Madness and Democracy: The Modern Psychiatric Universe (review)

Marcel Gauchet and Gladys Swain. Madness and Democracy: The Modern Psychiatric Universe. Translated by Catherine Porter. Originally published as La pratique de l'esprit humain (Editions Gallimard, 1980). New French Thought. Princeton: Princeton University Press 1999. xxvi + 323 pp. $29.95.

The origins of this book are unique: in 1980, Gladys Swain, a brilliant young psychiatrist, planned to publish the archival documentation surrounding the birth of the asylum in France. While writing the introduction, she argued passionately with her colleague, the philosopher Marcel Gauchet, about the issues underlying madness and democracy. And thus the introduction grew into this book--of 515 pages in the original.

In her medical thesis of 1970, Le sujet de la folie, Swain had single-handedly reformed our understanding of Philippe Pinel, the founder of her specialty in France. She provided a probing analysis of Pinel's Traité médico-philosophique sur l'aliénation mentale, while also proving that the myth of the "chainbreaker" was a sham. In the present book she argues that the insane asylum originated in 1802-11 at Salpêtrière hospice in Paris, where three men collaborated: Pinel, physician-in-chief; Jean Baptiste Pussin, administrator of the Salpêtrière's mental ward holding about three hundred patients; and J. E. D. Esquirol, owner of a small maison de santé across the street. Swain struggles with Pinel's dilemma: his famous "moral treatment" of the mental patient relied on a doctor-patient relationship of trust and empathy; how to transfer this therapeutic method to three hundred persons?

This book analyzes how the original alienists regulated the inmates' daily existence, their hours of sleep, meals, and work, thus hoping to change their behavior and eventually their minds. Pinel believed in work as a therapeutic means of reintroducing the recovering patient to social life. Behind that conception of the asylum, argue Gauchet and Swain, based on collective, well-intentioned coercion, lurked the method of the concentration camp and the gulag. They are heartened by the failure of the asylum.

In contrast to collective therapy, the authors believe, Pinel's method of individual psychologic ("moral") therapy had long-lasting consequences. Their argument is based on a close analysis of two original diagnoses that Pinel proposed in 1794: of "periodic insanity," and of "insanity without lesion of the understanding." In both cases he inferred that some portion of the insane patient's mind remained rational and that the therapist might communicate with that remnant of reason. Pinel took the irrational part of the human mind seriously, and thus stands at the head of a long line of psychiatrists who have studied mental illness. Gauchet outlines what would have been Swain's major argument in "De Pinel à Freud," the introduction to a new edition of Swain's thesis.¹

Gauchet and Swain view the asylum from the perspective of political philosophy, and as dedicated disciples of Tocqueville. The French Revolution heralded a new era of liberty and equality, so that never again, in our democratic societies, can man be permanently enslaved and exploited. There is a remnant of humanity in every human being, however deprived, handicapped, retarded, or alienated, and it is society's obligation to nurture it. And the original asylum, at the beginning of the nineteenth century, represents the first attempt, argue the authors, to redeem a large group of damaged human beings. Here they explicitly take issue with Michel Foucault, even though they acknowledge their indebtedness to his challenging analysis of the birth of the clinic. The intention of nascent psychiatry, they argue, was not to subjugate and intimidate the inmates of the asylum, but to help their recovery.

This is a very French argument, and not just because it sees the Revolution as the core event of modern history and Tocqueville as its most profound interpreter. This generation of French historians and philosophers searches so earnestly for the moral basis of democracy...