What we can learn from Michel Foucault
A key figure in critical discussions on psychiatry during the 1960 and 1970s was French philosopher and historian Michel Foucault. In his 1965 book Madness and Civilization: A History of Insanity in the Age of Reason Foucault analyses how society dealt with insanity throughout history, focusing on the Renaissance, the seventeenth and eighteenth centuries, and modern times. The point he makes is that whereas in the Middle Ages the so-called madman was a figure inside society, subsequent epochs defined him as an outsider. From then on, the insane person was an outcast that must be confined; a sick individual that should be studied and treated as a medical object. Key to this historical evolution was the creation of asylums at the end of the eighteenth century, for instance by Pinel, where the madman was treated by a new category of medical doctors: alienists, who above all functioned as authority figures. At first this subjection was explicit in the practice of moral treatment, which subjected the unreasonable insane to the discipline of the reasonable medical doctor. In the late eighteenth century, as positivism imposed itself upon medicine and psychiatry, this disciplinary power relation became less visible. It was still present but veiled under a naturalizing discourse that was henceforth used to explain madness.
As a consequence, in Foucault’s view madness is not so much a natural kind, i.e., an entity governed by natural laws, but what he calls “a reification of a magical nature.” In his view, psychiatry did not arise because medical doctors had suddenly discovered an underlying biomedical reality that could be linked to the behaviors of the so-called insane. On the contrary, psychiatry came into existence as it brought its own object into being: disciplinary practices first delineated a group of outcasts that were amenable for adaptation to society, and later defined them as proper objects for scientific study: “What we call psychiatric practice is a certain moral tactic contemporary with the end of the eighteenth century, preserved in the rites of asylum life, and overlaid by the myths of positivism”. By qualifying madness as a reification Foucault stresses that the early alienists, just like modern psychiatrists, turned their concept into an object. As a consequence ‘madness’ was no longer treated as an abstraction that can be used to make sense of reality, but as a biological or psychological reality that simply awaits clinical detection and scientific discovery. Such reification is a direct effect of adopting psychiatric discourse. Through the use of specific language, the concept under discussion is materialized, or as Nietzsche put it: “it is enough to create new names and estimations and probabilities in order to create in the long run new ‘things.’”
Meanwhile this notion of reification slowly became recognized as a problem in psychiatry. What is more, DSM-based diagnosis in particular was at last accused of promulgating such reification, thus giving rise to what Steven Hyman, a former president of the US National Institute of Mental Health, calls “an unintended epistemic prison.” Indeed, while the diagnostic categories of the DSM are nothing but conventional groupings of symptoms or “heuristics that have proven extremely useful in clinical practice and research”, people still tend to think of them as real entities. For example, reification is evident when people think of ‘ADHD’ or ‘schizophrenia’ as underlying diseases that give rise to characteristic symptoms, while in fact these labels are nothing but umbrella terms used to designate a collection of symptoms commonly associated with the condition. Reification produces the added problem of the so-called disorders being understood as quasi-material conditions that cause symptoms, while in fact they only indicate that a (certain) minimal number of category-specific symptoms have been observed in an individual. In other words, DSM diagnoses do not explain anything beyond this idle descriptive classification, yet people tend to invest belief in them as real entities, which is clearly absurd.
This brings us to the more serious problem of laypersons embracing psy-language and adopting diagnoses in themselves or applying them to others. Laypersons tend to think of psychiatric disorders as medical diseases with known etiology or pathophysiology. By ascribing to the language of DSM diagnoses, they materialize diagnoses into fixed conditions thought to govern the body and/or mind. Such attributions engender stigma and blind everybody from contextual factors that may be associated with a given condition; the net result is unsurprising, instead of facilitating therapeutic progress, the diagnosis itself actually hinders change. However, reification affects laypersons, just as it blinds professionals. In research and clinical practice, professionals often think of diagnostic categories as realities, which creates the so-called “epistemic prison” in the mind: professionals focus on discrete entities that obfuscate overarching and often obvious contextual influences. Disorders are seen as realities that need to be treated, or as observable surface phenomena that correspond with specific neurobiological disturbances. Research meanwhile teaches us that it is most unlikely that corresponding neurobiological patterns will ever be found for the numerous discrete disorder categories outlined in the DSM. For example, genetic studies demonstrate that no single gene variant, genomic locus or mutation is strictly linked to any of the common mental disorders, and that particular genetic variants are often found across different disorders. Nevertheless, many professionals seem to believe that disorder-related hidden entities do in fact exist. This bears witness to magical thinking, reminiscent of Foucault’s characterization of psychiatric disorders as reifications of a magical nature.
Yet in Foucault’s view, reification not only creates an epistemic problem, it above all installs power-related regimes. In his 1973-74 lectures at the Collège de France, he returned to the issue of psychiatric power and sharpened some of his former criticisms. There he specified that power mechanisms at work in psychiatry are far from obvious, but, on the contrary, are quite subtle in character: “disciplinary power is a discrete, distributed power; it is a power which functions through networks and the visibility of which is only found in the obedience and submission of those on whom it is silently exercised”. The kind of power that Foucault points to is not personal, but relational: it is a force embedded in the doctor-patient relationship. Psychiatric diagnosis is only one way in which power manifests and in Foucault’s view the exercise of power in diagnosis is mediated by a search for truth. When an individual receives a diagnosis, he enters a so-called ‘regime of truth’: by being labeled in terms of a nosological classification system, the individual receives a definition of ‘who he is,’ or ‘what he has.’ The diagnosis provides a name for what a given individual is living through in terms of a hidden disease-thing or -process, and it invites the individual to acknowledge what the doctor proclaims. Since psychiatric diagnosis is given in the name of truth, truth that resides in psychiatric expertise, the patient is subject to the discourse of the psy-professional. It pins the individual down to an “administrative identity in which one must recognize oneself”. Thus considered, psychiatric diagnosis has an alienating effect: a diagnosis is made up of bits of psychiatric knowledge that are imposed upon an individual from without. For example, when an individual believes that he suffers from ‘ADHD,’ as indicated by his doctor, alienation is at play: alien criteria dictate what is going on with this person, and bring about conclusions as to whether he has a disorder or not. As the criteria used for making the diagnosis are believed to match how the individual feels and behaves, these criteria obtain a status of truth.
An interesting more recent elaboration of Foucault’s point of departure can be found in the works of Nikolas Rose. Rose critically appraised how psychological diagnoses and tests provide “a mechanism for rendering subjectivity into thought as a calculable force.” In his view psychological assessment and evaluation practices provide a technology, starting from which contemporary man inspects and perfects himself, and likewise scrutinizes and manages the selves of others. Through the lens of psychology, we began to think of ourselves as manageable machinery. Tests and assessments map individual differences, appraise them in terms of statistical or other social norms, and engender “techniques for the disciplining of human difference”. With reference to the French philosopher Gilles Deleuze, Rose argues that psychological technologies created a ‘fold in the soul.’ Indeed, by applying psychological technologies we made a problem of our own inner life: “The fold indicates a relation without an essential interior, one in which what is ‘inside’ is merely an infolding of an interior”. Within this view the psy-disciplines did not so much get hold of the ‘essence’ of psychological life, which they (as would-be natural sciences) would like to catch, but merely installed a discourse through which we attempt to predict, adapt and govern the self. This trend towards self-government is directed by social ideals with which the individual identifies and takes as his ideal-ego. In our contemporary neo-liberal society, success, in all its varieties (beauty, performance, health…), is the ideal against which the individual is measured; it is the objective in line with which the individual refines his own functioning, and in line with which he is managed by others: “In the new domain of consumption, individuals will want to be healthy, experts will instruct them on how to be so, and entrepreneurs will exploit and enhance this market for health”.
This text is based on my book: Vanheule, S. (2014). ‘Diagnosis and the DSM – A critical Review’. London & New York: Palgrave Macmillan.