercial network in many countries.68 For Foucault, these paradoxes undermine the very coherence and revolutionary capacity to which psychoanalysis aspires, causing it to be ‘suspended, or at least (be) cut up, ripped up, torn to shreds, turned inside out, displaced, caricatured, dramatized, theatricalized, and so on’.69

Psychoanalysis, however, has not lost its critical value. It can still be used on a local level as a weapon of truth against the dominant medical discourse. It can serve as a local form of knowledge, as an alternative type of truth, which, along with other marginalized, disqualified forms of knowledge, the nonconceptual forms of knowledge below the level of scientific erudition (the personal experience of the doctor, the patient, the nurse, the delinquent), can exert considerable effects on the political status of psychiatry, its internal reforms and on the fate of madness as limit-experience in the West.70 In Foucault’s critique psychoanalytic truth does not yield a new, universal and neutral discourse. Rather, it is deployed from a position of combat inside a nexus of disparate truths engaged in agonistics and war. This agonistics of truth is a crucial element of Enlightenment critique.71 Foucault stresses the fact that what is called the Enlightenment cannot be exhausted in the alleged triumph of science which, as a state mechanism in the late eighteenth century, was in charge of the selection, normalization, hierarchicalization and centralization of knowledge. It was during the same period that intellectual debates, which occurred at the margins of scientific disciplinarity, provoked dispersal, heterogeneity and struggle among various forms of knowledge. Psychoanalysis has helped to renew these debates, which challenge the monopoly of science and dismantle the view that knowledge is a state of order, peace and rationality.72 It is one of those local and regional forms of knowledge which have resisted the principle of universality and consensus which scientific truth has increasingly imposed. This is why, in Foucault’s system, psychoanalysis is inserted in the wider domain of intellectual struggles which, since the late eighteenth century, have undermined the hegemony of the ‘enlightened’ scientific subject who exerts the power to exclude and disqualify forms of knowledge which do not meet the constraint of institutionalized truth:

The genealogy of knowledge must first — before it does anything else — outwit the problematic of the Enlightenment. It has to outwit what was at the time described (and was still described in the nineteenth and twentieth centuries) as the progress of enlightenment, the struggle of knowledge against ignorance, of reason against chimeras, of experience against prejudices, of reason against error, and so on […] when we look at the eighteenth century — we have to see, not this relationship between day and night, knowledge and ignorance, but something very different: an immense and multiple battle, but not one between knowledge and ignorance, but an immense and multiple battle between knowledges in the plural — knowledges that are in conflict because of their very morphology, because they are in the possession of enemies, and because they have intrinsic power-effects.73

The ‘Enlightenment’ is not the triumph of science over ideology, truth over error or light over darkness. On the contrary, Enlightenment critique is anti-scientific and anti-consensual, not in the sense that it refutes scientific knowledge and opposes reason, but insofar as it frees truth and reason from the totalizing effects of science and intellectual universality. This is why critical psychiatry promotes a pluralism of truths without, however, supporting their abstract multiplicity, their ideal democratic equality or their indefinite free interplay. It sets them in opposition, constant challenge and confrontation.74 It intensifies a war between regimes of truth, where no type of truth, be it prophetic, scientific or juridical, can ever prevail over others. No subject can ever claim to articulate a universal and absolute truth, to speak in the name of a ‘we’ or to occupy the position of a jurist or a philosopher. The subject engaging in truthful discourse (the psychiatrist, the patient, the analyst, the nurse or the magistrate) is not a totalizing and neutral subject, but a subject involved in an antagonistic process, whereby divisions, confrontations and struggles disturb the ordered harmony of unitary, formal and scientific theoretical discourses.75 The subject speaking the truth is engaged in a battle, has adversaries, and through its discourse, claims to clarify facts, dispel illusion and denounce error. Therefore, its truth cannot settle affairs, bring order or restore peace, but it can shift balances and accentuate dissymmetry. It is a truth which brings about conflict and dissent, but, more crucially, it is a truth which introduces otherness both by challenging our seemingly self-evident reality and by problematizing foreign forms of experience: ‘there is no establishment of truth without an essential position of otherness; the truth is never the same; there can be truth only in the form of the other world and the other life (l’autre monde et de la vie autre)’.76