The Place of Subjecthood in Madness

Previous articleNext article FreeSecond Look: Gladys Swain, Le sujet de la folieThe Place of Subjecthood in Madness: Toward an Intellectual History of Psychiatry on a Philosophical BasisMarianna ScarfoneMarianna Scarfone Search for more articles by this author PDFPDF PLUSFull Text Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinked InRedditEmailQR Code SectionsMoreThe title of Gladys Swain’s 1975 doctoral thesis in medicine was “La question de la naissance de la psychiatrie au début du XIXe siècle” [“The Question of the Birth of Psychiatry in the Early Nineteenth Century”]—altogether less resounding and more descriptive than that chosen for the book introduced here forty years after its publication.1 Le sujet de la folie [“The Subject of Madness”] appeared in a series published by Privat and edited by the history-minded psychiatrists Jacques Postel and Jacques Corrèze. It was the first actual work of history in that series; twelve preceding volumes had been no more than republications, with new introductions, of works—by Esquirol, Kraepelin, Charcot, Lasègue, Georget, Binet, Freud, and others—that had marked the origins and development of psychiatry, the idea being to show and make use of their value as primary sources. The book was reviewed in Isis in 1979 by Dora B. Weiner, who would herself, at the end of the 1990s, publish Comprendre et soigner: Philippe Pinel (1745–1826): La médecine de l’esprit, largely inspired by Swain’s reflections. Weiner wrote that Swain’s prose had “a futuristic and American look”—which remains quite an elliptical characterization by an Italian reading French, as I am—and she hoped “it may tempt a translator.”2 This translation never came, though American readers might have come to know Swain by way of Madness and Democracy: The Modern Psychiatric Universe, the English translation of La pratique de l’esprit humain: L’institution asilaire et la révolution démocratique, a volume coauthored with Marcel Gauchet, which widened and politicized her earlier reflections.3Gladys Swain’s work was that of a historian through and through: she searched sources thoroughly, reading and comparing texts and other relevant documents; her descriptions never failed to lead to interpretation; she assumed a longue durée perspective and made every effort to deconstruct the myths, ancient and modern, that haunt psychiatry and its history. Combing through the texts, giving a detailed account of the personal, professional, and institutional networks that marked the field of “alienism” in its beginnings, Swain was at pains to construct an intellectual history—or, more precisely, a history of the savoir psychiatrique that would take its place in a French-style history of ideas and would aim to explain the enigma of the subject of madness and its emergence at the start of the nineteenth century.Le sujet de la folie was forthright in pointing to the issue that faced the aspiring psychiatrist of Swain’s day: Where, in the timeline of psychiatry others had sketched out before her, should the birth of a curative—rather than punitive—practice and discipline be located? Why this emphasis on the early nineteenth century (whose revolutionary scope others had neglected)? Why that particular time, the 1800s, which in her book she matches to another, the 1900s, with Freud and psychoanalysis—but also, inevitably, the time she lived in, as a historian and even more as a psychiatrist? For the 1970s, when Swain was studying to become a psychiatrist, frequenting psychiatric hospitals and other institutions that proclaimed themselves to be modern and patient centered, was itself a decade in which madness became a topic of public debate: a decade when strong political and intellectual positions were voiced regarding the marginalization of the mentally ill, when the very idea of institutions for their treatment was questioned, when the world was moving tentatively toward a new model—care in the community—for the mentally ill, and when challenges were emerging to a strictly internalist historical account that had seen neither wavering nor any possible weak spots that might be explored to shed new light on a series of events. Admittedly, Michel Foucault had just recently written his own history, which put him, too, between disciplines, truly comfortable in none of them; and it was against Foucault’s views in Histoire de la folie à l’âge classique [History of Madness in the Age of Reason], his slipshod use of sources, his story built around stark oppositions—reason/unreason, dominance/passivity—his categories of knowledge and power, his account of exclusion, that Swain argued.4 The young psychiatrist countered Foucault’s powerful (and soon prevalent) interpretation with her own; it was less attractive, perhaps, in the 1970s, but since then it has been utterly unavoidable in any historical work on psychiatry and its new avatar, “mental health.” Utterly unavoidable, because instead of relegating the patient to the wings of the psychiatric stage (or the psychoanalytical setting), Swain puts the patient at center stage, as the subject of his or her own illness and life. If we find the patient and his or her well-being through “moral treatment” to have been central in the 1800s—as Swain argues—that centrality is only enhanced as it reaches its latest legitimation in the policy of “care in the community,” a policy of reaching out to patients instead of marginalizing them in an institution that tends to make their condition chronic. Here, though, we reach the present day, still rife with problems of this kind; and I do not propose to dwell on the light and shade of our contemporary debates.Le sujet de la folie helps us address an issue faced by anyone who has ever thought about himself or herself and his or her position in relation to others; and it is also an issue that has gnawed at psychiatrists in every age who have dealt at close quarters with the derailments of the human psyche. However helpless we may feel before such an abyss, this book nonetheless offers us some elements of a response: by going back to the sources, by a careful study of the texts and their background, we can discern a tipping point in the way psychopathological facts are thought about, one that occurred in the 1800s but whose effects have been operating ever since. Swain credits Philippe Pinel and his Traite médico-philosophique sur l’aliénation mentale ou la manie [Treatise on Insanity] with the initial construction of the conceptual framework within which the nature of madness and its treatment has been thought about ever since.5But what was the intuition that made Pinel the originator of modern thinking about psychopathology? It was not exactly an intuition from the realm of ideas; it was, rather, the product of long observation of and commerce with sufferers and an urgent need to draw up some nosology in order to give the new science something like the epistemological status and formal discipline enjoyed by the natural sciences. Observing “intermittent mania,” in which madness appeared only in episodic seizures, Pinel noticed the reservations the insane could have about subscribing fully to their own delirium, the possibility of standing back from their own alienation. Proceeding from the particular to the general, from species to genus, and from accidental manifestations to the essential form, he recognized total madness as a limit state, “total” only insofar as it affects the subject in his or her status as a subject; the alienated as subjects nevertheless maintain an internal distance from their alienation. So we see the idea of a physically located madness overthrown, in the same theoretical movement that discards the functional conception of mental disturbance.Dispensing with the notion of complete madness, positing a distance between the sufferer and his or her alienation, opens up a new vista for treatment: no longer does it consist in doing things to a person who is passive and completely lost, dealing from the outside with a circumscribed phenomenon that is to be mastered, and acting on the clinician’s will alone in order to rid the sufferer of his or her alienation. Now it is a matter of recognizing the sufferer’s own portion of activity as a subject in his or her own illness—a subject no longer regarded as totally taken over and, as it were, eclipsed by that illness—and establishing a relationship with that portion, on the understanding that access to it depends more on the suffering subject than on the therapist.Upstream from this establishment of a new framework for understanding the issue of madness—whose outward form is the dialectic “mad”/“not mad” within the subject and even the dialectic “mad person”/ “provider of treatment and possibly cure”—we can identify two concomitant factors that also took shape during this turning point of the 1800s. There was, first, a certain emancipation of psychic matters from the realm of religion and, second, the withdrawal of those psychic matters from clinical medicine as the latter, seeking to grow ever more objective, focused its gaze on the body and on the body’s mechanically measurable attributes and defects. Both factors had the effect of driving subjecthood underground, where pressure unavoidably built up for it to emerge elsewhere: subjecthood and also, in a sense, subjecthoods—free, equal, and fraternal, as represented in the fiery spirit of revolution—despite their differences (more or less accepted socially, more or less set forth in law) emerge in a reconfiguration of the inclusion/exclusion axis.If Foucault taught us to be wary of institutions and of the objectifying relationship with their inmates established by their science as much as by their power, the book of Swain’s whose acquaintance we renew today reminds us of the central position of the subject—of the subject whose mental illness is just a part of his persona—and of the relationship between individuals, both of them subjects, that she held had characterized psychiatry from the start, from when it was born and, given the name of “alienism,” practiced “moral treatment.” Mental illness has not led only to rejection; exclusion has not, historically, been the only response. Leaving behind the political enthusiasms and social emergencies of the 1970s, the story of psychiatry and mental health has unfolded in the decades since in a cross-fertilizing of these approaches: not exclusion alone, à la Foucault, with the great confinement of modern times, and a Pinel phase claimed to be nothing more than an intensifying rigidity whose gentle face hid the fact that it, too, was busy ostracizing unreason; nor only Swain’s inclusiveness, with its nod to the bourgeois revolution’s upending of ideas and social relationships. On the contrary, the history of psychiatry and mental health, which since the 1970s has never ceased to carve out a prominent space for itself at the crossroads of social, intellectual, and cultural history as well as the history of science, has been enriched since Swain by new approaches that have made it possible to set up, discard, or qualify arguments patently at odds with each other (the opposition is “political” but also claims to be one of method). Not just the history of psychiatric ideas and ways of describing madness, not just the sudden emergence of the “subject” whose subjecthood is asserted but who seems lifeless: nowadays historians get their hands dirty searching through dusty documents, case notes, patients’ writings, and everyday objects for the “living” traces of those subjects—whose existence and subjecthood Swain brought to our attention by her unflinchingly thorough reexamination of the early days of alienism.NotesMarianna Scarfone is lecturer (maître de conferences) in the history of health and medicine at the University of Strasbourg, with a specialization in the history of psychiatry and mental health in the nineteenth and twentieth centuries. Her research topics include colonial psychiatry, assistance to the mentally ill outside asylums, and historical visual approaches to psychopathology. Département d’Histoire des Sciences de la Vie et de la Santé, Faculté de Médecine, Strasbourg Université, 4 Rue Kirschleger, Strasbourg 67085, France; [email protected].1 Gladys Swain, Le sujet de la folie: Naissance de la psychiatrie (Toulouse: Privat, 1977).2 Dora B. Weiner, rev. of Gladys Swain, Le sujet de la folie, Isis, 1979, 70:606; and Weiner, Comprendre et soigner: Philippe Pinel (1745–1826): La médecine de l’esprit (Paris: Fayard, 1999).3 Marcel Gauchet and Gladys Swain, La pratique de l’esprit humain: L’institution asilaire et la révolution démocratique (Paris: Gallimard, 1980); for the English translation see Gauchet and Swain, Madness and Democracy: The Modern Psychiatric Universe, trans. Catherine Porter (Princeton, N.J.: Princeton Univ. Press, 1999).4 Michel Foucault, Histoire de la folie a l’âge classique (Paris: Gallimard, 1972).5 Philippe Pinel, Traite médico-philosophique sur l’aliénation mentale, ou La manie, 1st ed. (Paris: Richard, Caille, et Ravier, 1800); and Pinel, Traite médico-philosophique sur l’aliénation mentale, ou La manie, 2nd ed. (Paris: Brosson, 1809). Previous articleNext article DetailsFiguresReferencesCited by Isis Volume 109, Number 1March 2018 Publication of the History of Science Society Article DOIhttps://doi.org/10.1086/697184 © 2018 by The History of Science Society. All rights reserved.PDF download Crossref reports no articles citing this article

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