{"id":924,"date":"2015-10-30T20:13:54","date_gmt":"2015-10-30T20:13:54","guid":{"rendered":"http:\/\/testing.elotroalex.com\/foucault\/?p=207"},"modified":"2015-10-30T20:13:54","modified_gmt":"2015-10-30T20:13:54","slug":"foucault-413-anna-lvovsky-on-psychiatric-power-medical-expertise-and-sexuality","status":"publish","type":"post","link":"https:\/\/blogs.law.columbia.edu\/foucault1313\/2015\/10\/30\/foucault-413-anna-lvovsky-on-psychiatric-power-medical-expertise-and-sexuality\/","title":{"rendered":"Anna Lvovsky on Psychiatric Power, Medical Expertise, and Sexuality"},"content":{"rendered":"

By Anna Lvovsky<\/strong><\/p>\n

Psychiatric Power<\/em>\u00a0is an ambitious and provocative set of lectures, not least as a fulcrum between Foucault\u2019s more famous published works:\u00a0History of Madness<\/em>, on the one hand, whose approach Foucault now partly derogates, and\u00a0History of Sexuality<\/em>, which will synthesize many of its insights in several years\u2019 time.\u00a0Psychiatric Power<\/em>\u00a0lacks the tightness of either of those works; as Didier Fassin remarked\u00a0last week<\/a>, part of what makes Foucault\u2019s 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\u2019s treatment of the human sciences. Those two wrinkles are, first, the psychiatrist\u2019s bid for public legitimacy through the emblems of \u201cmedical\u201d science, and second, the role of sexuality in disrupting the normative relationship between patient and psychiatrist.<\/p>\n

A key theme throughout\u00a0Psychiatric Power\u00a0<\/em>is the psychiatrist\u2019s quest\u2014at times mercenary and at times almost endearingly desperate\u2014to 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\u2019s ability to portray himself as, or at the very least in the vestments\u00a0of<\/em>, the true \u201cdoctor.\u201d<\/span>\u00a0Thus, Pinel commands the patient\u2019s respect through his \u201ctokens of knowledge,\u201d 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.<\/p>\n

First, the psychiatrist\u2019s bid to establish himself as a genuine \u201cdoctor\u201d 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\u00a0doctor<\/em>\u00a0per se.\u00a0\u00a0 It appears as a given that the psychiatrist\u2019s path toward social stature and legitimacy is the model of the established (\u201ctrue\u201d) medical expert. Read at face value, indeed, the text of\u00a0Psychiatric Power\u00a0<\/em>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 \u201cshow[ing]\u201d the error of prior practitioners (p. 337). Reading\u00a0Psychiatric Power\u00a0<\/em>without additional context, one would not necessarily guess that its author ten years earlier wrote\u00a0Birth of the Clinic<\/em>, which explicitly complicates the historical view of medicine as a teleological march toward \u201ctruth.\u201d Or, more accurately, perhaps\u00a0Psychiatric Power<\/em>\u00a0illustrates the limitations of\u00a0Birth of the Clinic\u00a0<\/em>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.<\/p>\n

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 \u201cscience\u201d or \u201cmedicine\u201d suffice to win legitimacy for new professional industries. Rather, the acceptance of new medical or scientific insights as \u201cauthoritative\u201d 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 \u201cexpertise,\u201d but also identify gaps in lay knowledge to be filled with the possibility of \u201cexpertise\u201d to begin with. Pasteur himself was the subject of seminal analysis along these lines by Bruno Latour, who argued that Pasteur\u2019s triumph owed as much to the scientific persuasiveness of his research\u2014under whichever epistemic paradigm it was judged\u2014as 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\u2019s reception of psychiatrists who wielded the imprimatur of \u201cexpertise\u201d 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).<\/p>\n

Reading\u00a0Psychiatric Power\u00a0<\/em>against\u00a0Birth of the Clinic<\/em>, 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\u2019s 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\u2019s thoughtful history of the asylum, seems uncharacteristically thin.<\/p>\n

Second, in the January 9th\u00a0lecture Foucault propounds the fascinating notion that the \u201cdoctor\u201d facilitates the effective operation of the asylum, not through the content of his expertise on madness, but through his \u201ctokens of knowledge\u201d: those outward signs of expertise that, regardless of content, cement the doctor\u2019s authority before the patient. That notion is intuitively attractive, and it goes far in explaining the psychiatrist\u2019s early academic pretentions. Yet it remains unclear to me why the doctor\u2019s tokens of knowledge\u2014his intimacy with the patient\u2019s specific history, his contextualization of the patient\u2019s symptoms within a broader scientific framework, even his performative presentations before crowds of eager students\u2014augment the doctor\u2019s 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\u2014what 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\u2019s 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\u00a0whose\u00a0<\/em>reality the madman has rejected, change that evaluation? Why, in short, are \u201ctokens of knowledge\u201d that are essentially in the currency of an epistemic model that madness has rejected nevertheless something that madness respects?<\/p>\n

It is easy here to let \u201cknowledge\u201d simply drop out of the equation and to suggest that the tokens discussed by Foucault are in fact\u2014in an unusually apt distinction between the two\u2014tokens of power rather than knowledge. What ensures the patient\u2019s participation with the doctor and cements the disciplinary efficacy of the asylum is not the doctor\u2019s claim to expertise over any particular body of knowledge (which the patient disregards regardless), but rather the doctor\u2019s ability to enforce his will on the patient. Thus, the doctor\u2019s \u201ctokens\u201d do not hint at vast reserves of knowledge, but rather demonstrate his authority in extracting facts and commanding obedience from those around him\u2014undoing the patient\u2019s 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\u00a0truth\u2014<\/em>his identity as an expert or man of\u00a0medicine\u2014<\/em>seems largely irrelevant.<\/p>\n

Yet perhaps there is more to it than that. To take Foucault\u2019s \u201ctokens of knowledge\u201d at face value, one must presume that there is some material difference between the patient\u2019s capitulation to the doctor\u2019s will as a display of pure authority, and to the doctor\u2019s will as a display of rarefied knowledge. And here I wonder whether the concept of pleasure\u2014not so much the patient\u2019s recognition of the doctor\u2019s pleasure, but the patient\u2019s own pleasure in receiving treatment\u2014may have some explanatory power. If the state of madness is in some sense an attempt to usurp authority over knowledge\u2014the madman\u2019s insistence on and imposition of his own facts over the protestations of those around him\u2014then might there be some of form therapeutic value in inviting the patient to yield to the doctor\u2019s will as\u00a0part of<\/em>\u00a0a production of authoritative knowledge itself? That is, whether or not madness respects any particular\u00a0content<\/em>\u00a0of 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\u2019s broader analysis of madness as a battle over truth-production\u2014an analysis culminating, in the later lectures, in the hysteric\u2019s insistence on challenging the psychiatrist on the level of truth (as\u00a0Linda Zerilli may discuss<\/a>). Yet that suggestion also complicates Foucault\u2019s path toward that final example. If the patient in this context derives pleasure from\u00a0participating<\/em>\u00a0in the doctor\u2019s achievement of some expert epistemological status, how does that insight fit with Foucault\u2019s subsequent conclusion that the hysteric derives pleasure and power partly from subverting the psychiatrist\u2019s claim to knowledge?<\/p>\n

Finally, it feels incomplete to acknowledge\u00a0Psychiatric Power<\/em>\u2019s connection to\u00a0History of Sexuality\u00a0<\/em>without a word on the role of sexuality in these lectures themselves. The question of the sexuality\u2014exclusively, it seems to me, the patient\u2019s rather than the doctor\u2019s\u2014arises sporadically throughout these lectures, but it emerges most robustly in Foucault\u2019s final presentation on February 6th. In that lecture, Foucault ascribes two key functions to the patient\u2019s sexuality in the psychiatric ecosystem: first, as something ostensibly preclusive of genuine illness, disqualifying a patient\u2019s condition from being recognized and respected as \u201cmadness,\u201d and second, as the hysteric\u2019s preferred payment for her participation in the psychiatric relationship. Both of these propositions are intriguing, but I wonder whether they don\u2019t stand in some tension with the theoretical aims of\u00a0History of Sexuality<\/em>, to which Foucault\u2019s research in these years is building.<\/p>\n

First, there is Foucault\u2019s surprisingly under-interrogated historical assertion that anti-social behavior marred by sexuality or \u201clubricity\u201d 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\u2019s sexual behavior as reflecting not madness but desire, and specifically some form of rational,\u00a0lucid<\/em>\u00a0desire\u2014a desire antithetical to madness. It\u2019s a bold proposition about which I have reservations as a historical matter; among other things, it is difficult to square with Claude Francois Michea\u2019s 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\u2019s 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\u2019 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\u2014a sin to be avoided through the healthy exercise of one\u2019s moral rather than intellectual powers. Consistent with the rhetoric of sin, defining sexuality in opposition to madness places\u00a0accountability<\/em>\u00a0for abnormal sexual behavior\u2014earthly or divine\u2014squarely on the shoulders of the individual. One who engages in licentious sexual behavior cannot benefit from Foucault\u2019s envisioned exchange between patient and doctor, in which the patient produces a disease in exchange for the doctor\u2019s pardon of fault for his actions (p. 273).<\/p>\n

Yet to say that a patient\u2019s sexual behavior is something that cannot be explained away as irrational or sickly, that cannot be pardoned through science or medicine\u2014something for which individual is uniquely responsible and for which, more than for other perverse behaviors, he must be held to account\u2014sounds suspiciously like saying that sexual behavior reflects the individual\u2019s 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\u2019s true character\u2014something uniquely preclusive of the pardon of madness\u2014then it seems that this public already bestowed on sexuality the precise type of essentialized status that, in\u00a0History of Sexuality<\/em>, Foucault will credit the subsequent medicalization of sex with producing.<\/p>\n

Similarly, take Foucault\u2019s 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 \u201cget all [her] life, and [not] avoid hearing [her] recount [her] life,\u201d but in practice it is clear enough that he means the patient\u2019s\u00a0sexual\u00a0<\/em>life in particular (p. 322). What is less clear is why the patient\u2019s price for her participation in the patient-doctor relationship is a recitation of her sexual history specifically\u2014why it is her sexuality that the patient most wishes to impose on the outside world as a way to empower herself vis-\u00e0-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\u2019s sexuality emerges as either something uniquely central in defining the patient\u2019s self or at the very least something about which the patient uniquely hungers to\u00a0speak<\/em>\u2014<\/em>both diagnoses that Foucault will later suggest arise from the precise medicalization of sexuality that\u00a0Psychiatric Power<\/em>\u00a0only foreshadows. If, in the years before the rise of\u00a0scientia sexualis<\/em>, the hysteric compulsively insists on discussing her sexuality\u2014if the patient herself, in this time, presents her body to the psychiatrist as a\u00a0sexual<\/em>\u00a0body\u2014to what extent is\u00a0scientia sexualis\u00a0<\/em>responsible for designating sexuality as a unique truth of the self?<\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

By Anna Lvovsky Psychiatric Power\u00a0is an ambitious and provocative set of lectures, not least as a fulcrum between Foucault\u2019s more famous published works:\u00a0History of Madness, on the one hand, whose approach Foucault now partly derogates, and\u00a0History of Sexuality, which will… Continue Reading →<\/span><\/a><\/p>\n","protected":false},"author":1660,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[38957,38969],"tags":[],"class_list":["post-924","post","type-post","status-publish","format-standard","hentry","category-lecture-4-13","category-to-do-link-problems"],"_links":{"self":[{"href":"https:\/\/blogs.law.columbia.edu\/foucault1313\/wp-json\/wp\/v2\/posts\/924","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.law.columbia.edu\/foucault1313\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.law.columbia.edu\/foucault1313\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.law.columbia.edu\/foucault1313\/wp-json\/wp\/v2\/users\/1660"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.law.columbia.edu\/foucault1313\/wp-json\/wp\/v2\/comments?post=924"}],"version-history":[{"count":0,"href":"https:\/\/blogs.law.columbia.edu\/foucault1313\/wp-json\/wp\/v2\/posts\/924\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.law.columbia.edu\/foucault1313\/wp-json\/wp\/v2\/media?parent=924"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.law.columbia.edu\/foucault1313\/wp-json\/wp\/v2\/categories?post=924"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.law.columbia.edu\/foucault1313\/wp-json\/wp\/v2\/tags?post=924"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}