- The Contingent Object of Psychiatry
mental illness, dangerousness, law, genealogy
Wilson and Adhead’s plea that the British Government’s proposed new mental health legislation might entail a misappropriation of psychiatry’s true mission will strike a chord in numerous jurisdictions. Many European countries during the last northern summer will adopt mental health legislation that moves in the opposite direction to the United Nations Convention on Human Rights for persons with disabilities, and will allow for compulsory mental health treatment. In this author’s home state of Victoria, Australia, the Mental Health Act has five criteria that must be met for someone to be made an involuntary patient in an institution or hospital, in the community, or in one’s own home (Victoria 2003, s.6). One of the criteria is that the person is judged to be at risk of danger to themselves or others. Once made an involuntary patient, one looses the right to refuse medical treatment. At present, in various parts of the world, medical practitioners are being required to assess a person’s level of dangerousness with immediate consequences for that person’s liberty.
From the point of view of a historian of the human sciences, these events propel psychiatry into a dialogue with its recent past. The project of Western psychiatry is usually characterized as a breaking down of the walls of the old asylum that contained the lunatic in its dark recesses, and the subsequent unveiling of the mental patient thanks to the rational, liberatory practices of medicine. But modern psychiatry has also been shaped by the coming into being of particular conceptions of mental illness that are not all its own making. This entailed the removal over time of the mental defective and the mental deficient, the moral imbecile, the epileptic, the alcoholic, the chronically insane, and so on, from spaces in which psychiatry would seek to define it object—populations that psychiatry would determine to be “not amenable to treatment.” If we were to see this shaping in a Foucauldian sense, we would also want to include earlier eighteenth- and nineteenth-century separations of the lunatic and the criminal (Foucault 1965, 1979). Moreover, we might want to insist that the marking out of the modern mental health patient is first and foremost an administrative act—an act of separation and management within a bounded population—which then serves as a condition of possibility for the emergence of knowledges in psychiatric medicine, with the latter following rather than preceding the arrangement of bodies in the asylum/hospital.
The psychiatrist in public medicine may well be encouraged to shape a new mission according to the requirements of an administration concerned with managing dangerousness. A shift in the social vocation of the psychiatric expert has been observed over several decades, and may represent a profound departure from the traditions [End Page 69] of mental medicine (Castel 1991). Those “dirty words”—risk assessment—involve new strategies where face-to-face relations between carer and cared are displaced by an activity of calculating abstract factors deemed liable to produce risk—“a transition from the clinic of the subject to an ‘epidemiological’ clinic” (Castel 1991, 282). The broad contours of this shift sees the specialist medical carer take a back seat while the manager/ administrator assumes a more autonomous role of allocating individuals into various categories of risk. It is in this sense that the psychiatrist does not make a diagnosis as such, but rather contributes to a list of factors compiled to measure a level of riskiness. Risk assessment forms part of social surveillance that dispenses with the actual presence of the carer and the cared, and provides for a form of systematic predetection rather than treatment. As Castel (1991, 288) presents it,
(t)here is, in fact, no longer a relation of immediacy with a subject because there is no longer a subject. What the new preventative policies primarily address is no longer individuals but factors, statistical correlations of heterogeneous elements. They deconstruct the concrete subject of intervention, and reconstruct a combination of factors liable to produce risk. Their primary aim is not to confront a concrete dangerous situation, but to anticipate...