Foucault and Current Psychiatric Practice

The essay by John Iliopoulos is of great interest when one seeks to apply the thinking of Michel Foucault to contemporary, real-life psychiatric practice. It highlights, among other things, the diversity of roles filled by health care professionals in contemporary society. In particular, the issue arises when psychiatrists are asked to perform forensic or legal functions and not merely those associated with clinical expertise. The most problematic issue in this area is dangerousness and its assessment, a difficult and unsatisfactory exercise lacking in rigor or any developed science (Coid 1996). The problem could be seen in terms of a lack of adequate methodology or tools but, as Iliopoulos argues in pursuing a theme mooted by Foucault, it is much deeper and makes us examine the construction of contemporary psychiatry as a quasi-judiciary discipline.

The concept of dangerousness exhibits in a particularly illuminating way Foucault’s post-structuralist, deconstructive approach to the critique of medicine as a sociopolitical institution. Post-structuralism is derivative from and reactive to structuralism. I have discussed structuralism and post-structuralism in an appendix to The Mind and Its Discontents (2nd ed. Gillett, 2009). A central insight of structuralism is that truth and knowledge both reflect layers of meaning whereby the identification and construction of any phenomenon is articulated such that its connections and embeddedness in a particular discourse are laid bare. Thus, for instance, impulsivity could be understood as a function of neurotransmitter levels in certain neuronal assemblies, or in terms of the balance of excitation in certain functional cerebral systems, or in terms of the natural reactions of a human being to certain types of interpersonal and social interactions that tend to occur in certain cultural contexts. In any of these discourses, various aspects of the problem can be made visible and others recede from view. Discourse-specific rules govern the production of statements and render their subject matter accessible in terms of the connections, contrasts, and explanations that can be discerned so that the phenomenon can be thought about and interrogated.

A key passage from Foucault (in an essay reproduced as “Truth and Power”) offers a structuralist critique of the idea of an event or phenomenon at heart singular and yet able to be interpreted in various ways.

The problem is at once to distinguish among events, to differentiate the networks and levels to which they belong, and to reconstitute the lines along which they are connected and engender one another. From this follows a refusal of analyses couched in terms of the symbolic field or the domain of signifying structures and a recourse to analyses in terms of the genealogy of relations of force, strategic developments, and tactics.

(Foucault 1984, 56)

The idea of dangerousness and risk to society is in fact a hybrid of forensic and scientific discourse. Forensic discourse is itself odd or inherently demonstrates a multiplicity of levels, in that the categories embrace moral attributions, social contexts, quasi-legal and criminal regimes and their demands, clinical classifications and indicators, and psychological factors likely to be significantly related to activities considered disruptive in a given sociopolitical setting. Because there is no science that embraces this complex reality, we are forced to examine a further post-structuralist idea, that of the quilting point (or point de capiton).

If we consider any discourse and its symbolic order to be like a layer of phenomena identified by a set of interconnected meanings, then different layers of the human life-world are connected at various nodes or quilting points. At such a node, multiple discourses or ways of thinking of things intersect or are locked together, vertically as it were, because they concern an entity (such as the human being, or a disease event like a gastric ulcer). Necessarily there is no specialist discourse that completely or exhaustively delineates the quilting point because the node participates in multiple cross-grained networks of signification (a human being = a neural network, a psychological being well or ill adapted to a human context, a participant in a set of relationships, a moral agent responsible for certain events; a gastric...