Madness Silenced: A Foucauldian Reading of Paul Sayer's The Comforts of Madness
by Bruce Sarbit
June 11, 1998
Michel Foucault's history of madness is the lens through which this essay views Paul Sayer's fictional monologue of a completely immobile, mute mental hospital patient. The patient's reflections and experiences in an intensive treatment institution bring into vivid relief the dialectic of subjectivity and objectivity. His condition is figure to the ground of reason embodied in the novel's institution and its treatment efforts. Distinct parallels between the institution's treatment regime and the psychiatric practices of the late eighteenth century are consistent with Foucault's ideas on the pairing of knowledge and power. Rules of discourse governing treatment of madness, including emphasis on objectivity at the expense of subjectivity, have not altered much in the intervening years.
My purpose in this paper is to explore and promote attention to underrated subjectivity. I aim to do it by examining psychiatry's treatment of madness, treatment that has been zealously attached to objective reasoning. In much the same fashion, psychiatry's histories have generally been chronicles of objectivity applied to the treatment of madness. Ironically, it's because they have excessively valued objectivity that the psychiatric sciences and their histories have generated my purpose herein, for conspicuously untold is the story of madness' subjective silence.
Historical works have examined the relationship of psychiatry to madness several times and in diverse ways (see for example, Caplan, 1969; Ellenberger, 1970; Foucault, 1965; Grob, 1994; Porter, 1987; Scull, 1993). The relationship has, moreover, been explored profitably in many works of literature, art and film (for an exhaustive list, see the "Medical Humanities" web site at <http://endeavor.med.nyu.edu/lit-med>). In order to explore the story of silent madness, I will couple history and literature of the psychiatry/madness relationship in a Foucauldian analysis of Paul Sayer's fine novel, The Comforts of Madness. Foucault's challenging ideas assume new significance when they are reflected in and by Sayer's novelized examination of the relationship. The dimensions of, and impediments to, the relationship take on new clarity and importance so that the subjective dimensions of human nature, undervalued by the usual psychiatric responses to madness, can be more fully appreciated.
"Wearing away certain . . . commonplaces about madness"
Foucault's Madness and Civilization: A History of Insanity in the Age of Reason (1965) was the first phase of his grand project (the others parts dealt with criminality, illness and sex) whereby he tried to demonstrate that the "human sciences" defined and delimited human beings at the same time that they described them. By demonstrating how our knowledge of, and practices with respect to, human beings arose within discursive bases, Foucault established that the pairing of knowledge and power shaped the way in which we have related to one another.
In Madness and Civilization, Foucault scrutinized the historical relationship of madness and reason to the end of the eighteenth century. Convinced that during the two hundred years since then, psychiatric reason has not adequately explained, accounted for, or overcome it, he asserted that madness had proved to be reason's absolute limit. By examining the discursive origins of reason's response to madness, Foucault reinterpreted the history of psychiatric science as madness silenced by reason's tandem of power and knowledge.
Foucault's thesis received enthusiastic support from some quarters. Prime among them were mental health system critics who hailed its recognition of a lopsided allotment of power to medical knowledge within mental health institutions and psychiatric practice. Others (e.g. Feder, 1980) censured him for assorted failings. He spoke in grand generalizations, overstated his case, glossed over detail, exaggerated material that supported his position and ignored material that did not, the result being that his writing feels aggressive and didactic. Perhaps justifying it, there was purpose in Foucault's rhetorical style. He not only wanted to retell history, he also aimed to change the shape of current discourse. Convinced that patterns of communication had been governed by untenable rules, wanting to revolutionize them, his stated aim was: "to give some assistance in wearing away certain self-evidentnesses and commonplaces about madness, . . . that certain phrases can no longer be spoken so lightly, certain acts no longer, or at least no longer so unhesitatingly, performed, to contribute to changing certain things in people's way of perceiving and doing things, to participate in this difficult displacement of forms of sensibility and thresholds of tolerance." (1981, 11-12)
Foucault grounded his work in two interactive premises, the first being that all of our views, our ways of doing things, and our institutions are neither natural nor immutable. They are, instead, contingent on historical conditions. There was a time when they did not exist and there may come a time when they will be no more. Foucault's second premise argued that "progress" had to be viewed with suspicion. What others had valued as advancement, he saw as negative, his evidence being that history teaches us that one atrocity is inevitably followed by another.
We may not, maybe should not, always agree with Foucault. Still, his aim is compelling, and his writings are always interesting. By virtue of the profundity and force of Foucault's arguments, I know that I may no longer say or do certain things with respect to madness "so unhesitatingly". I now look much more critically at the unquestioned assumptions behind the discourse on madness in its relationship to psychiatry.
"Nowhere except in novels . . ."
The relationship between madness, psychiatry and the times has run so deep that it has been found in comparisons of early clinical case studies and fictionalized depictions of character. In fact, the historian of psychiatry, Henri Ellenberger (1970), noted that the remarkable case histories of the madhouse reformer, Phillipe Pinel, appear to have been, in some cases, borrowed from Balzac's novels. Pinel essentially confirmed this. As he detailed the virtues of his treatment methods, he admitted that his patient descriptions were inspired by idealistic novels of his day: "Nowhere except in novels have I seen spouses more worthy of being cherished, parents more tender, lovers more passionate, or persons more attached to their duties than the majority of the insane fortunately brought to the period of convalescence."
Ellenberger observes that the relationship operated in both directions, from literature to case studies and vice-versa. Literature influenced the way in which people viewed and described madness. Madness, in turn, affected literature. It might have helped early practitioners, as they tried to find ways to describe what they had encountered in their patients, to leave the facts behind and to try fiction instead. The flip side is equally plausible. The material of madness may have been experienced as stranger than fiction, so strange that, from time-to-time, case histories might have been written to read like fictional creations.
The two-way association is most pronounced in its relation to Freud. His case histories invariably read like well-crafted fiction (see, for example, The Wolf-Man by the Wolf-Man, 1971). The account of Dora's case is thought to correspond to earlier fiction by Schnitzler (Ellenberger, 1970). In the other direction, several novelists (Harrison, 1984; Yalom, 1992; Stone, 1971; Michalos, 1993) have fictionalized Freud's work and life without deviating too far from biographical reality. Others have been less constrained by facts. One imaginative author (Oatley, 1993) cast him as a detective who, in association with Sherlock Holmes, solved homicidal, psychological mysteries. Malzberg (1985) catapulted his fictional Freud into the twenty-fourth century. And, D. M. Thomas in The White Hotel (1981) fabricated Freud's case records and correspondence with respect to an actual client.
The connection continues through time and beyond Freud. Madness has been a central theme in several, profound works of fiction. Marge Piercy's Woman on the edge of time (1976) tells the story of a poor Chicano woman, unjustifiably committed to a mental institution. Elie Wiesel's Twilight (1988) follows a Holocaust survivor seeking truth at an extraordinary asylum for patients whose delusions are biblical. In Lying on the couch (1996), Irvin Yalom focusses on challenging issues which psychotherapists must confront both in therapeutic relationships and in their own lives. Other masterful works of madness literature include Lessing's Briefing for a descent into Hell (1971), Barker's Regeneration (1990), Schaeffer's Equus (1974), McGrath's Asylum (1998) and Kesey's One flew over the cuckoo's nest (1962).
The Comforts of Madness
Paul Sayer's The comforts of madness, winner of the prestigious Whitbread Book of the Year Award (both best first novel and grand prize) for 1988, is an outstanding instance of fiction depicting madness. Peter, a completely immobile and mute 33-year-old mental hospital patient, neither speaks nor moves. But, somehow (we must use our imagination), his monologue has been recorded. Through Peter, the dialectic of subjectivity and objectivity has been brought into vivid relief. His condition, construed as mental illness, becomes figure to the ground of reason as that is embodied in the mental hospital and in the efforts to treat him.
As Peter is being relocated to the experimental mental hospital, "One World Intensive Rehabilitation Centre", Anna, assistant to the Director, tells him about the philosophy which will govern his treatment there. His previous institution, she asserts, was inadequate, having failed to address and to treat him as a human being: "You were manhandled without a word, talked about as if you were some dumb animal" (1988, p. 28). At One World, he should expect treatment of a very different sort: "You will not be a 'case', no, you will be, first and absolutely foremost, a human being, a living, feeling, thinking man capable of all the sweetness and essence that is given to mankind" (28).
Anna confidently claims One World's familiarity and success with other clients who have conditions similar to Peter's. She sees him as a "type", neither singular nor special. "I know your type, Peter, and I know you're in there somewhere, listening to me, wondering, naturally, what you have been let in for. . . . Your case is not unique, though you may have been led to believe that it is" (28).
Anna claims to know, despite Peter's lack of acknowledgment, that, behind his inert exterior, he is listening to her and wondering what his experience at One World will be. She boldly predicts his cure, believing that given his full effort, he will, in time, emerge from his condition in the therapeutic environment created by One World. "Where you are going you will be treated with respect, and we expect that you will respond accordingly. . . . You will act for yourself, be able to shrug off the nightmare of your past. You need only have the simplest of faith in us and you will be rewarded. We can make you well again, but you must be prepared to make the greatest effort yourself. Work, Peter, work hard, and you will be whole once more" (28).
The usual therapies associated with contemporary treatment of mental illness are nowhere in evidence at One World or in staff discourse. Anna makes no mention of medications or such practices as shock treatments and behavioural therapies. The fundamental premise behind its way of operating is, instead, that if he is treated well and encouraged to get better, with full respect in a suitable environment, Peter will want to respond differently. He will see no reason to continue in immobility and silence. With his hard work, he will be able to overcome his condition and become a complete, self-governing human being.
At first glance, One World's approach constitutes a vast improvement over what Peter experienced in previous institutions. Talking to him, as a human being worthy of respect, is considerably better than talking about him. And, of course, it's better again than treating him as if he were a mere object or "dumb animal". Who would argue that living in an agreeable environment consisting of a community of caring people, fresh air and a significant degree of freedom is better than dwelling in a sterile, often heartless institution?
However, in the face of Peter's utter silence and persistent immobility, One World staff have made several assumptions which are revealed during Sayer's telling. Some of the assumptions are questionable; some are, perhaps, contestable. They start with a belief that they know what it is to be human. They judge that, in his current state, Peter is much less, that he is suffering from an extreme form of mental illness and is in dire need of their treatment. Understandably, they see nothing of value in his condition. A further assumption is that, while Peter's silence and immobility are not chosen, he can reclaim control and exercise the choice to speak and move. Anna and One World believe that Peter is "in there somewhere", listening and wondering. They have supposed that he has potential to respond to them and to the world-at-large, and furthermore, that someday, he will desire to respond, to speak and to move.
"This flaky receptacle that passed for a body"
Like Camus' Mersault, Sayer's Peter lacks clear boundaries. It is sometimes hard to tell where the world ends and where Peter begins, he has such meagre identity against which the world can be contrasted. From the start of his monologue we are aware of this, for there he says that he seriously doubts his name is Peter.
Peter doesn't seem to make an impact on others, to have any effect in the world. People fail to notice him. Much less do they care who he is or what he does. He is of no consequence to anyone, including his passive, depressed mother and his egocentric, ineffective father; both are too disturbed by their own concerns. Even his sister, the only person who shows him some measure of love or commitment, uses him for her own purposes, and then, abandons him.
Institutional caregivers respond to him with, at best, indifference. Even as they wash, dress or feed him, they give him minimal consideration. They do their work mechanically. All that matters to them is that he continues to live, or rather, that he does not die, during their shift. "They had contented themselves with the fact that I still lived, somehow, in spite of my thanatophile appearance and demeanour" (11). Most don't notice him at all as they go about their tasks. "And those that did see me, enacted their business with me, plied their trade as it were, did they ever pause to wonder at this flaky receptacle that passed for a body, to ask themselves if there was any kind of soul inside, bearing witness to the suns and moons that passed before its eyes?" (15)
Peter's lack of existential significance is illustrated in his recurrent dream. John, the Director of One World, fails to recognize Peter lying dead on a mortuary slab. Then, Peter, another of his selves, also steps forward to look at the body. He, too, shakes his head and walks away for failure to recognize the body as himself.
What small difference Peter makes is not his doing. He does nothing, yet people respond to him as an irritant. "Get him out of the way. . . . Further, further" (13-14), yells a nurse. Or, they blame him for things he could not possibly have done. For instance, a man in a nearby bed commits suicide; Peter knows that he will be held accountable. "I sensed I was to be implicated, ah God, I knew I was. Their wish to find a scapegoat . . . would be irresistible." (16)
Peter has no will to live, no life spirit. He wants nothing that might give him some essence. He craves neither meaning nor freedom, neither love nor knowledge. Life, his or others, means nothing to him. And, neither does death. He tells a poignant story relevant to this theme: "I debated over whether or not I should kill it (a toad found under a rock). I ought to, I seem to remember thinking. The act of destroying a living creature might have done me good in some way, have transmuted something, imparted some kind of power, reinforced me. But I had never committed such an act and my will was now in decline" (93).
In the next breath, Peter contemplates his own death by suicide. He quickly rejects the notion, not out of any desire to live, not out of any concern for others who might be upset by the action, not out of any fear of death or pain of dying, but rather because the idea is his, the only idea he seems to have formulated on his own. And, so, he immediately distrusts it, doubting that he could create something viable or worthwhile --- even the idea of his own death.
If he doesn't want to live and cannot take his own life, what, then, does he want? His answer is: "mastery, complete control over my fate, though I had not the vaguest idea of how I was to achieve it. For the moment it became just a heavy notion, . . . a silent wilfulness spreading, drying me out, looking for a reason to take me over." (87)
The answer leads him to add utter immobility to his long history of mutism. Because the unacceptable alternative is to let him die, institutional care is required; every aspect of his life must be managed by others. He gives up all responsibility for his life and death to institutional care. This state, so utterly repellent to most of us, seems to be the "mastery" he wants.
" . . . my history, a calamity of baubles"
Peter recognizes how compelling is our curiosity with respect to the causes of his condition. Now, he would never have shared his memories willingly, having repressed the experiences of his pathetic existence exceedingly well. But, when One World drugs him and hangs him by ropes, prone and facing down, he has little choice but to remember his tale. Even then, there is no bitterness, no spite, and of course, no willingness. He surrenders his story to us with a dispassionate resignation: "my history, a calamity of baubles, something to appease my tormentors' appetites for motive, for cause and effect, neither of which have I genuinely seen to exist. So what? Here, have it anyway" (84).
Peter remembers "the spectacle of the cat". His sister found a dead cat and decided to cremate it. While Peter did not understand the rites, he was swept along by her preparations. As the cat burned, Peter distanced himself from the proceedings. However, he continued to watch. He wonders if this was the point at which he "became unhinged" (84). The experience of the cat's interment touched off exacting explorations of his body culminating in a recognition of his finitude and, then, deep dread. "That this skin, these bones, eyes, teeth, organs, would also one day end up as ashes, as nothing, imparted in me a dread I had not known before" (86-87).
His mirrored explorations, his prodding and pulse-watching, do little to reassure him that his existence is of any value. He envisions a meaningless finale as ashes. Without reason to be hopeful about his life, he gives up all struggle and retires to a still place beyond himself. Even when his father is extremely illness, too weak to leave his bed, Peter finds no will to give him help. "I began taking more and more to my bed, lying there still as the depths of the sea, slowing my breath until my ribs ached. The process at work within me was slowly gaining the upper hand. Somehow I was beginning to see my withdrawal from life as a way of lifting myself above time, transcending the conflict around me, holding at bay the demon that had come for my father and might soon come for me." (p. 93)
The demon doesn't come, but then, neither does inspiration nor motivation. He is found, hospitalized and nursed back to some semblance of health before being sent to a boy's school. Nothing changes. The boys there tease and beat him while the teacher merely pretends to care and understand. One hot summer day, Peter leaves the school. He walks a great distance along the nearby beach until, affected by sunstroke, he falls to the ground. While he is lying in a daze, a small girl shows him a toad that she has skewered to a stick. The toad is alive, but it must keep still because any movement will cause it incredible pain or even death. Peter runs away from her, falling and blacking out, hoping to die and to be carried away by the tide.
Once again, death eludes him. When he is found, he cannot move and has absolutely no desire to do so. He ends his dreadful, pre-institutional life with these thoughts: "Nothing was left in me at all. . . . I reflected on the first wave of a warm, comforting stillness breaking over me, a quiet madness of my own making. In a funny sort of way it was how I imagined a homecoming might be" (105).
Then, with his last act before a life of absolute immobility, for the first time, he smiles.
"What kind of creature are you, Peter?"
It's rare that psychiatry deems its understanding so weak that it cannot name a condition and proceed to prescriptive action of some sort. Anna, however, cannot identify the condition or malady from which Peter suffers. As she prods and pokes him, she essentially asks him to provide his own diagnosis. "What kind of creature are you, Peter? . . . How do we describe your state, your malady? Are you psychotic? Traumatised? Hysterical? A sad case? Or are you simply having us all on? Tell me, Peter, are you, perhaps, nothing more than an old fraud?" (24-25).
Anna isn't inhibited by the fact that she doesn't know the answers to these questions. She chooses Peter from among many other patients, and continues to assert One World's confidence in treatment. Nor is Anna disturbed by a reminder that a "successfully treated" One World patient, with characteristics similar to those of Peter, committed suicide upon release from the institution.
While Sayer does not let us in on One World's diagnostic conclusions, like Anna, I wonder if Peter is depressed. Does he suffer from organic brain damage, withdrawal, catatonia or fear? Are his conditions of immobility and speechlessness the manifestations of Post-Traumatic Stress Disorder? Peter, himself, also wonders about what caused his condition. "All right, so what was my problem, then? . . . What made me the way I was in the first place? Illness? Paralysis? Trauma? Maybe the last, yes, maybe, but my intransigence was not the result of an accident, not that" (47).
As I search for a fit between his condition and the way in which One World experiences it, I am, like most of my colleagues in psychotherapy, drawn to the instrument most commonly used for that purpose, the American Psychiatric Association's Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV) (1994). Measured against the diagnostic categories of the DSM-IV, Peter's condition seems to be most closely aligned with, and to follow from, the category known as Elective Mutism. First identified in 1877 as aphasis voluntaria, it has, more recently, been replaced by, or renamed, Selective Mutism (American Psychiatric Association, 1994; Wright et al, 1994). A rare disorder with typical onset during preschool years, the condition of Elective Mutism was explained as a choice not to speak in particular social situations in which speech is expected, and where that choice hinders either achievement or social communication.
The switch from "elective" to "selective" is more than just a change of name. In the first place, it disputes the belief that the child elects to be mute. The new diagnosis instead considers mutism to be a problem beyond the sway of patient will. Secondly, the new diagnosis challenges the assumption that failure to speak generalizes to all speaking situations. It essentially contends that mutism is situation-specific, happening in some situations, but not in others.
Perhaps the best-known case of mutism is portrayed in One flew over the cuckoo's nest, both the novel (1962) and the movie. The book's narrator, Chief Bromden, a massive, aboriginal inmate is housed in a strictly managed ward of a mental hospital. Entirely silent, he is thought by institutional staff to be deaf and "dumb". We assume that, by way of being mute, he avoids some combination of institutional coercion and the unhappiness of his own life. We only discover that Chief Bromden's silence has been willful when he speaks to a newly admitted patient, the high-spirited Randall McMurphy. No one prior to McMurphy had given Chief Bromden any cause to speak. But, McMurphy awakens the passion of the patients, including Chief Bromden, by his refusal to comply with the institutional demands for obedience, with games, new experiences and an unauthorized expedition. He moves them to rebel against the soul-deadening tedium of Nurse Ratchet's oppressive regime. In the truly memorable climactic scene, McMurphy is brought back to the ward lobotomized, purged of his defiance, devoid of his previously buoyant character. Deeply disturbed by the changes in his friend, Chief Bromden compassionately smothers him. Then, in an act of heroic proportions, he tears an apparently immovable basin from its base, heaves it through a huge window and escapes to the fields and freedom.
Is Peter's condition a case of Elective Mutism, a variant of Kesey's literary example? At first glance, Peter's immobility would seem to be an important difference between his condition and that of Chief Bromden. Yet, in a sense, immobility is more of the same, a bodily extension of the mutism. While their cases feel significantly dissimilar, the critical difference is not likely to be found in Peter's immobility. Certainly, the outcomes, as we understand them, are dramatically different. Chief Bromden's transformation is the heroic ground of Kesey's novel. His recovery of speech and resolution is evidence of his having elected mutism until he had reason to speak. On the other hand, Peter's lack of change suggests that his mutism and immobility are not elected. Ironically, the only evidence we see of Peter's willful determination comes when he tells us that, even if he could speak or move, he wouldn't.
For further parallels with Peter's condition, it is instructive to consider the condition known as "locked-in syndrome". Result of a massive stroke, it is a disorder in which, like Peter, the person is completely aware but unable to speak and to move. Perhaps the only depiction of the condition is in Jean-Dominique Bauby's, The diving-bell and the butterfly (1997). This moving book is an autobiographical account of Bauby's experience and thoughts subsequent to his devastating transformation. Bauby, incredibly, dictated the book letter-by-letter by blinking his left eyelid, his only functional muscle, as the alphabet was recited to him. The difference between Bauby and Peter might be construed to be that one eyelid, the solitary movement, but for the fact that Peter would likely have been unwilling to speak or move even if he could have done so. What's just as important, perhaps, is the institutional view of their conditions. Bauby's condition, for obvious reasons, was interpreted in strictly physical terms. Peter's is, maybe arbitrarily, categorized as an illness of the mental sort: no one among the One World staff considers the possibility that Peter can neither move nor speak for physical reasons, for reason of brain damage.
We might also want to explore whether or not Peter's condition corresponds in any meaningful way to the sleeping sickness described in Oliver Sacks' Awakenings (1990), book and movie of the same name. Sacks' patients were the nearly-immobile-and-speechless victims of an epidemic of encephalitis lethargica. Having identified some parallels between the symptoms of his patients and those of Parkinson's disease, Sacks conducted therapeutic experiments with the anti-Parkinsonian medication, L-Dopa. The improvements in patient mobility and speech were so remarkable that the "awakenings" were celebrated as a great breakthrough. Despite some similarities, the evidence that Peter suffers from a sleeping sickness is, it seems to me, negligible-to-none. In fact, One World's response to him is an indication that, despite his inertia and lack of speech, they sense, by way of his eyes, that his mind is alert, free of a lethargy or sleep disorder.
" . . . they will be mad as the lunatic."
By excluding diagnostic categories or discussions of the same, Sayer has avoided the opportunity to judge One World's choice in this respect. All we know is that One World exudes abundant confidence. It presumes to know what "type" of problem it is dealing with, to know what to expect from Peter, and to believe that its practices, for starters, respectful treatment within an agreeable environment, will reap the desired dividends. Peter will, Anna declares, eventually be able to "shrug off the nightmare" of his past life and to act for himself.
However, the nightmare continues. Peter remains speechless and immobile. When its therapeutic environment and strategies fail, One World deals with Peter in a dramatically different way. Time-and-again, Peter is forced to do things against his will. When he attempts to quit eating, Anna stuffs a cloth soaked with nauseating liquid into his mouth. He is subjected to forced walking movements on a bizarre, Kafkaesque machine. Finally, he is hung by ropes and given defence-breaking drugs which compel him to recall long-suppressed memories. The more One World's reasoning and new science are found to be ineffective, the more that patience with Peter's condition ends. The institution cannot cope with a continuation of Peter's sort of madness. His abiding silence and lack of movement are viewed as glaring evidence of its failure. More and more desperate, coercive measures are invoked.
One World's theories on the nature of mental illness, its diagnostic and treatment efforts, are gravely challenged by its failures with Peter. If John and One World, like his previous caregivers, had seen improvements in Peter's condition as implausible, failure to effect changes, to get Peter to speak and move, would have been accepted with some equanimity. However, John's reaction to the failures is directly proportional to his investment in Peter's cure. He had staked the institution's reputation and, presumably, its future on the renown and money that would come when news of its astounding success in Peter's case would be announced.
With The Comforts of Madness, Paul Sayer has written an instance of psychiatric reason exceeding its capacities. One World's reason could not adequately explain, much less overcome, Peter's madness. As a consequence, his madness became One World's limit and an illustration of Foucault's thesis: objective reason cannot truly understand madness in its subjectivity.
A marvellous joke, told by Freud to Theodor Reik (1962), exemplifies this idea.
A certain patient in a mental institution had argued long and hard that he must be served only kosher food. Finally, unable to avoid the extra work and expense (in having to deal with him), the director of the institution acquiesced.
A few days later, on the Sabbath, the director was strolling around the grounds, when he came upon the same patient sitting in a chair and smoking a cigar.
'Wait a minute, Schwartz,' he said. 'I thought you were so religious that we had to bring in special food for you. And now, here you are smoking on the Sabbath!'
'But, Doctor,' Schwartz replied. 'Did you forget? I'm meshugah (crazy)!'.
One World apparently forgot that Peter was meshugah, that his condition was beyond its reach. As Peter continues in his condition, the confident certainty of the institution unravels. Believing themselves to be wise, even in the face of such failures, the institutional caregivers become as mad as the madman. When he discovers a protest letter, written by anonymous patients, an effort to make authorities aware of One World's offenses, John becomes unbalanced; he goes mad. Despite other, incomparably more plausible options, attributing the insurrection to the most unlikely rebel, silent and immobile Peter, he yells hysterically: "God, but you're a cunning bastard. . . . If I were not a scientific man I would say you were the Devil himself. What chaos, what evil you must carry around in you. If I ever come across your case again I shall not be able to account for my actions. How do you do it? What demon's secret have you learned? Tell me. Tell me now, you bastard. Tell me" (117).
Bizarre as it may seem, Peter's condition of silence and immobility has turned out to be a greater menace to John and One World than the other more vocal and overt forms of madness.
How can it be that a silent, immobile person inspires such loathing, such anger, such a mad response? How can Peter be considered to pose such a threat to John's psychiatric reason? Sayer doesn't answer these questions himself. However, Michel Foucault does.
"That other form of madness"
Foucault (1965) deliberately selected the vague and non-medical word "madness" over others such as "mental illness" or "insanity". He knew that the term he used had to be outside the rigidly defined realm of reason established in relation to such topics by science, in particular, by psychiatric and psychological science. The word "madness" seemed to suit his needs perfectly. Unlike the vocabulary of the DSM, it was neither categorizable nor painstakingly describable by objective criteria with corresponding prescriptions. The word "madness" was, rather, an obviously subjective judgment.
Foucault's main ideas, in a nutshell, are these. Toward the end of the eighteenth century, judgments of certain behaviours associated with madness were placed in the hands of medical science which was granted authority to approve them as the objective facts of insanity or mental illness. Furthermore, it had the right to sanction institutionalization on such a basis. Reason, as medical science, seized the high ground of objectivity. The treatment and confinement of people labelled insane or mentally ill was, in essence, grounded in, and justified by, the fact that madness was unable to speak the language of reason. Madness was, as a consequence, attached, in partnership, to an increasingly spurned subjectivity.
Recognizing that his history of madness had not been advanced before, Foucault wrote: "We have yet to write the history of that other form of madness, by which men, in an act of sovereign reason, confine their neighbours, and communicate and recognize each other through the merciless language of non-madness." (1965, p. ix)
He set himself the task of showing, historically, how reason and madness had become dissociated, one from the other, and how they had shifted to non-communicating camps.Mainstream histories of psychiatry and psychology had ventured to demonstrate how madness, under the more precise and objective rubric of mental illness, had been assigned to the wisdom of scientific, psychiatric reason (see, for example, Ellenberger, 1970). Foucault aimed to show just the opposite, that madness had been estranged by reason's progression.
"We must describe, from the start of its trajectory, that 'other form' (of madness) which relegates Reason and Madness to one side or the other of its action as things henceforth external, deaf to all exchange, and as though dead to one another." (1965, ix)
Foucault called his history an "archaeology of that silence" (1965, xi) between reason and madness. It portrays a disturbingly uneven distribution of powers. Foucault's version of reason, in its various scientific psychiatric and psychological incarnations, acted as if it had exclusive sovereignty in the domain of mental health. Challenges to its authority were dismissed or suppressed. Madness, as depicted by Foucault's history, was forced to play a mute and submissive role as it awaited reason's therapeutic ministrations.
In Foucault's account, the treatment of madness had nothing to do with the expansion or improvement of knowledge through science. In fact, he believed that such histories had been produced to glamorize their subjects at the expense of alternative truths (which, of course, he was prepared to teach us). Foucault would never have viewed treatment reform as an "act of 'liberation'" (1965, 243). Nor would he have seen it as the emergence of more sensitive attitudes and compassionate care, changes which histories typically depict as having been initiated by such champions of psychiatric reform as Phillipe Pinel in France and the Tukes in England.
"Evidence of a broken dialogue. . . "
Foucault's history in Madness and Civilization traces the evolution of all-embracing devotion to reason. This evolution, he claims, has been so prevalent during the last two centuries that the dialogue with madness has ground to a halt. As reason's language thrived, in its complexity, sophistication and power, the dialogue, which had always been awkward and difficult, even at the best of times, diminished to the point of oblivion. The communication became almost entirely unidirectional. No longer an exchange of perspectives, it became a monologue in which reason did all the talking. Madness, for the most part, languished in acquiescent silence.
Despite the groundbreaking works of R. D. Laing (1965), efforts to make the therapeutic enterprise more subjective (Bugental, 1987), and to generate the Buberian I-Thou encounter (Friedman, 1967) with madness, the relationship continues to be very one-sided. The irrationality of madness might still be thought of as squelched and controlled. Madness is still banished to institutions, even though there is an escalating campaign toward community-based mental health programs. The use of certain psycho-surgical procedures is still considered appropriate by many practitioners. Restrictive legislation for confinement purposes is still invoked. Increasingly, madness is treated with masking medications and with several types of intrusive, manipulative therapy. Irrationality is still assigned to specialist professionals for whom the notion of "madness-as-disease" constitutes the primary, sometimes only, understanding and way of relating to it.
The net result is that, in-or-outside of institutions, madness is only able to communicate through the intervening filters of reason. Reason insists on order and arrangement, imposes myriad restrictions, and applies pressure to conform. There is no acceptable neutral or common language. Nor is any effort made to establish one. So, communication, if it happens at all, happens in the inflexible languages of psychiatric reason, where madness has been transformed in its image and then, reconstructed as mental illness. "The constitution of madness as mental illness, at the end of the eighteenth century, affords the evidence of a broken dialogue, posits the separation as already effected, and thrusts into oblivion all those stammered, imperfect words without fixed syntax in which the exchange between madness and reason was made" (1965, x).
From Foucault's perspective, then, there is no dialogue with a silent, muzzled madness, but only "a monologue of reason about [it]". He believes that we can understand how that came to be by looking differently and more critically at how the Tukes devised York Retreat's moral treatment.
Foucault's analysis of York Retreat was brutally critical. Certain that efforts to change institutions were condemned to maintain them, he argued that the Tukes had not actually replaced restraints and confinement with more humanitarian approaches to madness. They had merely created a new kind of prison, one in which the insane were held responsible for their actions. In Foucault's history, the constraints of conscience were shown to be, at most, insignificant variations on iron fetters. Instead of freeing its residents from constraints, York Retreat imposed "the stifling anguish of responsibility" on them (1965, 247). Viewed as a consequence of responsibility's absence, madness was treated with coercion, usually a non-physical variety, to labour under observation. The Tukes' professed aim may have been to build patients' esteem. However, says Foucault, pressure to work more likely produced significant inhibition and distress. Work at York Retreat had no particular productive utility, Foucault tells us. It was, rather, a way to limit liberty and to effect submission to institutional order in the name of teaching responsibility. While physical constraints also removed liberty, they failed to reorient the mind of the mad as effectively as did regular work. Work had the advantage of requiring considerable movement of the body. It also required attention to function and the duty to produce a result. All of this helped to mould patients into responsible community members.
One of the most important features of institutional life at York Retreat, of asylum life generally, according to Foucault, was non-reciprocal, one-way surveillance. Institutional observation, by virtue of the confining environment, was able to pursue madness wherever it moved. It could monitor patients at all times. It could track them even when they tried to conceal themselves from the objectifying gaze and the inevitable judgments that followed. The judgments at York Retreat were often attached to performance at formal ceremonies such as afternoon tea parties. There, the mad would demonstrate their ability to act in a cultivated and refined manner in the observing and evaluating presence of a fatherly director and a "family" of staff.
Foucault explained that the processes of surveillance and judgment created an "authority", as a middle ground or mediating factor between coercive reason, embodied in the institutional guards, and the madness of the patients. "The space reserved by society for insanity would now be haunted by those who were 'from the other side' and who represented both the presence of the authority that confines and the rigour of the reason that judges. The keeper intervenes, without weapons, without instruments of constraint, with observation and language only" (1965, 251).
Where the relationship had previously been structured by means of forceful constraint, now unreason acquiesced to a reasoning and supposedly sane authority. The change from chains to observation and language was not an instance of madness liberated. Rather, argued Foucault, it was a case of madness mastered. Tuke had essentially created, in the microcosm of York Retreat, a milieu which reproduced, in structure and power relations, the bourgeois family. In relation to the authority, madness became an alienated minor. The mad person was transformed into a child who, as dependent subject, was assigned "to the authority and prestige of the man of reason" (1965, 253), to the wise Father figure, for purposes of re-education.
Foucault's historical perspective enabled him to see one other change which he believed to be more critical than all the others. York Retreat, and asylums generally, added the "apotheosis of the medical personage" as a key authority to the other changes it had wrought. For the first time, the physician's influence was felt, mainly in two ways. In the first place, the medical certificate became mandatory for confinement purposes. Secondly, the asylum was converted into a medical space, the "mental hospital".
However, Foucault contended, the doctor's importance and authority, especially in the early years, were justified neither by specific medical skills nor by a particular body of objective, scientific knowledge. In fact, William Tuke remarked how much more important to the doctor's authority were moral standards than medical methods. The Tukes' contemporary, John Haslam, described the effective institutional physician in terms having nothing to do with medical practice. "The keeper of madmen who has obtained domination over them directs and rules their conduct as he pleases; he must be endowed with a firm character, and on occasion display an imposing strength. He must threaten little but carry out his threats, and if he is disobeyed, punishment must immediately ensue" (Haslam, 1798, in Foucault, 1965, 272).
The physician could only exercise such authority if he had fully assumed the persona of "Father". He would function well as physician if he exercised the tasks of surveillance and judgment in the name of order, re-education and the effort to help patients achieve their moral rehabilitation.
Foucault showed us how the structures of bourgeois society, specifically, Father-Child relations (the theme of paternal authority), Transgression-Punishment relations (the theme of justice), and Madness-Disorder relations, (the theme of social and moral order), invested the physician with his power to cure madness. And, it is to the extent that the patient finds himself, by such positivistic, structural connections, objectified, observed and judged, perhaps, as Foucault says, "alienated", within the doctor-patient couple, that he has assigned to the doctor the almost miraculous power to cure him.
"A violent and tenacious resistance"
One of the most significant of Freud's many contributions to psychotherapy was his deep understanding of the weighty influence of resistance on client progress toward mental health. He taught us that resistance was a substantial, perhaps principal, concern of the therapeutic process: "When we undertake to restore a patient to health, to relieve him of the symptoms of his illness, he meets us with a violent and tenacious resistance, which persists throughout the whole length of treatment" (1916/17).
Freud recognized client resistance as it occurred in two principal circumstances. He saw it in the client's failure to follow the "basic rule" of psychoanalysis, to express whatever came to mind, no matter how painful, silly or irrelevant the thought might have been. He also witnessed it in the client's unwillingness or inability to accept the therapist's insights. In essence, then, Freud viewed resistance as the client's disinclination to act in accordance with psychoanalytic reason's rules. He saw it as a "violent and tenacious" opposition to the system which aimed to bring that client to a state of mental health.
Resistance, as viewed by Freud and therapists in general, assumes numerous forms, as many, we suppose, as there are clients, and, perhaps therapists who encounter them. Most often thought of as involuntary behaviour, resistance is witnessed in disparate client acts. Savage outbursts, insolence, obfuscation or stony silence are all acts that keep the therapist from accomplishing his or her goals for the client. While different therapists emphasize certain forms before others, and while they may attribute resistance to various causes, most would agree that it must be worked through if ever the client is going to get well.
Attributing resistance to Peter is One World's ultimate presumption. In so doing, it credits what might be its own deficiencies to a willful defiance on his part. Not for a moment does John consider the possibility that Peter's continuing silence and immobility might have been exacerbated or reinforced by One World's diagnostic misunderstandings or methodological flops. The irony, of course, is that the One World assumption is, in the final analysis, correct. Peter wants things to stay that way. Even if he could, he would not terminate his resistant silence or his obdurate immobility. Remaining in his condition is alright with him.
Sayer does not emphasize Peter's resistance to treatment, but, then, how could he? A mute and immobile patient does not make a particularly plausible rebel. Peter cannot rant against his keepers as did Antonin Artaud. He cannot, like Kesey's McMurphy, inspire fellow patients with spirited escapades. He cannot break out of the institution like Chief Bromden for he lacks the ability to change his immobility and mutism. Notwithstanding the fact that he cannot rebel overtly, Peter will not have others messing with his mind. They can (and do) do whatever they wish to his body. But he will not be defined by that. Without any feeling in, or control over, his physical body, Peter has more narrowly situated himself in his mind. His mind is his home, the universe over which he has dominion. He rebels, silently and without movement, against any efforts to master him in this domain.
In an introspective moment, Peter imagines his mind to be well-ordered. But, he wants more than order. He also wants to be free of institutional controls, even well-intentioned ones, that aim to change him. He wants to have exclusive access to his mind and thoughts. He fancies himself to be like a security guard so that he can control and retain the key to his mind. Others, especially authorities, doctors and directors, cannot explore, negate or confuse the arrangements he has created in it.
How nice it would have been to have had some kind of order in my head, to have had my mind sectioned off into compartments, little boxes on the dusty floor of my brain, here my grievances, in this one my fears, here the past, here the dark future. I should have visited each at will, or perhaps I should have left them all tightly locked, keeping the key of course, admiring and fussing over their security, pondering how I might make them even more innocuous. I should never have thrown the key away, that would never have done since I should always have been in deepest fear of someone finding it and undoing my work" (57).
"Enslaved sovereign, observed spectator"
The Comforts of Madness is, at one level, about the institutions in which Peter is housed, about the mental health system and its models of reason. At another level, it is about what it's like to look out at, and to experience, the world from Peter's perspective, from the standpoint of madness. The novel reminds us that there is another perspective, ours, and, by so doing, restores our attention to processes that are fundamentally subjective.
The book's cover captures the essence of this perspective, which is the critical difference between an objective and a subjective focus. From inside an eye, we peer out at the ward of a mental hospital. We can, of course, focus more objectively on the ward, on its sterile, inhuman environment, and its activities. On the other hand, we can be affected by the fact, and the impact, of the viewer's perspective. Then, because that perspective is Peter's, we might ask the questions of subjectivity, about what it's like to experience the world from inside a stationary frame.
The difference between subjective and objective is not an either/or. It is, rather, a matter of both. There is no world-out-there without an in-here, subjective perspective. There is no subjectivity without the world-out-there. We move forever between the two. In relation to this, Michel Foucault (1970), once again, offers particularly valuable reflection. In a brilliant analysis of Velázquez's painting, Las Meninas (The Maids of Honour), he discusses the human being's place both in the painting and in the larger scheme of things. In so doing, he highlights the subjectivity/objectivity dialectic.
Two persons in the painting are particularly important to Foucault's analysis. On the one hand, he must account for the painter. On the other hand, he must consider whoever occupies the space where we, the observers of the scene, are located. We observe the enigmatic painter between brushstrokes. He stands back from his work, presumably to consider his subject who, we infer from his gaze and posture, sits in our position. His hand, holding an immobile brush, is "suspended in mid-air" (1971, 3), waiting for the inspiration of the gaze to guide it. "Between the fine point of the brush and the steely gaze, the scene is about to yield up its volume." (1971, p. 3). In this stationary position, the painter is neither here nor there, but is, instead, somewhere between. It is almost as if he "could not at the same time be seen on the picture where he is represented and also see that upon which he is representing something. He rules at that threshold of these two incompatible visibilities" (1971, 3). He stands at the juncture between being the observed object, on the one hand, and the representing, artist subject on the other.
The painter and several others are staring out at the persons who occupy the same position we inhabit outside the painting. The painting is structured so that it could be us (although a mirrored reflection at the back of the room suggest they, very likely, are a king and queen). For that reason, we, the viewers, constitute an integral part of any reflections. A surface analysis suggests a simple reciprocity. We look at the picture in which others look at us. We are not just observers of the picture. We are the observed. We are those whom others look at, and at the same time, the painter paints. We are in the place where the observed, as the model, and observer meet. "In this precise but neutral place, the observer and the observed take part in a ceaseless exchange." (1971, 4-5). "Man appears in his ambiguous position as an object of knowledge and as a subject that knows: enslaved sovereign, observed spectator, he appears in the place . . . from which his real presence has for so long been excluded" (1971, 312).
Man is not only nature's knower and its creator. He is also observed, the object of others' knowing. These must be continuous, in constant flux between one and the other, or man will put himself at risk. He cannot be, successfully anyway, only one of the two, knower or known. He must find a way to be both, to find some measure of balance.
Man cannot be entirely objective, only knower, and maintain his sanity. Or, conversely, he cannot be pure known, a mindless object, devoid of any subjectivity. If he fails to acknowledge his own subjectivity, cannot or refuses to see himself as known, that is, tries to be pure knower, he will, as One World and John did, find that he is out of balance or incomplete. If, on the other hand, he revokes his status as a knower and attempts to exist in a state of pure knownness, he becomes as a vegetable, alive but without the spirit, will or purpose that makes him human.
In an unexpected way, Peter doesn't suffer the problem of imbalance to the extent that One World does. He is, despite obvious skewing, both sides of the split. He is known insofar as he is kept in institutions, moved from one to another, and treated without his say-so by authority figures, including One World with its particular form of psychiatric reason. And of course, he is, by way of fate, kept enslaved in his own condition, observed, watched and treated by others. He is as close as one can get to pure object status. Yet, Peter is also a knower. He is, in a real sense, the sovereign, dominant keeper of his mind, that realm to which no one else has access. And, as the novel's narrator, he acts as knowing witness to all that happens to and around him.
Ironically, without even trying, without doing anything, Peter becomes, in a significant sense, the ultimate extension of knower. He becomes the spectator and judge, appropriating the role of authority, of observing critic that has, always before, belonged to John. Or, at least, John experiences it that way. He looks into Peter's eyes, presumably to see if he can understand Peter, or can discern motive and modus operandi. But, in the continuing encounter with nonresponse, John's gaze is reflected back. He sees himself, as in a mirror, and, therefore, feels known, possibly for the first time. It is, then, as if he and not Peter, was under scrutiny. Roles have reversed, and the consequence, as we have seen, is that reason, unprepared for the experience, itself goes mad. From the passively accepted position of spectator/judge, by way of his silent knowing, Peter brings mighty reason to its knees. When John recognizes that he no longer controls the processes of surveillance and judgment, that he no longer sits, wise and unquestioned, in the chair of objective, psychiatric reason, his authority is challenged so seriously that he breaks down.
"To listen with the mind of Madness"
Silence may be the most enigmatic and challenging of all the forms of resistance to be confronted by scientific reason's psychiatry. Silence forces therapists out of the customary, comfortable realm where objectivity may be professed and purportedly practised, where science and logic, diagnostic systems and prescriptions, function most effectively. It casts them into the elusive and uncertain world of subjectivity and inference. It pushes them into a need to dialogue with the world of madness. But, because silent madness does not answer, and because silence is a manifestation of madness with which psychiatric reason cannot communicate on its own terms, reason is foiled and frustrated. It can neither understand nor speak to the silence of madness.
This is, ultimately, why Peter is so great a challenge to One World and to John. The failure of all efforts of a seemingly reasonable therapy to remedy what is interpreted as Peter's resistance is the damnation of reason itself. One World depends on its being able to break through the resistance. When it cannot, when all its therapies fail, when Peter's silence and immobility remain, when, worse still, there is the insurrection from within the patient ranks, psychiatric reason, in John's hands, loses its grip. Peter's macabre silence and haunting immobility propel John to unusual extremes of inference and speculation. He is driven to the uncomfortably uncertain ground of subjectivity, and ultimately to his own insanity. Reason, thus, plunges into madness, John's plainly absurd charge that Peter is responsible for the letters of complaint.
One World fully expected to be able to use its philosophy and methods to good effect. John and Anna honestly believed that their powers of psychiatric reason would help to erase the resistance that stood between their perspective and Peter's condition. They trusted that, whatever kept Peter immobile and mute, they would be able to see a successful end to his condition. They were not prepared for a condition requiring that they limit or redefine their brand of reason.
The Comforts of Madness demonstrates what may transpire when the practitioners of psychiatric reason, in their positions of power and supposed objectivity, encounter resistance that does not conform to expectations and assumptions about the nature of mental illness. It was not enough for One World to speak to Peter with reason's confident rhetoric. It had to listen with the subjective mind of madness to the mute voice that, despite all institutional efforts, survived in its mad subjectivity within Peter.
Old wine in a new bottle
I was truly intrigued by Paul Sayer's "One World", and wondered if it had a non-fictional equivalent. I was surprised by my answer: One World seems to be an up-to-date York Retreat, a contemporary version of the Quaker institution. There are, in One World's operations, numerous, direct parallels to the moral treatment applied to their patients by the Tukes. I was surprised because, in the first place, there is no reason to believe that Paul Sayer intended the similarities. Secondly, I am accustomed to thinking of the two institutions as separated by a significant period of time and a multitude of advances in psychiatric science.
In other ways, I am not so surprised. I recall that Foucault warned me to be suspicious of apparent progress. So, when One World professed to cure where others had failed, I should have known something was suspect. Foucault also advised me to look for the rules of discourse behind practices, and demonstrated in Madness and Civilization that those rules hadn't so much changed as been renamed. Sayer's institution seems to be the old wine of psychiatry in a new bottle.
The similarities between Sayer's institution and York Retreat are so many that Foucault's schema feels fundamentally valid. One World is guided by the same attachment to reason that shaped the York Retreat response to its patients. Both institutions adopt a lop-sided dependence on objectivity, on knowing without self-reflection. Moreover, both employ, as the ground for their objectivity, the fundamental tactics of surveillance and judgment. They subject their patients to observation and evaluation against rigidly defined institutional standards for behaviour.
Similarities are also evident in the use of the institutional "family". York Retreat patients were made to participate in the social activities of the community. So, too, is Peter expected to relate to staff and other patients at One World. Several people, including John and Anna, talk to him as though he is capable of verbalized response. One patient, the Major, even shares with Peter thoughts that he would not dare divulge to others. When John sees Peter as responsible for the letter that might spell demise for One World, he asks, how dare Peter, as a well-treated member of the One World community, complain about institutional methods? In so doing, John takes on the role of "Father" to Peter-as-child. He is the modern-day Tuke insofar as he plays a sane and wise man, a moral authority, in order to accomplish his adopted ends.
At both institutions, One World and York Retreat, patients were expected to feel the great need to be responsible and, then, to feel guilty if and when they failed to measure up. The similarities are further evidenced in a combination of orientations: first, the institutional insistence on having the patient assume responsible self-control, and second, the bid to make that happen through kindness and encouragement rather than through fear of staff or physical restraints.
John and One World emphasized, at least until their frustrations set in, a treatment that was little more than applied common sense and humanity. That's precisely what York Retreat purported to do. But, just as Quaker philosophy led, over time, to the complexities of our current approaches to mental illness, so did One World choose to employ more and more complex enterprise to get Peter to move and to speak. One World started with the relatively simple method of holding and moving him in a kind of dance. When that didn't make a difference, they placed him in a contraption that moved his body as if he were walking. When he didn't talk, they turned from casual conversation to drugs and elaborate methods to stimulate his memory and speech.
"Can't anything be done for the poor creature?"
One question remains for me. In a sense, it is the novel's ultimate question. After her visit with him, Peter's sister, Alison, asks his nurse, "Can't anything be done for the poor creature?" While the nurse's answer is, "I'm afraid not", my own answer is neither as categorical nor as negative. I balk at accepting defeat, at resignation, and certainly, at euthanasia. I continue to consider how I would work with Peter having read The Comforts of Madness from the perspective of Michel Foucault's historical analysis.
On the one hand, I continue to believe that Peter is acutely ill and in need of care. I hope that Foucault would not have me deny that. But, even if he did, I can find no justification for allowing Peter to remain in his condition. I think of the condition as inhuman, and invoke my equivalent of the Hippocratic Oath. I cannot abandon him, but must do what I can to bring him to a state of existential humanness. Besides keeping him alive, that means striving to increase his measure of choice and meaning at the same time that I try to decrease his alienation and distance from life and others. I find myself, wanting to be compassionately responsive to him. Like the doctor who visits him in his last days, I might say, "The poor man. We must do our best by him. Occasions like this . . . require the very best we can offer by way of our imagination, our compassion." (134) That doctor's "very best" was to arrange for Peter's death. I, however, would continue to bring all of my skills to bear in the effort to help him emerge from his condition. I also imagine that, I might proceed, short of using coercive procedures, leg fetters or responsibility, in much the same fashion as York Retreat or One World, treating Peter with respect, encouraging him to want what life has to offer.
On the other hand, in light of my Foucauldian analysis, I would certainly fear to make the same mistakes that have been bred by reason's discursive rules and questionable assumptions. That means that I would avoid imposing the demand for responsibility. I would shy away from the temptation to approach Peter with wisdom wrapped in my professional authority. I would, as much as possible, attempt to break the habit of observation and judgment from positions of supposed objectivity. I know that I cannot force Peter to change. I also know that I won't return to the conditions that existed before the Tukes and Pinel commenced the reign of reason in relation to madness. They were right to reform the "barbarous" institutional conditions. That's not where I will part company with their treatment methods.
I am, I realize, unsure about how to proceed from this new perspective. Unable to look to the two hundred years of history and experience that have followed from reason's efforts, lacking the security that comes from standing on the shoulders of two centuries of medical giants, their unsuccessful approaches and acclaimed successes, I am tackling new frontiers.
How will I deal with Peter? In light of my Foucauldian analysis, I imagine that I will dialogue with him, if necessary in silence. I will resist the great temptation to fill that silence with my words. I will be patient, in a different way than Peter is, of course, but I will be patient nonetheless. I will be with him, one human being with another, without any assumptions or confining diagnoses about his condition. I will approach him without any battery of objectifying tests, and without my usual impulse to move to prescriptions and insights. I will respect his right to be different, meaning that I will never judge him to be less human than I am. Perhaps Peter and I will find ourselves on what Buber calls the "narrow ridge", the place where healing comes from meeting. In all likelihood, I will be out there on that ridge alone much, maybe all, of the time. Approaching him without the trappings of authority, as neither "Father" nor physician nor psychologist to him, I will, instead, be myself, whatever that may mean, in my encounters with Peter. He will not be "patient" or "client" to me, but instead, will be whoever he is.
The essence of my Foucauldian response to Peter is in my need and willingness to find a balance between subjectivity and objectivity, in my need and willingness to be both knower and known. I will allow myself to be observed as much as I am observer, known as much as I am knower, subjective as much as I am objective. I cannot and will not emphasize one pole of the dialectic, especially the pole of the knowing objectivity that has been associated for two hundred years with psychiatric reason's reign, for that is the pole that proved to be One World's undoing and, in its encounter with reason's absolute limit, madness.
Michel Foucault's challenging ideas with respect to madness take on such impressive clarity when mirrored in Paul Sayer's novel, The Comforts of Madness, that, I believe, he could not have asked for a more fitting literary expression of his ideas. The Comforts of Madness is a particularly penetrating commentary on the relationship of madness to psychiatry, painting as potent a picture as any of the previously mentioned novels which have explored the association. Peter's condition and One World's response to it are so thoroughly plausible that we can extrapolate effortlessly from Sayer's fictional world to the real world of psychiatry and madness.
In One World's treatment of Peter, we found direct parallels with York Retreat's practices as those were described by Foucault. We saw a corresponding use of observation, judgment and authority, the same requirement to work, an equivalent emphasis on objectivity, all despite the passage of time and many methodological changes. Foucault's Madness and Civilization primed our suspicions of apparent progress and also taught us to see that the rules of discourse governing the treatment of madness hadn't so much changed as been renamed.
I considered another outcome to be a principal purpose for the essay. Hoping that the dimensions of, and impediments to, the relationship between psychiatry and madness would assume new clarity in light of my examination of them, I foresaw that readers might come to appreciate subjective dimensions of human nature which have been greatly undervalued by the commonplace psychiatric responses to madness. Throughout the essay, we have seen that the psychiatric response to madness is dominated by a focus on objectivity. What that focus has done, as demonstrated by the problems in One World's response to Peter, is make us miss or ignore the essential subjectivity that must be fostered if there is to be a dialogue with madness.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV). Washington, DC: American Psychiatric Association, 1994.
Barker, Pat. Regeneration. Harmondsworth, UK: Penguin Books, 1990.
Bauby, Jean-Dominique. The diving-bell and the butterfly. (trans. by Jeremy Leggatt). New York: Knopf. 1997.
Buber, Martin. Ecstatic Confessions: The heart of mysticism (ed. by Paul Mendes-Flohr; trans. by Esther Cameron). Syracuse, N.Y.: Syracuse University Press, 1996.
Bugental, James F. T. The art of the psychotherapist. New York: W. W. Norton, 1987.
Caplan, Ruth B. (in collaboration with Gerald Caplan). Psychiatry and the community in nineteenth-century America: The recurring concern with the environment in the prevention and treatment of mental illness. New York: Basic Books, 1969.
Ellenberger, Henri F. The discovery of the unconscious. New York: Basic Books, 1970.
Feder, Lillian. Madness in literature. Princeton, New Jersey: Princeton University Press, 1980.
Foucault, Michel. Madness and civilization: A history of insanity in the Age of Reason. (trans. by Richard Howard). New York: Vintage Books, 1965.
Foucault, Michel. The order of things. New York: Vintage, 1970.
Foucault, Michel. Questions of method: An interview with Michel Foucault. Ideology and Consciousness, 1981, 8 (Spring).
Friedman, Maurice. To deny our nothingness. New York: Delta, 1967.
Freud, Sigmund. Introductory lectures on psychoanalysis, Part III. General theory of the neuroses. Lecture XIX: Resistance and repression. In The complete psychological works of Sigmund Freud, Vol. 15. New York: Norton, 1916/1917.
Grob, Gerald N. The mad among us. New York: Free Press, 1994.
Harrison, Carey. Freud: A novel. Harmondsworth, UK: Penguin Books, 1984.
Holland, Norman N. Holland's guide to psychoanalytic psychology and literature-and- psychology. New York: Oxford University Press, 1990.
Kesey, Ken. One flew over the cuckoo's nest. New York: Viking Press, 1962.
Laing, R. D. The divided self. Harmondsworth, UK: Penguin Books, 1965.
Lessing, Doris . Briefing for a descent into Hell. New York: Vintage Books, 1971.
Malzberg, Barry N. The re-making of Sigmund Freud. New York: Ballantine, 1985.
McGrath, Patrick. Asylum. New York: Random House, 1998.
Michalos, Peter. Psyche: A novel of the young Freud. New York: Doubleday,1993.
Oatley, Keith. The case of Emily V. London: Secker and Warburg, 1993.
Piercy, Marge. Woman on the edge of time. New York: Fawcett Crest, 1976.
Porter, Roy. Mind-forg'd manacles. London: Athlone, 1987.
Porter, Roy (ed). The Faber book of madness. London: Faber and Faber, 1991.
Reik, Theodore. Jewish wit. New York: Gamut Press, 1962.
Sacks, Oliver. Awakenings. New York: HarperCollins, 1990
Sayer, Paul. The comforts of madness. Great Britain: Sceptre, 1988.
Shaffer, Peter. Equus. New York: Avon, 1974.
Scull, Andrew. The most solitary of afflictions. New Haven: Yale University Press, 1993.
Stone, Irving. The passions of the mind. New York: Doubleday, 1971.
Thomas, D. M. The white hotel. New York: Viking Press, 1981.
Wiesel, Elie. Twilight (trans. from the French by Marion Wiesel). New York: Schocken, 1988.
Wright, Harry H., Holmes, George R., Cuccaro, Michael L. and Leonhardt, Tami V. A guided bibliography of the Selective Mutism (Elective Mutism) literature. Psychological Reports, 1994, 74, 995-1007.
Wolf-Man. The Wolf-Man: The double story of Freud's most famous case. New York: Basic Books, 1971.
Yalom, Irvin D. When Nietzsche wept. New York: HarperPerennial, 1992.
Yalom, Irvin D. Lying on the couch. New York: BasicBooks, 1996.
Received: October 10, 1997, Published: June 11, 1998. Copyright © 1998 Bruce Sarbit