“As anyone can see for himself, this passion for equality has lately gained an increasing hold on the human heart, especially in France,”1 wrote Tocqueville in Democracy in America. Now, during the period when Tocqueville was drafting his book, this “French passion” for equality was practiced within a society and within the context of a government (the July Monarchy) that had witnessed the triumph of a form of “alienism” based, in large part, on the revolutionary postulate of equality between the madman and the non-madman.
In order to attempt to understand how and to what extent equality and/or democracy are directly involved in the life of asylums, I have chosen to turn my attention to three key dates in the history of psychiatry that may serve as a few illustrations (among others) of the “complicity” between ideology and medicine, politics and the clinic. These dates are, first of all, March 16, 1790, and then the years 1805 and 1838.
March 16, 1790
The first date, March 16, 1790, corresponds to the day when the law abolishing lettres de cachet was promulgated. Lettres de cachet authorized the established power to lock anyone up upon petition from the family or by order of the king. Article 9 of the new law clarified the status of the allegedly “demented”:
For the space of three months, starting from the day of publication of the present decree, persons held on account of dementia will be questioned, at the behest of our prosecutors, by judges, following the usual procedures, and, in accordance with their orders, visited by doctors who, overseen by the district police chiefs, will explain the true situation of the sick persons, so that, once the ruling has been made about their state, they will either be released or looked after and cared for in hospitals recommended for that purpose.
“This decision of the first revolutionary Assembly defines the terms of the entire modern problem of madness,” as Robert Castel has rightly commented.2
With the suppression of arbitrary power on the part of the king and the delegation of powers to the judicial system (prosecutors and judges), to the administration (district police chiefs), and to the medical profession, the madman who before was to be incarcerated without further ado became a citizen to be evaluated and a sick person to be looked after and cared for. While this gesture on the part of the Revolution did change the status of madness by making of the madman a patient rather than a beast to be locked up, it did not, for all that, liberate madness. On the one hand, Philippe Pinel’s much-talked-about “liberation of the deranged [les aliénés] from their chains” has more to do with myth than with reality; on the other, the asylum, which replaced the prison, is above all a place of confinement.
Let us make a first point of note: by acquiring his status as a citizen-patient, the madman gains a form of equality before the law, but not his freedom.
The year 1805 witnessed the publication of Jean-Étienne Dominique Esquirol’s dissertation, Des Passions considérées comme causes, symptômes et moyens curatifs de l’aliénation mentale (On the passions considered as causes, symptoms, and means for the cure of mental derangement), the title of which, by creating a continuity between the normal passions and their pathological excesses, confirmed the political revolution then underway: any man can go mad; any mad person deserves to be treated fully as a man. One may enter into madness, but one can also escape from it, for madness was said to be curable. The madman was no longer stamped with the sentence of unconditional incurability and was no longer condemned to the near-sacred status of demented. Moreover, passion was no longer to be contrasted with reason. There are, according to Esquirol, good and bad passions, those he called “artificial passions,” which were said to be a corrupt or exaggerated form of the healthy passions, ones liable to produce harmful effects on the organism. In other words, there is reason in the madman, but there is also, in a latent state, potential madness in the reasonable man.
In establishing these parallels and these equivalences, Esquirol thereby confirmed, through the clinic and in the clinic, this “postulate of equality” between two worlds that had previously been mutually exclusive. In this sense, he was following in the footsteps of his teacher Pinel, who was working out, during that same period, what was fittingly called moral treatment. Such “moral treatment” was supposed to make of the deranged person an interlocutor and to establish a “dialogue with the insane” (to borrow the title of a book by Gladys Swain). It is here that things become complicated.
Pinel never elaborated theoretically on this much-talked-about treatment, which he always preferred to discuss via illustrative examples. He would often repeat the basic rules: listen, console, reassure, and distract the patient from the exclusive object of his delusion; always opt for kindness and gentleness over brutality; avoid repression; prohibit the use of physical violence to the greatest extent possible. These are truly excellent principles, and it would not occur to anyone to criticize him. A year after his arrival at the Bicêtre Hospital, and thanks to his treatments and to the attention he paid to nutrition and hygiene, the mortality rate, which was more than 60 percent in 1788, had, according to him, fallen to 14 percent. This figure would suffice to show the progress the Revolution had made in the asylums—and to bring out, at the same time, the barbarous customs of the Ancien Régime.
Moral treatment consists, first of all, in protecting the deranged person, and then in gaining his trust, in order to reestablish oral contact with madness. Pinel listened to the madman and made him speak, using common sense and consoling words. He also used trickery in dealing with madness, imagining “curative fictions” that were meant to respond to “delusional fictions” (Jean Starobinski). He set up, for example, a fake court within the asylum, with doctors disguised as judges, and simulated a trial in order to convince a patient, who was persuaded that he had been condemned to the guillotine, of his innocence.
These commissioners, clothed in black and surrounded with all the pomp of authority, congregated around a table and summoned the melancholic man to appear before them. They questioned him about his profession, his prior conduct, the favorite newspapers he read, and his patriotism. The accused reported everything that he had said, everything that he had done, and challenged them to render a definitive verdict, because he thought that he was in no way guilty. In order to sway his imagination that much more forcefully, the presiding officer of this small committee read aloud the following verdict:
We, the commissioners, by virtue of the full power granted to us by the National Assembly, have, in following the usual procedures, legally examined the cit[izen] . . . , and we acknowledge that we have found in him nothing but the sentiments of the purest patriotism; he is therefore acquitted of all charges against him, and we order that he regain his full liberty and that he be returned to his family; but since, for a year, he has obstinately refused any kind of work, we deem it fitting that he still be detained at Bicêtre for six months, in order to practice his profession on behalf of the deranged, and we make the head nurse of the home responsible, upon his life, for the execution of the present order.
They then filed out silently. According to all appearances, the deepest impression was left on the mind of this deranged person.3
Another ruse was to prick the pride of an excessively prideful person (which brings one back to the idea of a passion as a cause and as a means for curing mental derangement):
Three deranged persons, all of whom believed that they were sovereigns and who had each taken the title of Louis XVI, were fighting one day over their rights to royal treatment, asserting such royal rights in a bit too forceful a way. The head nurse approached one of them and, drawing him aside a bit, said, in a serious tone: “Why are you getting into a quarrel with those people, who are clearly mad? Isn’t it known that you alone ought to be recognized as Louis XVI?” The latter, flattered by this tribute, withdrew immediately, looking down at the others in a disdainfully haughty way. The same trick worked with a second one; and so, in an instant, no trace of the dispute remained.4
The countless gripping [passionnants] examples Pinel offers in his Traité médico-philosophique show to what extent his therapy was really based on speech and on the simulacrum of a democratic society (simulated with the very best of intentions) that was nonetheless accompanied by another aspect that was still more problematic. For, moral (that is to say, mental, but also moralizing) treatment rests on a method: intimidation. “One of the great principles of the moral regulation of maniacs,” wrote Pinel, “is therefore to suitably break their will and to tame them not by injuries and violent acts but by an imposing terror apparatus that might convince them that they are not at all masters in following their fiery will and that they have nothing better to do than to submit.”5 Break, tame, submit: the program is quite unambiguously straightforward.
A second point of note: this political and clinical equality in principle was distorted by the system of domination imposed by the doctor. In other words, the asylum that is egalitarian in its aims is not very democratic in its operation, when the chief doctor is absolute master, the center around which everything converges and from which everything radiates.
This system could not help but harden in the course of the following decades, decades that were to witness the failure of moral treatment alongside the triumph of the asylum. The logic of confinement would ultimately win out over the free flow of speech. That is what was confirmed, and even instituted, in the Act of 1838, called the “Act of the Deranged”—which is my third and final date.
The Act of 1838, which would go on to govern mental derangement in France until 1990, notably ordered the creation of one asylum per département and instituted the modes of internment by creating the notions of “voluntary placement” (a strange label for designating internment at the request of a third party, generally the family) and “official placement” (upon order of the prefect), with each placement requiring a medical opinion. Moreover, the asylum doctor possessed all powers, in particular that of deprivation of one’s freedom, since a deranged person cannot be released without the consent of the chief doctor. This law was sharply criticized as soon as it was promulgated, in that it erected the asylum into the ultimate solution (Esquirol, the main architect of the law, even spoke of the asylum as an “instrument of healing”) and disregarded individual freedom (“free placement” had not, for example, been foreseen). In his famous investigative report, Chez les fous (Among the mad), published in 1925, Albert Londres wrote: “The Act of ’38 was not based on the idea of caring for and healing people stricken with mental illness, but rather on the fear these people inspire in society. It is a law of removal.” He also wrote: “By declaring the psychiatrist infallible and all-powerful, the Act of 1838 allows arbitrary internments and facilitates such attempts. . . . Under the Act of 1838, two-thirds of the inmates are not truly deranged persons. Inoffensive people are turned into prisoners with unlimited sentences.”6
As early as the Second Empire, numerous “antipsychiatrist [anti-aliénistes]” movements were to rise up against this established situation. The most appropriate response was to be given only after World War II, with the “institutional psychotherapy” movement launched by psychiatrists who had been struck by the parallel between psychiatric asylums and concentration camps. At issue was not so much the care of the mad as the institution that locked them up, its structures, its ossified hierarchies, in order that democracy might be established where there had been totalitarian excess.
After this very brief glimpse at three dates, I will not venture to conclude that the “passion for equality,” of which the asylum would have been for a time the laboratory, can be said to have led to the dead end of the nondemocratic asylum. I simply believe it is necessary to reflect on the paradoxical relationships that the notions of equality and democracy may entertain within a framework like that of psychiatry, about which Lucien Bonnafé has said, “A society is to be judged by the way in which it treats its mad people.”
1. Alexis de Tocqueville, Democracy in America, trans. Arthur Goldhammer, vol. 2, part 2, ch. 1 (New York: The Library of America, 2004), p. 581 (emphasis added).
2. Robert Castel, L'Ordre psychiatrique. L'âge d'or de l'aliénisme (Paris: Editions de Minuit, 1976), p. 9.
3. Laure Murat, L’Homme qui se prenait pour Napoléon. Pour une histoire politique de la folie (Paris: Gallimard, 2011), p. 96.
5. Philippe Pinel, “Observations sur la manie pour servir l’Histoire naturelle de l’homme,” 1794, quoted by Jacques Postel, Genèse de la psychiatrie. Les Premiers écrits de Philippe Pinel (Le Plessis-Robinson: Synthélabo, 1998), p. 245 (emphasis added). During the Restoration, Esquirol was to recall: “It was thought that moral treatment as applied to maniacs consisted in reasoning with them, in arguing with them; that’s an illusion. . . . Moral treatment consists in grabbing their attention. While these sick persons are audacious, reckless, they allow themselves to be dominated easily.” Esquirol, “Manie,” Dictionnaire des sciences médicales, vol. 30 (Panckoucke, 1818), p. 464.
6. Albert Londres, Chez les fous (1925; Paris: Serpent à plumes, 1999), p. 153.
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