From Madness to Mental Illness: Psychiatry and Biopolitics in Michel Foucault
Abstract and Keywords
This chapter explores Michel Foucault's contribution to a critical assessment of modern and contemporary psychiatric practice. It focuses firstly on the History of Madness (1961): the social, political, cultural, epistemological construction of the object "psychiatric patient" and "psychiatric pathology"; the gradual historical shift from "madness" to "psychiatric pathology" and its social and epistemological consequences; the horizons and limits of the romantic task Foucault assumes on this basis (namely, the idea of letting the voice of madness come back and speak again, "under" the language and categories of medical knowledge); the critique Jacques Derrida formulated (Writing and Difference, 1967) about this project, and particularly about Foucault's reading of Descartes. Secondly, it examines Foucault's course on Psychiatric Power (1975), focusing on the sociopolitical consequences of this medicalization process: i.e., the construction of the object "psychiatric patient" as "disciplinated bodies", and the general context of this anthropological metamorphosis Foucault studied in his books Discipline and Punish, The Will to Knowledge, and in his course Naissance de la biopolitique (namely, the shift, during the last two centuries, from a disciplinary model to a biopolitical model of power and, more specifically, of administration of mental illness and mental health).
Madmen, Criminals, Sinners
The list of Foucault’s interests and fields of research spans a quite unusual variety of topics and issues, including crime, madness, epidemics, health, hunger, punishment, wars and strategies, pleasure and asceticism, masturbation and chastity, military life and hermaphroditism, schools, mental hospitals, prisons, barracks, factories, and companies. Foucault’s style of inquiry typically lies halfway between, on the one hand, history and philosophy and, on the other, epistemology of the human sciences and genealogy of the main social, political, and economic institutions of modernity.
The list would be as long as that of the disciplines whose function it is to address the same topics with a descriptive, prescriptive, contemplative, or administrative approach. Such a function is the object of Foucault’s archaeological and genealogical inquiry, an inquiry into the historical process which gradually led to the emergence of numerous practices and disciplines which radically contributed to the framing of what we optimistically call “man”: psychiatry, physiology, medicine, economics, human sciences, penitentiary architecture, Polizeiwissenshaft, jurisprudence, practices of state administration, contemporary and modern biopolitics, ancient forms of wisdom, monastic life and early-Christian moral precepts, the grammar of Port-Royal, and so on.
It is a strange quasi-Borgesian list. However, upon closer scrutiny, behind the sequence of these quite surrealistic trouvailles one detects both a continuity and a thin web of connections extending from one context to another and influencing the course of Foucault’s (p. 86) research and production—from History of Madness (1961)1 to The Birth of the Clinic (1963), Words and Things (1966), Discipline and Punish (1975), The Will to Knowledge (1976), The Cure of the Self (1984), and The Usage of Pleasures (1984). Each time, Foucault focuses on the other (hidden) side of a given phenomenon, and attempts to explain the visible side through this concealed side, the clean and reassuring surface through the secret life of an apparently anonymous depth. Tell me how you deal with madness—he seems to imply—and I will tell you what your beliefs about reason are, what kind of “rational” subjects your disciplines and practices produce. Tell me how you deal with crime, how you build your prisons, what use you make of your spies and laws, your guards and judges, your doctors and nurses, and I’ll tell you who you want to be, and what you think “being” means.
In a mental hospital, one is sometimes isolated and chained, freed or judged, healed or made ill. The closer we look, the thinner the boundaries between the science of police and the science of madness, the architecture of prisons and the architecture of schools, the madman and the criminal, the healthy and the ill, the normal and the abnormal, the child and the savage start to appear. Here, again, the web of archaeological and genealogical connections becomes visible. Depending on the circumstances, illness can be seen in different ways: as a kind of pathology or deviance, as an anomaly waiting to be cured or a guilt deserving punishment, as an eccentricity to hide, as a sin to confess or as a possession to exorcise. Illness is everywhere and nowhere—and so are crime, normality, justice, and, on the other side, the sick person, the criminal, the child. Everywhere we look, we find imperceptible relationships, derivations, interruptions, and recommencements. Kant wrote that the goal of every philosophical quest is to answer the question: “What is man?” However, according to Foucault’s archaeology, “man” is the most emblematic and illusory of modern inventions; it is the concept, the grandest one, and the most pregnant with manifold and disturbing consequences. It is not incidental that History of Madness, written as a doctoral thesis, was then complemented by another thesis dedicated to Kant’s anthropology (it was a rule of the French academia that a doctoral dissertation should be accompanied by a second one). The modern invention of the human sciences, conceived not only as descriptive but also, and even more so, as prescriptive sciences, would thereafter occupy a key position within Foucault’s work (Foucault 2008).
Look, Liberation, Subjugation
One section in History of Madness (Foucault 1961) is of particular interest here. Foucault focuses on Philippe Pinel, the French psychiatrist who marked a turn in the history of the treatments of mental illness. In Paris, during the French Revolution, Pinel finally broke the chains that still confined the madman in the dungeons of the Bastille. Against the violence of the iron fetters and the practice of abandoning the “senseless” people (les insensés) to a destiny of dark meaninglessness, Pinel opposed a totally different vision of alienistic medicine. Madness, far from being senseless darkness, entails a meaning on which to shed light: it has become a “moral illness,” and it is on the moral level that it should be treated. Pinel was a liberator.
(p. 87) Foucault, however, looks at the other side of this “liberation.” In this kind of humanistic or humanitarian psychiatry, he finds all the evidence for a new and different paradigm of subjugation (assujetissement). What is Pinel’s “moral treatment” about? Foucault answers by pointing to three figures of rare effectiveness. The first is that of “silence.” An old priest, suffering from delusions of grandeur, thinks he must re-live the Passion of Christ. Pinel orders him to be freed from his shackles, but forbids anyone to talk to him: “This rigorously observed prohibition had a more tangible effect on this man so imbued with himself than either the irons or his cell; he felt humiliated by the abandonment, and by this new form of isolation within his full liberty” (Pinel, quoted in Foucault 2006, p. 496). The shame resulting from being exposed to the gaze of other people and the silence filling his days become his new way of relating to others. The result of this change, in turn, is a new relationship with himself.
The second figure is called “recognition by mirror.” Three madmen believe they are kings. A guard, properly instructed, suggests to one of them that disputing with the other two is a waste of time, since they are evidently crazy. Madness, argues Foucault, is invited to look at itself using the other person as a mirror. But a further step shifts the focus of such revelation: “One day when he was less agitated the guard approached him and asked him if he was king, why didn’t he bring his detention to an end” (Foucault 2006, p. 498). He finally sees the contradiction and, fifteen days later, gives up his royal title and his delirium and returns to his family and usual life. Again, madness has seen itself. This time, however, it has done so not by looking at the others, but by looking directly at itself. Faced with its own reflection, madness feels shame, confesses its waywardness, and turns into an object of confession, complaint and evaluation (Foucault 2006, pp. 498–500).
The third figure is that of the “perpetual judgment.” Thanks to this new mirror effect, madness is relentlessly invited to judge itself; yet it is also continuously judged from the outside, and not by a moral and/or scientific conscience, but rather before a sort of invisible and permanently active jury. When the “alienated patient” takes a bath, Pinel explains referring to a female patient, “the fault that has been committed or the omission of the important duty is recalled,” and suddenly a jet of ice-cold water is thrown on her; the patient “is made to understand that it is for her good and that recourse is regretfully made to measures of such violence” (Pinel, quoted in Foucault 2006, p. 501).
At the end of the eighteenth century, Foucault concludes, no liberation of the mentally ill took place, but, rather, what emerged was an objectification of the concept of their freedom—which does not mean this was simply a false liberation. If this were the case, it would be enough to achieve a “real” and true liberation, which in turn would mean that the results of Foucault’s archaeology are quite poor. Rather, what Foucault implies is that every liberation, precisely because it is a “real” liberation, is at the same time a form of subjugation, and overlaps perfectly with its opposite: the other side of any liberation is the threat of being subjected. Over the course of his following works, Foucault would dedicate further reflections to such mysterious coincidences of opposites.
Subject and Device
The triple articulation of the “moral treatment” is a good example of what, in the following years, Foucault would define more and more as a kind of “device.” A device is, in this case, a (p. 88) specific articulated space. There would be no need to free the madmen if they did not already inhabit the space of a “great confinement,” according to the definition in History of Madness: walls, corridors, large common rooms and tiny isolated cells, and then also the particular disposition of doors, windows, slits and passageways. But no mental institution or penitentiary may exist without a certain society, a certain urban planning, and a certain set of laws. These forms of organization are connected to executive powers, habits and, ultimately, to countless functions, attendants, and tricks which work as guarantors of such space and its effectiveness.
Thus the device is a space, a set of things, a web of relationships, and a constellation of bodies; it is the madman looking at the other madmen, and vice versa. It is the madman’s word amidst the confusion of the other madmen’s words, but also the attendant’s word which sets him free and subjects him at the same time, isolating him from the buzz of his mates by according him an inner silent voice and an instrument of complaint and confession, of liberation, and further condemnation. In these passages from History of Madness, we find the prefiguration of Foucault’s future interests in Christian confession as forerunner of psychoanalytic talk, which will be developed in The Will to Knowledge of 1976. The device is all and none of this at the same time: it is not something that can be defined or grasped as such. It is the functioning and the objective effectiveness of a number of elements which no intentionality predisposed or set in motion. It is an uninterrupted genesis of structures, potential differences, resistances, and getaways. Some empty space becomes available and is immediately filled, and a certain matter shows itself malleable to the action of opposite forces. Various forms of organization are built or destroyed. The issue of subjectivity compacts itself around certain points in this field of structures. At the same time it splits along certain lines of fracture appearing in the field. We are what we can be; we think what we must think.
Disciplined Bodies, Souls at Work
Years after the publication of History of Madness, Foucault shifts the object of his inquiry from mental hospitals to prisons. The results of such inquiry appear in the middle of the 1970s in a book entitled Discipline and Punish (1975). The shift is worth mentioning, considering that Foucault would return to the topic of madness with a radically different perspective in a series of lectures on The Psychiatric Power held at the Collège de France in the years 1973–1974 (the transcripts have been published under the same title in 2003, long after Foucault’s death).
Let us begin with Discipline and Punish. This time Foucault’s goal is to study the complex juridical, police, and penitentiary devices. He believes that, in order to reconstruct the history of modern subjectivity, it is necessary to analyze the practices surrounding and regulating a context which is by definition peripheral to the political apparatuses, and to the great discourses of reason. Again, Foucault shows that the center is shaped at the periphery. “Man” is defined where the devices concern themselves with “almost-human” or “non-human” figures such as criminals, those who have been convicted, sentenced, and tortured.
In Discipline and Punish, Foucault examines the two extremes of the functioning of the juridical-penitentiary device. The first is characterized by the practice of public executions. The book starts with a dazzling description, both for the virtuosity of Foucault’s rhetoric and the disturbing content of the scene. It is the description of the execution of a certain (p. 89) Damien, his hands and feet tied to four horses pulling in four diverging directions, quartering the body of the unfortunate before the eyes of an enchanted crowd. The public torment, Foucault notes, is designed as a perverse and somehow grandiose show, offered to the crowd as simultaneously both a warning and a feast thrown by a sovereign who is the personification of power and the final target of any crime, whatever its seriousness. Each punishment means the reaffirmation of an absolute sovereignty, a power which invisibly rules and judges, but also carves in the most visible and showy way the insignia of its overwhelming force in the bodies of its subjects, and in the theater of the public square.
At the other extreme from the seventeenth-century absolutist monarchies, we have the nineteenth-century ascending bourgeoisie and incipient industrialization. At this stage, the juridical and penitentiary device undergoes a profound transformation. The value of each operand has changed: the judgment has now become public and the trial is a debate taking place, at least in theory, before everyone’s eyes. The punishment, instead, is hidden, even invisible, and is usually inflicted within prisons located at the extreme periphery of towns: nothing spectacular and no trace of quick, intense, and disturbing actions targeting the body of the condemned. On the contrary, what we have is a slow and meticulous work which acts on the body only to reach the soul, forcibly disciplining the inmate’s gestures in order to build a new person. Each time the bodies and souls are shaped by the devices. The spectacular torment had molded bodies in a specific manner, creating an object that did not exist before: it had provided both women and men with a body which would serve as a public stage or as a document into which the power was to carve its prerogatives. Two centuries later, the prison molds “disciplined bodies” (as Foucault puts it) which are transformed to fit the narrow spaces of the cells, and made to adapt to the fine web of limits and passageways which either block their passage, or through which they slither. The intentions of these bodies are shaped by the piercing look which scans them continuously from a hidden and invisible point of view. This way, the condition of the prisoner is a permanent and inescapable visibility.
Thus, looking becomes an anonymous and impersonal function, a force that unfolds independently of the presence or the absence of an observer and an observed. Even if the guard were not there, the inmate would believe he is being watched. In the end, he would watch himself, having incorporated that anonymous look which inspected him and anatomized the most common of his gestures. This process generates a new kind of subject and/or object, a subject which coincides completely with this procedure of self-control. All of its actions are inscribed in the space of this conformity. This subject continuously works on itself. Or, better still, the “subject” here becomes nothing but the name of this relentless inspection and rectification of behaviors and intentions. This leads to a condition in which the work of optimization, and the optimization of work, become the two inseparable faces of the disciplined subject—of the “docile bodies,” as Foucault puts it in Discipline and Punish.
The Deposition of Sovereignty and the Instauration of the “Psy-Function”
In his lectures on Psychiatric Power, Foucault develops two theses which are of particular interest here. The first relies on the analysis of a famous episode, mentioned by many (p. 90) scholars after Foucault to explain the shift from sovereign power to disciplinary power. As we will see, psychiatry plays a decisive role in this shift.
The episode is the madness of King George III (Foucault 2003, lecture of November 14, 1973). The king has gone insane and, following the diagnosis of the psychiatrist Francis Willis, is deprived of his entire authority. It is a sort of “upside down consecration,” writes Foucault. George III is forced to live the rest of his life in a surveyed isolation, not so different, apart from its distinguished luxury, from that of any other “mad” Englishman of his time. Psychiatric power is the new sovereign, the new holder of a power that no longer works in accordance with the schemes of sovereignty.
Foucault uses this episode as an emblem, and in this emblem we must read a metaphor and a synecdoche at the same time. First the metaphor: the king is taken to a padded room, but it is the entire traditional device which is dissolving, undermined by an anonymous, multiform power embodied by grey functionaries instead of the representatives of an ancient war-like prestige. The scene takes place away from indiscreet eyes, in that silent privacy which is the key setting of the disciplinary power. The king deprived of his powers is not abandoned to the will of an enemy ruler who has defied and crushed him on the battlefield. He is left to a number of attendants and procedures that will help him contain the explosion of his madness, channeling his disordered energies into a peaceful administrative routine. Now the synecdoche: the psychiatrist has become one of the many functionaries of the new power, insofar as psychiatry has become one of the many disciplines configuring its new paradigm. At the same time, psychiatry and the psychiatrist stand for the whole system of these new disciplines: they give shape to the spirit, the techniques, and the tools which every other disciplinary power will adopt in order to exercise its minute and invisible control over bodies, gestures, and intentions.
The second thesis brings us much closer to our time and enables us to understand the position psychiatry occupies in it (lecture of November 7, 1973). Psychiatry crossed a very important threshold between the early modern age (including the seventeenth century) and the liberal age (nineteenth century). This threshold concerns the criteria for recognition of mental illness and, consequently, the position and function of psychiatry with respect to the mentally ill person. In the age of Descartes, madness was conceived as a mistake of judgment or as a wrong representation of oneself and the world. To suffer from delusions meant to believe in something “wrong,” which bore the imprint of alienation from the realm of founded beliefs, immediately verifiable by comparing the madman’s views with the real world. Thus, the experience of madness, and the intervention of those who had to deal with it, occurred within the context of knowledge and representation. At the beginning of the nineteenth century, however, a new standard of identification and perhaps, at a deeper level, a new function of psychiatry start to emerge. Psychiatry deals no longer with the problem of recognition of madness, but rather with that of managing its consequences. According to this epistemologically and practically changed scenario, the madman becomes, above all, a man or a woman who is the victim of a force he or she cannot master.
The writings of Philippe Pinel and other psychiatrists mentioned by Foucault leave no doubt about this. The passions of the mad person are not controllable, the ideas that inhabit his delirious mind are not wrong so much as violent, and even dangerous to himself and to others. The psychiatrist is faced with a new field of phenomena wherein he finds new objects worthy of inspection, because something new and different has attracted his attention. Now it is the force, not the mistake, which stands out in that field, and the goal of the psychiatrist (p. 91) is the control of a force, not the identification of a mistake. By concentrating its efforts on the handling of a force which is primarily seen as excessive and incoherent, psychiatry turns into a key element within the set of disciplinary knowledge and techniques. In the age of liberalism and mass industrialization, where an embryonic globalization of markets is emerging, each discipline has to conceive of man as a bundle of forces in need of regimentation, of continuous supervision, and of scrupulous adjustment to a certain standard prescribing the “good use” of such forces. Once again psychiatry, according to Foucault, appears both as part of the disciplinary system and as the whole system itself. Together with the legion of different professionals who would join his cause during the nineteenth and the twentieth century (psychologists, psychoanalysts, pedagogues, and social workers), the psychiatrist becomes the purest expression of a function whose final goal is the public order and the individual’s most efficient performance in interaction with other individuals.
In one of his most intense lectures on Psychiatric Power (held on November 28, 1973), Foucault calls this phenomenon the “psy-function.” At this stage, madness has become yet another object: no longer a mistake, nor a violent, overwhelming power. Rather, it is seen as a kind of white noise, a lack of efficiency, or wasteful expenditure of the energy the individual should have been able to perfectly coordinate with the other forces forming what we usually call “society.” The psy-function aims at restoring the efficiency of the individual and of the collective performance. Its role is to reduce people’s bodies, behaviors, and physical and psychological performances to a certain standard and economy of forces, which in turn liberalism considers as the goal and proper good of society, or as the ground on which society spontaneously tends to organize itself (Foucault would study the developments of disciplinary powers into another paradigm of power, called “biopower,” in a later period of his teaching: see the courses on Security, Territory, Population (1977–1978), and Birth of Biopolitics (1978–1979)).
This way, psychiatry takes on a unique aspect amongst the medical sciences, to which it nevertheless refers more and more often during the nineteenth century, especially since the neurological dimension has become a significant part of its language. A famous French surgeon cited by Georges Canguilhem (2002, p. 90) once said that health is that precarious condition which never looks promising and always turns into disease. If this is true, we could say that the goal of psychiatry as a psy-function is not so much that of healing and restoring mental health, but rather that of managing an uncertain condition which fluctuates between pathology and non-pathology, without belonging to either field. This kind of “grey zone”—neither health nor illness—is in fact the only source of the variability of a parameter which, in the end, has nothing to do with the individual’s illness or well-being, because it is concerned only with the quality and nature of the control exercised by psychiatry on some of the behavioral performances of such individual.
The Invention of Human Capital
In his course on Psychiatric Power, Foucault points out that all this implies a “confiscation” of everyone’s body, time, and life (lecture of November 21, 1973). One could argue that before the emergence of the psy-function, things such as a virgin body, time, and life never existed. The specific performance of the sovereign’s power was to display the body of the condemned (p. 92) as a place for exemplary and showy punishments. The specific performance of today’s disciplinary power is the constant exploration and optimization of a set of behavioral performances: rather than the confiscation of a certain resource or skill, this means, simultaneously, the invention, promotion, and exploitation of a new resource. Thus, the new paradigm of the liberal age invents, promotes, and exploits a new resource: the time and life of people considered as a mass, as a social organism, and as an organic whole.
This is one of the points Foucault would elaborate with increasing clarity over the following years. We find it, plainly stated, throughout The Will to Knowledge (1976). Power does not move from the center to the periphery, from the top to the bottom, nor from the instance which denies or censors to the force which is diminished or annihilated. Rather, its functioning is more articulated, for power positions itself horizontally and proceeds by means of alliances, complicities, and co-options. It completes and promotes its counterpart, urges and triggers the forces upon which it works, and channels and empowers the energies it wants to administrate. To govern—once the symbolic threshold of the deposition of George III is crossed—does not mean to say no, nor does it mean to kill an enemy: it means to say yes, to sign alliances, to orient and to enrich a potential. Foucault’s psy-function operates in the same way, and prepares new functions which will further promote this subtle art of optimization and exploitation of individual and collective performances. The result is that, on the one hand, European societies become “psychiatrized,” and, on the other, the psy-function becomes “sociologized.” In other words, the psy-function becomes the science of society itself, the main instrument of theoretical analysis and of practical intervention on the social organism, and the key paradigm for the optimization and empowerment of its global performances.
In this context, the practice of writing, verbalization, data collection, and the art of statistics play a key role (Foucault 2004a; on Foucault 2004a, see Redaelli 2011, pp. 134–173). Schools, barracks, hospitals, but also police stations, courts of justice, prisons, and mental hospitals, become places where behaviors and exceptions to the rules are constantly catalogued and monitored. The continuous examination typical of the disciplinary power grows stronger with the diffusion of such filing systems and techniques of recording, extraction, and confrontation of data. What Foucault had defined as “disciplined bodies” have now become a general stock of “life” reduced to long data strings, recorded in neat charts where every measure is set in relation to a reference value, and exemplified in schemes that sum up differentials which are ever-changing and in constant need of updating and correction. The intervention of such a power does not consist in the exceptional and spectacular punishment of an extraordinary crime, but rather in the restless process of assessment and correction of the tiniest flaws and the less perceptible performances. The key instruments of this kind of power are statistics, the careful management of data variability, and the identification of arithmetic laws and techniques which allow for the management of aleatory factors. The actions of children and elderly people, workers and housewives, insane patients, sick people, and criminals have become more and more traceable and targetable. The effect of the whole device is the unprecedented possibility of optimizing a given resource, and the definition of that particular object of administration which is the human performance: the “human resource” in its totality.
Indirectly, this change reshapes the nature of the individual as it emerged from the practices of disciplinary power of the eighteenth and nineteenth century. The individual itself is now conceivable only as a resource to administrate and optimize, as an anonymous and (p. 93) generic sum of behavioral potentialities. A new paradigm takes the place of the disciplinary power. The twentieth century begins under the sign of the so-called “biopower.” This is the main thesis of the course taught by Foucault in the years 1978–1979, entitled Birth of Biopolitics (Foucault 2004b). The target of biopower is that new field of objectivity represented by the life of a population, and that new system of variables represented by the vital performance of a society. This kind of resource becomes visible and manageable only under particular conditions, that is, only when it is watched and governed from far away, not with the eyes of the guard watching a line of cells, but with the detached and synoptical look of the statistical researcher, the demographer, the epidemiologist, and the economist. These are, in fact, the “new” sciences or, better, the new devices which emerged between the eighteenth and the twentieth century: their nature and their role in shaping a society which is still, in many ways, our society, form the object of Foucault’s research (Foucault 2004a, 2004b).
In the age of biopower, the management of such new forms of objectivity represented by the “vitality” of a population has become the main goal of power, which aims to promote its quality, intensity, and duration. These are guaranteed through different initiatives such as mass education, vocational training, and the national welfare state. Among the resources whose highest profitability must be guaranteed by the individual we find: personal behavior, the sum of competences and skills (including, in some cases, even the biological competences of the body), exposure to certain forms of sickness and the capacity for recovery, genetic patrimony and the promises and threats inscribed in the genes. In terms of anonymous performative efficiency, the general and statistic vitality of the population finds its precise equivalent in the individual. There is in fact nothing individual in these “individual” resources, but rather a certain quantity of forces, a certain supply of competences, a certain capital of capabilities (behavioral or biological) whose expression must be developed and optimized. The individual has become conceivable and manageable only as a “human capital” (Foucault 2004b, lecture held on March 14, 1979).
From one point of view, this shift was not hard to predict. Its premonitory symptoms could be easily spotted in the features of the already-mentioned psy-function. The idea of madness being a force to tame and a chaotic energy to measure and organize anticipated this outcome: the individual becomes a capital of competences and possibilities, waiting to be regimented and brought to full expression. From another point of view, this displacement takes place only by the end of the nineteenth and in the first half of the twentieth century, when the psy-function and the disciplinary powers adopt new tools and a new logic. In particular, this happens when the path of the psy-function overlaps with that of the statistical approaches to those new fields of objectivity, which are the social body as a whole and the collective efficiency as a general flux and capital.
Logic of Optimization
The liberal man, who exchanges goods according to the principle of utilitarianism, the comparability of values, and the equity and equilibrium of transactions, is now eclipsed by the neoliberal man, shaped by the values of an almost Darwinian struggle. Such values consist in producing the same goods with lesser resources, in reaching the highest productive efficiency compared to market averages, in exploiting every resource (human and non-human) (p. 94) to obtain the highest standard of performances, and so on. The result is not equilibrium, but disequilibrium—not equality, but inequality, and struggle for life (Foucault 2004b, lecture of November 7, 1979).
The “value of life,” so often mentioned in the age of neoliberalism, seems almost invariably destined to turn into this kind of strictly economical evaluation and re-evaluation of a set of biological and behavioral capabilities. What we are dealing with here are, in fact, strictly non-individual and non-subjective sets of capabilities: the pure manual ability for certain physical work, the simple conversation skills necessary for working in a call center, the people skills required by management positions, and, finally, a general willingness to pursue an education which is sufficiently differentiated to meet the needs of a certain productive mechanism and, on the other hand, undifferentiated enough to meet those of a totally different one. The worker has become entirely unspecific, amenable to forming and re-forming, being trained and trained again, and not opposing resistance to any of the incoming work opportunities. Therefore, the final result of the total transcription of the disciplined body into the malleable and optimized categories of the management of human resources is the “vitality” of such a completely de-individualized individual. Moreover, it is not out of place, in this case, to talk of mere “vitality,” because, in this new context, there is no longer any difference between behavioral performance and cognitive performance, between biological performance and intellectual performance, and between relational performance and productive performance. All has become “resource,” and all that biopower needs to do is to design and provide the conditions for its highest profitability, maximizing the profitability of that capital with respect to its performance.
“Optimization,” then, becomes a sort of keyword for this reading and planning of individual behavior and society, which works almost exclusively in arithmetical and economical terms. The distinction between means and ends, as such, loses meaning. Nothing in this scenario can be considered “worthy,” nothing here is a goal or an end. It can only be computable as a step along the path leading to a further step. Any attempt to establish a link between points A and B will result only in the planning of a better way to multiply the resources amassed at point A, in order to create other resources to be amassed at point B. Then, another identical operation will multiply and amass the resources of point B at another point C. The individual itself will survive only as the empty space where means and ends coincide: the perfectly indifferent space where the capital to be exploited, and the instance that promotes its exploitation, completely overlap. While the individual designed by the disciplinary power controlled and punished itself, the human resource designed by the biopolitical device promotes and exploits itself. And it promotes and exploits itself in order to promote and exploit itself again and again, more and more deeply, without any trace of what classical metaphysics would have called telos.
DSM and Insurance Companies
At this point we might ask what place psychiatry occupies within this new paradigm. In many ways, psychiatry lay at the beginning of the path that leads to it. Such a paradigm, however, absorbs psychiatry and assigns a new function to it.
(p. 95) The most widespread model for psychiatry in the Western world is represented by the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM has become a key device of our time, a point where the three separate paths described by Foucault meet in an increasingly systematic convergence.
Let us briefly recall these three paths: firstly, the establishment of the psy-function as a general function of enunciation and regulation of disciplinary powers, together with some key aspects of biopower; secondly, the establishment of writing as a means of objectification, schematization, constant evaluation and re-evaluation of the variables targeted by disciplinary powers and biopowers; thirdly, the emergence of a particular approach, based on what might be named an “insurance logic,” meaning a logic that is profoundly consubstantial to the logic of the financial enterprise.
We can start from the last point—a point only briefly mentioned by Foucault’s analysis, but which lies at the core of L’état providence, written by François Ewald, a pupil of Foucault’s, now arguably one of the leading scholars of French insurance economy. The logic of the enterprise is, for reasons that are far from incidental, based on risk. The way an enterprise works is the way of the bet. The entrepreneur invests money today, foreseeing a possible profit tomorrow. There is more: the businessman invests a capital which will be fully available only at a later time, if everything goes according to his plans. This is the reason why, at the beginning, the modern enterprise presupposed what Marx called “primary accumulation,” whose function was later taken over by the resources lent by the banking system. In an entrepreneurial system, wealth is produced through debts, and every debt becomes a resource only in the sense that it is the postponement of a present vacuum to a future one.
From another point of view, each debt can be postponed to the future and finally solved only at the cost of a risk which is entailed by it: the risk of insolvency. The answer, in this case, can only be one: the multiplication and systematization of all those procedures which deal with risk insurance, whether it concerns monetary capital, a set of means of production, material wealth, a certain stock of relational skills or personal resources, or a certain package of cognitive and behavioral capabilities (both individual and collective). Now that an enterprise is more often than not an individual enterprise, and the individual is increasingly described and “planned” as the entrepreneur of himself (Foucault 2004b, lecture of November 14, 1979), insuring one’s skills and resources has become crucially important: the purpose is to guarantee and preserve such fragile resources for the entire course of one’s life, from the education of souls to the training of the bodies, from the preservation of health and physical efficiency to the management of aging, illness, or death.
Thus, an increasing share of the contemporary insurance device concerns the insurance of the human capital which lies in the cognitive, behavioral, affective, or relational skills of an individual who has become the entrepreneur of himself (entrepreneur de soi-meme). But this is precisely the point where the path of the insurance device intersects with the other two paths mentioned earlier, generating a grid within which the management of health and the management of human capital broadly overlap. It is in this context that we must recognize—in Foucaultian terms—the relevance of the DSM as a device. On the one hand, in fact, the role of the psy-function, and more generally of all biomedical knowledges, is to evaluate the individual’s cognitive and behavioral capabilities each time, and, in a broader sense, to assess the “vitality” of that same individual, together with the set of biological resources available to him or her. The point is to identify which typologies and levels of risk are linked to those resources, so that the insurance company may define its own system of warranties, (p. 96) calculating the probabilities that a certain risk may occur, the amount of the premium paid by the insured client, and the indemnity remitted by the insurance company. Here, the biomedical knowledge is already governed by biopower, and its business is not therapy, but the administration both of a capital and of the risks connected to the future exploitation of such capital.
On the other hand, after two centuries of waiting, the device of writing has finally allowed the psy-function and the insurance function to speak the same language. More precisely, the writing device shaped the psy-function and the insurance function from their very origin: the result is that now they completely concur on a certain standard of objectivity, translate and confront jointly defined symptoms, calculate with the very same tools the inefficiencies and the probabilities of recovery from certain diseases, and, finally, they identify which individuals society, conceived as an enterprise, should or should not make its bet on. In brief, the optimization of the biomedical administration of wealth goes hand in hand with the biopolitical optimization of human capital.
Mental Illness and Neoliberal Reason
Every tool prescribes the rules of its own use. It is also true that those rules always allow a margin of freedom, in the sense that somehow we can apply to that same tool the rules of another tool and use it differently. However, the roots of the DSM lie in an insurance-oriented mentality, and this clearly affects the kind of psychiatric model such tool suggests and, inevitably, prescribes to those who adopt it.
It is well known that the DSM was elaborated in the USA as an answer to a number of clearly disciplinary needs, in a Foucaultian sense. On the one hand, it has military origins; it is a tool designed for the psychological and behavioral screening of groups, based on the model of other similar tools already in use by other branches of military medicine. On the other hand, the reasons that led to its formulation are extremely rational and simple, in the sense of that organizational rationality and constant optimization of processes which are the essential form and content of neoliberal reason.
In fact, the whole US health care system follows a private insurance-like policy. In the USA the insurance function is not performed by the government (as it is in Europe with the welfare state), but by private companies tied to an openly entrepreneurial logic. Such a situation, by the way, reveals and uncovers an intrinsic component of European public welfare, which is in fact quickly evolving toward a privatized model. Given these circumstances, it should come as no surprise that the need for standardized tools for quantifying the biological damage suffered by a certain individual emerged in the United States much earlier than it did in other countries. Such measurements take into account the past conditions of the individual as a possible cause of such damage, and the costs of both the therapy and the other means necessary to sustain the individual in the event of an incomplete recovery. The DSM is, from this point of view, nothing more and nothing less than the accomplishment of a purely medical insurance-oriented need, within the specificity of the psy-context or function.
This means two things. On the one hand, the DSM should be considered a collateral effect of a broader phenomenon, which consists in the fact that medical sciences have grown in the (p. 97) direction of the logic of insurance companies, carrying psychiatry along in the process, and transmitting to it their need for, so to speak, informatized and economically optimized diagnoses and prognoses. The information written in the medical records must be as simple as possible, easy to exchange and compare, constantly updated, and immediately translatable into other languages—above all, into the language of enterprises and insurance companies. Such language is influenced by the logic of statistics and risk management, which expresses the relationship between the costs of a therapy, its individual benefits, and its collective consequences. On the other hand, it is precisely biomedical knowledge and the public or private insurance logic which were originally shaped in accordance with the procedures of control and restoration of performance efficiency, developed for the first time in the history of European societies by psychiatry and the Foucaultian psy-function.
However, the biomedical paradigm seems to incorporate the “psy” paradigm. The cognitive and behavioral (and affective, and intersubjective, etc.) functions described and transformed by the DSM into something computable are defined in total analogy with the damages and the biological functions verifiable inside any biomedical laboratory. As we have seen, it is the biopolitical paradigm which produces a general flattening of physical, cognitive, behavioral, affective, and relational performance. In each of these cases, the question is simply to calculate the profitability of a certain set of resources, belonging not so much to an individual, but to the “vitality” of a group or population. On its part, the psy-paradigm dictates to the biomedical sciences a kind of clinical approach in which the diagnosis is not entirely therapeutically oriented (recovery from a disease), but aims at handling certain inefficiencies in view of their sustainability and their statistical, epidemiological, and economic significance. The list of these resources must include not only physical strength and the ability to carry on heavy tasks (which were paramount when production was mainly industrial and grounded in the assembly line), but also the relational and cognitive, affective and hermeneutical skills needed to fill the increasing demand for the organizational professions which characterize our society—including a capability which classical metaphysics considered specific to mankind and exquisitely spiritual: language. Just consider how much of our lives as consumers and/or producers is based on the use of logos, that is, on the human ability to exercise a linguistic or in general a semiotic function, to interact in a world of signs and to be oriented by, or led by, a jungle of images or a web of spectacular functions.
Thus, psy-device, biomedical device, and insurance device converge in the definition and production of man as a bundle of economically relevant performances, as a web of abilities and resources which might be damaged, restored, organized, and optimized. From this point of view, the DSM represents the exact reverse of those business manuals used in the departments of economics as well as in personnel departments. Such manuals imposed the theme of organizational efficiency, thereby promoting a restless activity of corporate training focused on the definition and promotion of certain behaviors. The optimum of those behaviors could be defined, first, in terms of adaptive efficiency to the enterprise organism, then, in terms of the capability of an individual to interiorize that same entrepreneurship, and finally, as the almost automatic coordination of the individual self-entrepreneur monads. Management manuals, from this point of view, optimistically develop the pars construens of a certain human type, whose deconstruction is carried out in a perfectly specular manner by the DSM. In other words, if in Descartes’ time madness was defined as déraison, in the time of organizing reason, of the insurance-like management of resources and of biopolitical performance optimization, madness can only be regarded as mental illness. Mental illness, in (p. 98) turn, can be conceived only as behavioral inefficiency, lack of relational skills, inadequate cognitive or affective proficiency—that is, as a human capital waiting to be restored, and as a biological capital waiting to be optimized.
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(1) All dates in brackets refer to the original date of publication of Foucault’s works. Quotations are then referenced directly in the text following the author–date style.