[Paleopsych] City Journal: (Foucault) Theodore Dalrymple: In the Asylum

[Premise Checker]

Theodore Dalrymple: In the Asylum
http://www.city-journal.org/html/15_3_oh_to_be.html
2005 Summer

    The Victorian lunatic asylums of my city were magnificent, from the
    purely architectural point of view. Municipal pride, manifested by
    artistic embellishment without utilitarian purpose, shone out from
    them. They were built on generous grounds in what were then rural
    areas, outside the city bounds, on the theory that rustic peace had a
    healing effect upon fractured minds--and also that remoteness would
    protect the sane of the city from distressing contact with the insane.
    The city expanded and soon engulfed the asylums, but the grounds
    remained, often the only islands of green in a sea of soot and red
    brick. These grounds, right up until the asylums closed, were tended
    with a care that spoke of love and devotion.

    For all who worked in them, the asylums provided a genuine sense of
    community. Indeed, by the time of their closure, they were the only
    real communities for miles around, the surrounding society having been
    smashed into atoms. They held annual cricket matches and other
    sporting contests on their spacious lawns, and hosted summer and
    Christmas balls. The staff were often second- or third-generation
    employees, and the institution was central to their lives.

    The patients benefited from the stability; the asylum was a little
    world in which they could behave as strangely as they pleased without
    anyone caring too much. They were free of the mockery and disdain with
    which people elsewhere would greet their strange demeanor, gestures,
    and ideas: for in the asylum, the strange was normal. Within its
    bounds, there was no stigma.

    But of course, there was a very dark side as well. Physical
    conditions, especially for those patients so chronically ill that the
    wards were in effect their homes, were appalling. There was no
    privacy, with beds sometimes packed so closely together that no one
    could walk between them. The smell of urine so deeply impregnated the
    furnishings and floors of the dayrooms that it seemed ineradicable
    (not that anyone tried to eradicate it). The stodgy food and physical
    inactivity meant that chronic constipation was universal; and most
    patients looked as if they had filtered their food through their
    shirts, blouses, and sweaters. Aimless wandering in the corridors was
    the principal recreation for many patients, who rarely saw a doctor,
    therapeutic impotence being more or less taken for granted.
    Individuals had lived in these conditions for more than half a
    century; and it was possible until the late 1980s to find women who
    had been committed to the asylums in the 1920s merely for having borne
    illegitimate children. As in the Soviet Union (though to a far less
    sinister degree), deviance was sometimes labeled madness and treated
    accordingly.

    Most of the staff were kindly and well-meaning, but, as in any
    situation in which some human beings have unsupervised care of and
    power over others, opportunities for sadism abounded. Usually these
    were minor: I often saw nurses denying cigarettes to patients, telling
    them to come back in a few minutes, for no other reason than the
    pleasure of exerting power over a fellow being. But from time to time,
    far worse cruelty would surface, always hushed up in the name of
    institutional morale. This was easily done, since very few outside the
    asylum concerned themselves with what went on inside.

    For most of their existence, the asylums were custodial rather than
    therapeutic institutions. Their methods now strike us as laughably
    crude. One asylum doctor published a memoir just after World War I in
    which he described how he and his colleagues treated suicidal
    melancholics and agitated paranoiacs. They sat the melancholics
    against a wall, placing a bench in front of them to prevent them from
    moving, while an attendant watched them to ensure that they did not do
    away with themselves. Croton oil, a very powerful laxative, subdued
    the agitation of the paranoiacs, who became so preoccupied with the
    movement of their bowels that they had no time or energy left to act
    upon the content of their delusions.

    Attempts at cures were often more desperate than well-advised. One of
    the asylums of my city had the best-equipped operating theater of its
    time, where an enthusiastic psychiatrist partially eviscerated his
    patients and also removed all their teeth, on the theory that madness
    was caused by a chronic but undetected and subclinical infection
    (called "focal sepsis") in the organs that he removed. Later, a
    visiting neurosurgeon used the theater to perform lobotomies on
    patients who were scarcely aware of what was being done to them.
    Doctors also tried more "advanced" treatments, such as insulin coma
    therapy, in which they gave schizophrenic patients insulin to lower
    their blood sugars to the point at which they became unconscious,
    sometimes with fatal effect.

    It was not difficult, then, to present asylums as chambers of horrors,
    where bizarre sadistic rituals were carried out for reasons
    unconnected with beneficent medical endeavor. And it so happened that
    one of the most powerful critics of both the asylum system and
    psychiatry as a whole--powerful in the sense of having had the
    greatest overall effect--published his attack in 1961, not long after
    the introduction of medications so efficacious in the treatment of
    psychosis that the asylum populations had already begun to decline, as
    patients were discharged back into the outside world. The name of the
    critic was Michel Foucault, and within a few years his Madness and
    Civilization had spawned an entire movement, though of somewhat
    disparate elements.

    Foucault was not so much concerned by the cases of abuse or the poor
    conditions in asylums, as a mere reformer might have been. In the
    tortuous prose then typical of French intellectuals, he was concerned
    to assert that the separation of the mad from the sane, both
    physically and as a matter of classification, was neither
    intellectually justified nor motivated by beneficence. Instead, it was
    an instance of the exertion of power by the rising bourgeoisie, which
    needed a disciplined and compliant workforce to fuel its economic
    system and was therefore increasingly intolerant of deviance--not only
    of conduct but of thought. It therefore locked deviants away in what
    Foucault called "the great incarceration" of the seventeenth and
    eighteenth centuries, of which the asylums of the Victorian era were a
    late manifestation.

    In Foucault's Nietzschean vision, all human institutions--even, or
    especially, those of avowedly beneficent intent--are expressions of
    the will to power, because such a will underlies all human activity.
    It is not really surprising, then, if asylums had turned into nothing
    but chambers of horrors: for psychiatry, and indeed the whole of
    medicine, to the rest of which Foucault soon turned his undermining
    attention, were not enterprises to liberate mankind from some of its
    travails--enterprises that inevitably committed errors en route to
    knowledge and enlightenment--but expressions of the will to power of
    the medical profession. The fact that this will was cloaked under an
    official ideology of benevolence made it only the more dangerous and
    sinister. This will needed to be unmasked, so that mankind could
    liberate itself and live in the anarchic Dionysian mode that Foucault
    favored. (A sadomasochistic homosexual, the French philosopher later
    lived out his fantasies in San Francisco, and died of AIDS as a
    result.)

    Foucault inspired subsequent critics of psychiatry, of varying degrees
    of scholarliness, rationality, and clarity of exposition. Among the
    best was the influential historian Andrew Scull, whose history of the
    origins of asylums, Museums of Madness, nevertheless implied that the
    arrogation of insanity to the purview of doctors in the eighteenth
    century did not grow out of any natural connection between the
    phenomena of madness and the endeavor of medicine--still less out of
    the practical ability of doctors of the time to cure madness (witness
    their failure in the case of George III)--but on the medical
    profession's entrepreneurial drive to increase its influence and
    income. The fact that the mad eventually came under the care of the
    medical profession was thus an historical accident, the result of the
    shrewd maneuvering of the doctors: some other group--the clergymen,
    for example, or the tailors--might have occupied the same position had
    they maneuvered as successfully. Founded on so illegitimate a basis,
    psychiatry was by implication a totally false undertaking.

    This argument overlooks a few obvious facts, however. What could have
    been said of madness could have been said of dysentery and
    pneumonia--that the doctors of the time had no power to cure them and
    that therefore these diseases were not properly the province of
    physicians and might just as well have been handled by tinkers or
    topographers. If the Foucauldian style of thought had prevailed at
    earlier times, with that mind-set's failure to understand
    imaginatively what is required to go from a state of complete
    ignorance to one of partial knowledge, and how it is often necessary
    to act in a state of ignorance, no one would ever have discovered
    anything about the cause or treatment of disease.

    Moreover, the connection between madness and medicine is not entirely
    arbitrary and unfounded, as Scull suggested (though in my opinion the
    scope of psychiatry has since expanded illegitimately, especially in
    the grotesque overprescription of psychotropic medication). The
    eighteenth-century doctors had in this respect a better grasp of
    reality than Professor Scull, for organic conditions leading to
    madness and dementia must have been very common at the time. It has
    been plausibly suggested (though not conclusively proved) that George
    III was suffering from porphyria, possibly exacerbated by lead
    poisoning, for instance, and at the end of the nineteenth century, up
    to a quarter of the population of the asylums was suffering from
    general paralysis of the insane, the last stage of syphilis. Dare I
    mention that were it not for modern medicine, I myself would long ago
    have ended up in an asylum, one of those apathetic creatures that the
    physiognomists of madness in the nineteenth century so eloquently
    portrayed in their drawings, because I suffer from hypothyroidism,
    which is the most common of all endocrine diseases and which untreated
    can lead to madness and finally to dementia?

    Another rhetorically powerful critic of psychiatry, also influenced by
    Foucault, was R. D. Laing, himself a psychiatrist. It was he who, in
    the 1960s and 1970s, gave currency to the idea that madness was an
    alternative, and in some ways superior, way of being in the world:
    that madness was in fact true sanity, and sanity true madness, insofar
    as the world itself was quite mad in its political, social, and
    domestic arrangements. According to Laing, it was the unequal power
    within families, and the distorted communications to which this
    inequality gave rise, that caused the condition in young people known
    as schizophrenia. To hospitalize them and treat them against their
    will was thus to punish them for the sins of their parents and to
    maintain an unjust social order at the same time.

    This view became extremely popular in an era that uncritically
    criticized all institutions. The psychotic came to be viewed by
    right-thinking people as victims of injustice rather than as sufferers
    from illness (an attitude reinforced when it was discovered that young
    men of Jamaican origin living in Britain had a rate of schizophrenia
    six, seven, or eight times that of young white men). What was required
    was not treatment but restitution.

    These ideas paved the way for an ill-conceived and hasty
    deinstitutionalization of the mentally ill. Thanks to effective
    treatments, the numbers requiring to be institutionalized were
    declining anyway; politicians hoped to save money by
    deinstitutionalization and were all too willing to believe that the
    mentally ill could be managed almost without any institutions
    whatever; and finally, criticisms of the Foucauldian mold--that
    society had no right to impose restraint upon the mad--entered common
    consciousness. Madmen had a right to wander the streets, and other
    citizens had the duty to put up with it.

    The asylums of my city closed within a few short years. The patients
    were sent to live in what bureaucrats insisted upon calling "the
    community," because of that term's connotations of warmth and welcome.
    With varying degrees of assistance and supervision, they were expected
    to live independently; they were given their autonomy, whether they
    wanted it or not. Many coped adequately with their newfound freedom,
    but many did not. And meanwhile, hospital provision for the mentally
    ill declined to such an extent, both for budgetary and ideological
    reasons (hospital admission was to be avoided at all costs, in a
    fetishistic kind of way, irrespective of the logic of the individual
    case), that every time it became imperatively necessary to admit a
    psychiatric patient, the entire system experienced a crisis. Madmen
    were left in police cells for days on end while hospital beds were
    found for them; sometimes, not a single such bed could be found in an
    area with a population of 4 or 5 million.

    Every day in my work as a prison doctor, I witnessed the effect of
    this lack of provision. Ironically, the splendid new hospital wing of
    the prison, built with few expenses spared, rose on the grounds of an
    asylum that had just been closed down; but inside the hospital, we
    were re-creating the conditions of eighteenth-century Bedlam. Modern
    walls do not a modern hospital make. Unearthly screams rent the air;
    foul smells offended the nostrils. Madmen threw their clothes through
    the windows, started fires in their cells, tore up their sheets,
    wrapped towels around their heads, angrily addressed their
    hallucinatory interlocutors while standing stark naked on their beds,
    refused all food as poisoned, and spat at passersby. All that was
    lacking were visitors from the outside world who had paid their
    pennies to laugh at the lunatics; I suggested that we re-institute
    this great tradition to improve the prison's finances.

    The cases would go like this: a madman would commit an offense--say, a
    completely unprovoked assault on a person in the street (unprovoked,
    that is, from the victim's point of view; the perpetrator would
    believe that the victim had been threatening or insulting him). The
    police would arrest him and take him to the police station. They would
    recognize that he was mad--his speech would be rambling and
    incoherent, he spoke of things that were not, and his behavior was
    completely beyond the bounds of reason. They would call a doctor, who
    would say that yes, the man was mad, but that no, he could not be
    admitted to a hospital to be treated, because there were no beds
    available.

    The police then faced a dilemma. They could either release the man
    back into the community, whose sense of social solidarity he had so
    reinforced by his unprovoked attack on a random stranger, or they
    could charge him and put him before the courts. Sometimes they would
    do the one, sometimes the other. I have known lunatics released from
    police custody who clearly had intended to kill their victims in the
    street (and were handed back the weapons with which they intended to
    do it), because a policeman did not want to charge a man who was so
    obviously not responsible for his actions.

    At other times, depending on who knows what factors, the police would
    bring the man before the courts, where a system of psychiatric
    screening had been set up. Theoretically, the accused found to be
    psychiatrically unwell by the examining nurse would be diverted from
    the criminal justice system into the psychiatric system. But the
    nurse, knowing that no hospital beds would be available were she to
    declare the accused mentally ill, and not wishing to accept the labor
    of Hercules involved in trying to find such a bed, declares the madman
    (so mad that it requires no expertise at all to detect his madness) to
    be fully sane, or a malingerer, or to be currently under the influence
    of marijuana, so that his madness will pass within a short time and
    results from voluntary intoxication, which is no excuse under the law
    for his crime. Thus the madman is remanded into custody; and the nurse
    calms her conscience with the hope that the prison doctor will
    recognize the man's madness and will try to find a hospital bed for
    him.

    Unfortunately, things do not go smoothly in the prison. The doctor
    cannot find a hospital bed for his mad patient; the psychiatrists
    outside the prison consider that the patient is now in a place of
    safety--the prison--where he will not be deprived of medical
    attention, and he is therefore of lower priority for a hospital bed
    than a lunatic still at large in the community. He is thus kept, often
    for months, in the prison on remand.

    As the law now stands in Britain, prison doctors are not permitted to
    give treatment against a patient's will, except under the direst
    emergency, for fear that they might abuse such power and forcibly
    sedate whomever they choose contrary to the patient's human rights.
    Hence psychotic patients are now kept in prison hospitals for months
    without any treatment whatsoever, thus taking part in an interesting
    if not altogether pleasing experiment in the natural history of
    psychosis, such as has not been conducted for many years.

    Recently, for example, I observed a psychotic patient for several
    weeks, who addressed the world night and day through his prison window
    in words of muddled religious exaltation, who refused all food on the
    grounds that it was poisoned, his flesh melting away before my eyes,
    who attacked anyone who came within reach, and who painted religious
    slogans on the walls of his cell with his own excrement, thus
    imparting a nauseating feculent smell to the entire hospital.

    It might, of course, be alleged that he behaved in so disturbed a
    fashion because he was incarcerated, and that his conduct was (in the
    opinion of R. D. Laing) a meaningful and enlightened response to his
    terrible social situation, and that he, of all the 1,400 prisoners in
    the prison, was acting in the most appropriate way under the
    circumstances. But this would be not only to ignore his medical
    history but also the fact that he was incarcerated in the first place
    because he had viciously and without provocation attacked a
    79-year-old woman in a church, injuring her badly while reciting
    verses from the Bible, which suggests that his disturbed mental state
    preceded his incarceration and was not a consequence of it.

    I checked the situation with lawyers. Although he had a fully
    documented history of psychosis and an entirely favorable response to
    treatment, attested to by both doctors and relatives (who said that
    when treated he was a pleasant and intelligent man), I was not
    entitled, in the name of human rights, to treat him against his will.
    In the name of human rights, therefore, the prison officers and the
    other prisoners had to endure weeks of revolting air, as well as
    disturbed nights in which sleep was all but impossible, while he lived
    in conditions that Hogarth might well have painted with justified
    moral fury.

    The doctors to whom I proposed to send the patient accepted the
    conditions in which he lived with Buddha-like calm that would have
    been admirable had the suffering been theirs. Only the prison
    officers, among the most despised of all public servants, seemed to be
    moved by the scandal of the situation. The doctors, by contrast, were
    now so inured to such situations that they accepted it as normal and
    nothing to get excited about. The shortage of beds and the
    administrative difficulties that this shortage caused had steadily
    eroded their common humanity. It was only when I threatened to expose
    the scandal publicly and had taken photographs of the man's cell and
    said I would send them to the government minister responsible for
    prisons (a proceeding completely against the rules, but supported by
    the prison warden, who did not want his prison turned into a surrogate
    lunatic asylum) that the man was finally found a place in a hospital,
    where he could be treated.

    Of course, Foucault might have put a completely different construction
    on the outrage of the prison officers and the desire of the man's
    relatives for him to be treated and returned to normality. He might
    have interpreted all this as an intolerant refusal to accept the man's
    alternative way of life, a refusal even to try to interpret the
    meaning of the communications that he coded in his own excrement. For
    Foucault, their concern, couched in the terms of humanity, concealed a
    drive for power and domination, used to produce conformity to
    debilitating and dehumanizing bourgeois standards. But such an
    interpretation would surely mean that common humanity and a feeling
    for others are qualities whose very possibility he would radically
    deny: that the only relations that could exist between men are those
    of power, and that all else is illusion.

    I am aware that hard cases make bad law, but I could cite many such
    cases as the one above; of cases, for example, where doctors have
    changed their diagnoses in order to avoid the responsibility of
    finding hospital beds for their patients, and where they have even
    perjured themselves in court to evade that responsibility, to the
    great detriment of the patient and the safety of society alike. These
    are now part of everyday practice.

    The shortage of beds, brought about by the desire to make financial
    savings in the context of an ideological assault on the notion of
    psychiatric illness, has corrupted doctors and nurses by slow but
    inexorable steps.

    I am also aware that many horror stories could be told of doctors who
    have been overzealous (to put it mildly) in their attempts to cure
    their patients or to spread their fields of operations to their own
    material and social advantage. There is no simple formula for avoiding
    the Scylla of zealotry on the one hand and the Charybdis of
    abandonment of responsibility on the other. The art is long, life is
    short, the occasion fleeting, and judgment difficult. But the
    difficulty must be faced.

    One thing is certain: that Foucault and his ilk are no guides to how
    to treat a man like the one I have described (and such as I have come
    across every day). Should he have been let free, to continue his
    Dionysian assaults on defenseless old ladies, on the grounds that they
    were life-enhancing? I cannot see that this represents anything but a
    preference for barbarism.