Foucault 4/13: Anna Lvovsky on Psychiatric Power, Medical Expertise, and Sexuality

By Anna Lvovsky

Psychiatric Power is an ambitious and provocative set of lectures, not least as a fulcrum between Foucault’s more famous published works: History of Madness, on the one hand, whose approach Foucault now partly derogates, and History of Sexuality, which will synthesize many of its insights in several years’ time. Psychiatric Power lacks the tightness of either of those works; as Didier Fassin remarked last week, part of what makes Foucault’s lectures so fertile is their wrinkles, those gaps and repetitions yet to be smoothed out for publication. I would like to take this opportunity to consider two such wrinkles, which may shed some light on the complex trajectory, and limitations, of Foucault’s treatment of the human sciences. Those two wrinkles are, first, the psychiatrist’s bid for public legitimacy through the emblems of “medical” science, and second, the role of sexuality in disrupting the normative relationship between patient and psychiatrist.

A key theme throughout Psychiatric Power is the psychiatrist’s quest—at times mercenary and at times almost endearingly desperate—to establish himself as a figure of authority, both before the patient and before society more broadly. By the nineteenth century, that quest comes to depend largely on the psychiatrist’s ability to portray himself as, or at the very least in the vestments of, the true “doctor.” Thus, Pinel commands the patient’s respect through his “tokens of knowledge,” while his successors chase public status by trying to approximate the diagnostic regularities of physiologists. Both theaters of prestige, it seems to me, call for greater analysis.

First, the psychiatrist’s bid to establish himself as a genuine “doctor” is among the most intriguing themes of these lectures, not least because it gives rise to that complex symbiosis of power between patient and psychiatrist. Yet Foucault leaves unaddressed the preliminary questions of why asylums or psychiatrists must establish their legitimacy by imitating the doctor per se.   It appears as a given that the psychiatrist’s path toward social stature and legitimacy is the model of the established (“true”) medical expert. Read at face value, indeed, the text of Psychiatric Power frequently seems to naturalize the medical profession, portraying the history of physical medicine as a teleological progression toward superior scientific knowledge rightfully resulting in a corresponding boost in professional prestige: the rise of centralized hospitals and statistical reasoning allowing for more nuanced diagnoses, Pasteur and his germ theory “show[ing]” the error of prior practitioners (p. 337). Reading Psychiatric Power without additional context, one would not necessarily guess that its author ten years earlier wrote Birth of the Clinic, which explicitly complicates the historical view of medicine as a teleological march toward “truth.” Or, more accurately, perhaps Psychiatric Power illustrates the limitations of Birth of the Clinic itself, which focused more on how new discourses of medical truth gained ascendancy within the medical profession than on how those discourses won recognition from the lay public.

As a generation of scholars deeply indebted to Foucault have shown, however, the social legitimacy of scientific expertise, including medical expertise, does not necessarily track the development of new scientific insight, nor does the imprimatur of “science” or “medicine” suffice to win legitimacy for new professional industries. Rather, the acceptance of new medical or scientific insights as “authoritative” depends on the contributions of numerous factors and social allies outside the field of medicine itself, which not only let the lay public select among competing modes of “expertise,” but also identify gaps in lay knowledge to be filled with the possibility of “expertise” to begin with. Pasteur himself was the subject of seminal analysis along these lines by Bruno Latour, who argued that Pasteur’s triumph owed as much to the scientific persuasiveness of his research—under whichever epistemic paradigm it was judged—as to a network of political and social allies that set the scene for its dissemination. Or, to take an example close to my own heart, one may consider the difference between the American public’s reception of psychiatrists who wielded the imprimatur of “expertise” to legitimate state laws against sexual predators in the mid-century (warm), and of those who invoked their professional authority to decry popular stereotypes of homosexual effeminacy (rather chilly).

Reading Psychiatric Power against Birth of the Clinic, it may be obvious enough why psychiatrists must marshal the language of scientific medicine to impress other doctors, but it is less clear why psychiatrists must impress other doctors in order to impress the lay public. To take as one’s premise, without more, that psychiatrists must establish their social status by partaking in the particular currency and prestige of the scientific or medical community is to assume the primacy of science as a source of social prestige: to assume that science coming out of the Enlightenment is the preferred and reliable imprimatur of authority. And that assumption, set against Foucault’s thoughtful history of the asylum, seems uncharacteristically thin.

Second, in the January 9th lecture Foucault propounds the fascinating notion that the “doctor” facilitates the effective operation of the asylum, not through the content of his expertise on madness, but through his “tokens of knowledge”: those outward signs of expertise that, regardless of content, cement the doctor’s authority before the patient. That notion is intuitively attractive, and it goes far in explaining the psychiatrist’s early academic pretentions. Yet it remains unclear to me why the doctor’s tokens of knowledge—his intimacy with the patient’s specific history, his contextualization of the patient’s symptoms within a broader scientific framework, even his performative presentations before crowds of eager students—augment the doctor’s authority before the patient. As Foucault notes, after all, a defining characteristic of patients admitted to asylums is their insistence on the reality of a world that everyone else denies—what Foucault characterizes as their sovereign-like arrogance in insisting that their facts, and no others, have the weight of truth. In context, why should a patient’s confrontation with a doctor who manifests unique expertise over the reality that the madman has rejected, and whose expertise earns him utmost esteem from those whose reality the madman has rejected, change that evaluation? Why, in short, are “tokens of knowledge” that are essentially in the currency of an epistemic model that madness has rejected nevertheless something that madness respects?

It is easy here to let “knowledge” simply drop out of the equation and to suggest that the tokens discussed by Foucault are in fact—in an unusually apt distinction between the two—tokens of power rather than knowledge. What ensures the patient’s participation with the doctor and cements the disciplinary efficacy of the asylum is not the doctor’s claim to expertise over any particular body of knowledge (which the patient disregards regardless), but rather the doctor’s ability to enforce his will on the patient. Thus, the doctor’s “tokens” do not hint at vast reserves of knowledge, but rather demonstrate his authority in extracting facts and commanding obedience from those around him—undoing the patient’s faith in his control over his own reality by establishing a reality at the sole discretion of the doctor. That the doctor also claims access to a superior form of truth—his identity as an expert or man of medicine—seems largely irrelevant.

Yet perhaps there is more to it than that. To take Foucault’s “tokens of knowledge” at face value, one must presume that there is some material difference between the patient’s capitulation to the doctor’s will as a display of pure authority, and to the doctor’s will as a display of rarefied knowledge. And here I wonder whether the concept of pleasure—not so much the patient’s recognition of the doctor’s pleasure, but the patient’s own pleasure in receiving treatment—may have some explanatory power. If the state of madness is in some sense an attempt to usurp authority over knowledge—the madman’s insistence on and imposition of his own facts over the protestations of those around him—then might there be some of form therapeutic value in inviting the patient to yield to the doctor’s will as part of a production of authoritative knowledge itself? That is, whether or not madness respects any particular content of expert knowledge beyond its own reality, might madness not still respect and wish to participate in the very fact of expertise? The suggestion is not counterintuitive, and it falls neatly into Foucault’s broader analysis of madness as a battle over truth-production—an analysis culminating, in the later lectures, in the hysteric’s insistence on challenging the psychiatrist on the level of truth (as Linda Zerilli may discuss). Yet that suggestion also complicates Foucault’s path toward that final example. If the patient in this context derives pleasure from participating in the doctor’s achievement of some expert epistemological status, how does that insight fit with Foucault’s subsequent conclusion that the hysteric derives pleasure and power partly from subverting the psychiatrist’s claim to knowledge?

Finally, it feels incomplete to acknowledge Psychiatric Power’s connection to History of Sexuality without a word on the role of sexuality in these lectures themselves. The question of the sexuality—exclusively, it seems to me, the patient’s rather than the doctor’s—arises sporadically throughout these lectures, but it emerges most robustly in Foucault’s final presentation on February 6th. In that lecture, Foucault ascribes two key functions to the patient’s sexuality in the psychiatric ecosystem: first, as something ostensibly preclusive of genuine illness, disqualifying a patient’s condition from being recognized and respected as “madness,” and second, as the hysteric’s preferred payment for her participation in the psychiatric relationship. Both of these propositions are intriguing, but I wonder whether they don’t stand in some tension with the theoretical aims of History of Sexuality, to which Foucault’s research in these years is building.

First, there is Foucault’s surprisingly under-interrogated historical assertion that anti-social behavior marred by sexuality or “lubricity” cannot be recognized as a symptom of genuine illness. At least until the late nineteenth century, Foucault suggests, either the public or the medical profession would have insisted on interpreting a patient’s sexual behavior as reflecting not madness but desire, and specifically some form of rational, lucid desire—a desire antithetical to madness. It’s a bold proposition about which I have reservations as a historical matter; among other things, it is difficult to square with Claude Francois Michea’s mid-nineteenth century studies attributing homosexual behavior to physiological deviation, which suggest at least the possibility of a medical justification for abnormal sexuality. But let us accept Foucault’s assertion on its face. The proposition that the mid-nineteenth century public would have resisted viewing sexual perversity as a sign of madness fits neatly enough (with some decades’ leeway) with the historical view that the late-nineteenth century ushered in the colonization of sexuality for medicine, replacing a religious approach that defined perverse sexuality as a matter of licentiousness—a sin to be avoided through the healthy exercise of one’s moral rather than intellectual powers. Consistent with the rhetoric of sin, defining sexuality in opposition to madness places accountability for abnormal sexual behavior—earthly or divine—squarely on the shoulders of the individual. One who engages in licentious sexual behavior cannot benefit from Foucault’s envisioned exchange between patient and doctor, in which the patient produces a disease in exchange for the doctor’s pardon of fault for his actions (p. 273).

Yet to say that a patient’s sexual behavior is something that cannot be explained away as irrational or sickly, that cannot be pardoned through science or medicine—something for which individual is uniquely responsible and for which, more than for other perverse behaviors, he must be held to account—sounds suspiciously like saying that sexual behavior reflects the individual’s true or inner self. If, as Foucault suggests, the nineteenth century public prior to the rise of a science of sexuality already characterized sexual behavior as something reflecting an individual’s true character—something uniquely preclusive of the pardon of madness—then it seems that this public already bestowed on sexuality the precise type of essentialized status that, in History of Sexuality, Foucault will credit the subsequent medicalization of sex with producing.

Similarly, take Foucault’s equally fascinating (and under-interrogated) proposition that the hysteric asserts her will against the psychiatrist through a recitation and pantomime of her sexual history. Foucault ventriloquizes the hysteric as insisting that the doctor who seeks to diagnose her traumas must “get all [her] life, and [not] avoid hearing [her] recount [her] life,” but in practice it is clear enough that he means the patient’s sexual life in particular (p. 322). What is less clear is why the patient’s price for her participation in the patient-doctor relationship is a recitation of her sexual history specifically—why it is her sexuality that the patient most wishes to impose on the outside world as a way to empower herself vis-à-vis the doctor. That patients who finally get their chance to reveal themselves to the psychiatrist focus consistently and specifically on their sexuality would appear, once more, to essentialize sexuality as a constitutive element of identity. The patient’s sexuality emerges as either something uniquely central in defining the patient’s self or at the very least something about which the patient uniquely hungers to speakboth diagnoses that Foucault will later suggest arise from the precise medicalization of sexuality that Psychiatric Power only foreshadows. If, in the years before the rise of scientia sexualis, the hysteric compulsively insists on discussing her sexuality—if the patient herself, in this time, presents her body to the psychiatrist as a sexual body—to what extent is scientia sexualis responsible for designating sexuality as a unique truth of the self?

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