Tuke's Healing Discipline: Commentary on Erica Lilleleht's "Progress and Power: Exploring the Disciplinary Connections Between Moral Treatment and Psychiatric Rehabilitation"

T HE TARGET OF ERICA LILLELEHT'S interesting comparison between 19th-century moral treatment and 20th-century psychiatric rehabilitation is contemporary psychiatric rehabilitation. Using Foucault's (1979) Discipline and Punish as her critical foil, she argues that psychiatric rehabilitation is "an approach to madness fraught with paradox." The paradox lies in the fact that the techniques of psychiatric rehabilitation can be practiced in a manner that contradicts its professed humanitarian intentions; notably, liberating the mad from "resource dependency and segregated living." The lesson to be drawn from this paradox is that "our practices, may be shaped and reformulated to serve goals of which we are only dimly aware." The resulting "mindfulness" is supposed to make us more careful and critical of what to count as success and progress in psychiatric treatment.

Although I am sympathetic to Lilleleht's critique of psychiatric rehabilitation, I find it lacking in constructive alternatives. For now that we are more mindful, what are we to do? What alternatives are there? To be fair, proposing and exploring alternative solutions to the problems she identifies is not one of Lilleleht's stated goals. But in this case the failure to consider alternatives borders on a lack of depth. Luckily, there is a good alternative close at hand: moral treatment. Now Lilleleht does of course discus moral treatment at some length. But she fails to exploit its deeper ramifications for her topic. This probably is due to her exclusive reliance on Foucault's cynical and negative view of discipline, which she adopts without argument. Reject that view, and you have a very different picture of moral treatment and its possibilities than the one Lilleleht presents. My goal in this commentary will be to try to take Lilleleht's valuable discussion a step further by considering aspects of moral treatment she does not consider.

Lilleleht is sympathetic to moral treatment and she notes that it has several virtues compared to psychiatric rehabilitation. The focus on the whole individual as a narrative unity is one virtue. The fact that in moral treatment "control" is at least explicit and open for all to see is another. Finally, there is also the point that moral treatment and its "technologies of control" were once deployed with good intentions. However, in the end these positive features of moral treatment are eclipsed by the dark shadow of Foucault. For according to Foucault, moral treatment is really just another oppressive technology of control. This certainly is his judgment in Madness and Civilization (Foucault 1965/1988). It is also the only interpretive option available to Lilleleht given her adherence to the critical framework of Discipline and Punish (Foucault 1969). This damning verdict on moral treatment hinges on the premise that discipline and control are necessarily bad; that they are always tantamount to psychic oppression and imprisonment. But that premise is highly questionable. To fully appreciate the value of Lilleleht's comparison, we need to reject this dogmatic premise. We also need to go further into the history of moral treatment than she does.

In offering moral treatment as a possible alternative to psychiatric rehabilitation, one must be careful. After all, in the end the asylums built in the name of moral treatment turned out to be gigantic, prison-like warehouses where just about every single principle of the founding fathers was violated (Scull 1993). In this case, Foucault's cynicism about the legacy of moral treatment is well-taken. Evidently, this dark age of moral treatment is not the place to look for our constructive alternative. Kirkbride's variety of moral treatment is a slightly better option. As Lilleleht notes, this vision of moral treatment does not easily lend itself to Foucault's criticism of institutionalized, self-perpetuating, disciplinary technologies of oppression. Nevertheless, it remains true that as it was practiced in 19th-century psychiatry, moral treatment of the Kirkbride variety is still too closely...