- Psychiatric Power and Its Reversals: Can We Keep Practice Humane?
Power, social hygiene, guidelines, rationality
Iliopoulos’ paper is a timely intervention in the current crisis of psychiatry, a crisis that has not yet emerged in fully recognized form (cf Bracken 2008). There are few psychiatrically informed responses to Foucault (see, for example, Bracken  and Roberts ), so it is important for the conversation with Foucault’s ideas to develop. Foucault showed those psychiatrists that would listen that power is ubiquitous and inescapable. Although some psychiatrists relish this power, many feel power is thrust upon them, and that they should use it humanely. Following Laing’s critique of psychiatry, many people came to psychiatry with the aim of understanding the “mentally ill” with humanity, caring for them as suffering individuals, not simply incarcerating them as part of a universal trope of social hygiene. But power, the Hobbesian Leviathan, leaves you nowhere to hide.
Iliopoulos looks at the current situation of psychiatric power, developing Foucault’s thesis that power is distributional, or relational, not a substance residing in a place, person or structure. Iliopoulos’ thesis is two-fold: first, psychiatric power has shifted from a position when the psychiatrist had authority, respect, and decided treatment including whether to compulsorily confine patients, to a position determined by a different sort of social hygiene. This is based on care in the community, with the connotation of greater freedom, and liberation from the asylums, yet hand in hand with control of risk and danger plus the whole panoply of current interventions, guidelines, and surveillance, not just of the patient, but of the psychiatrist and other mental health professionals. The media plays a part in this, especially when there are highly publicized murders by psychiatric patients such as Christopher Clunis.
Implicit in this is the second part of Iliopoulos’ thesis, which is that psychiatric power is being undermined even while on the surface it is written into ever more detailed and all-encompassing policies, into practices that are prescribed in advance using the “evidence base,” and while the law is broadened to rein in danger wherever detected. Iliopoulos, as I understand him, is saying that the ever closer prescription of psychiatric practice, together with the legal and forensic aspects of this, encircles and undermines what used to constitute psychiatric power. Because the system becomes [End Page 63] more sophisticated, with greater expectations of service delivery (delivery is to be emphasized here) psychiatry is more vulnerable to its failures, and must audit every aspect of practice—self-surveillance—to police its own practitioners. Emphasizing the notion of delivery underlines the language of “packages of care” and the technological modus implicit, sometimes explicit, in the medical model: illness diagnosis operation/intervention.
Iliopoulos discusses Foucault’s ideas on how forms of rationality become embedded in institutions and structure the institution’s reality. Foucault says that forms of rationality constitute the logic of each society. Societies form institutions based on this rationality, which is explicit. We could think of child protection, and the explicit policies and procedures taken up by social services, police child protection teams, and the new legislation that goes with this, such as criminal record bureau checks for any adult working with children. While we might do an “archaeology” (Foucault 1966/1989) to look at historical changes in these forms of rationality, we do not have to dig to find what is current. The forms of rationality we are subject to are at the surface in documents all can obtain. For example in UK psychiatry we have the NICE guidelines, and now the revised 2007 Mental Health Act, as well as the Mental Capacity Act with its provisions for Deprivation of Liberty. The Human Rights Act explicitly excludes the ‘mentally ill’ from the right to freedom, giving them instead the right to treatment.
As Iliopoulos (2012, 50) argues “nowadays, rationality is concerned with the management of the population,” although of course this is not new, one current area being “the elimination and prevention of risks.” Using statistics and controlling epidemics are central, which we saw recently with swine “flu,” although the population is controlled more easily than the virus. Iliopoulos states, in...