Madness and Civilization: A History of Insanity in the Age of Reason

In the 19th century, confinement was reassessed as a form of cruelty that inhumanely repressed the “mad.” This understanding was the inverse of the 18th century’s conviction that confinement was cruel to the non-”mad” because it placed them in proximity to the “mad.” Foucault argues that this evolution of attitudes towards “madness” occurred slowly within the spaces of confinement themselves; those who witnessed the “mad” in prison settings realized that there was some sort of medical difference at play, and demanded separation between the “mad” prisoners and the non-”mad” prisoners. Gradually, “madness” became conflated with confinement, such that the general public saw the “mad” as the only ones deserving of confinement.

At the same time, economic changes allowed for what Foucault calls the “rehabilitation of the pauper” within society (239). As the industrial revolution demanded a larger workforce, the poor became valued contributors to the economy, resulting in their gradual release from workhouses and prisons. In previous eras, the mercantile economy had relegated the urban poor to economic uselessness. Confining the poor was now seen as an “economic error,” because it was detrimental to the workforce, not because it was inhumane. The liberation of the poor, however, presented a problem for administrators: how to manage the “mad,” who would now be left alone in confinement. As Western Europe modernized, it was unclear what place, if any, would be found for “madness.”

Histories of psychiatry prior to Foucault often presented Pinel and Tuke’s Reform—a movement to create ethical practices in psychiatric treatment—as a positive development. Foucault interprets the reform movement differently. William Tuke’s organization of the Retreat—a 1796 treatment center in England considered the first asylum—he argues, was based on the idea of religious segregation. It was founded by and for Quakers though it was later opened to patients of all backgrounds. Based on Quaker ethics, the “moral treatment” stressed kindness, temperance, order, and communal trust. Tuke believed “mad” people had the capacity for self-control and encouraged them to heal through exercising moral judgment and self-restraint.

Tuke organized the Retreat as a familial structure, placing himself and the other asylum workers as paternal authority figures over their patients. However, to Foucault, the moral treatment model had drawbacks. The “madmen” housed at the Retreat could be made to feel responsible for their own their inability to cure or control themselves, which Tuke claimed they should be able to do. With the facility’s religious patriarchal structure, the patients might be encouraged to see Tuke as a God-like figure and fear punishment for their failings. This dynamic, Foucault argues, inverted the historical dynamic in which the non-”mad” were afraid of the “mad;” now people with “madness” would live in fear of the condition they could neither control nor understand.

Similarly, Pinel implemented an asylum based on a secular approach to “moral treatment.” Although this approach differs from Tuke’s, both systems removed physical restraints like shackles and chains and provided opportunities for creative pursuits and social interactions. Like Tuke, Pinel emphasized improved diets and hygiene, physical exercise and calming leisure activities, like crafts and nature walks. Despite the beneficial aspects of this approach, Foucault critiques the framework that emphasizes patients’ self-awareness of their own supposed faults. Since even the secular version of “moral treatment” was based on a Christian value system, it contained the same biases that led earlier generations to ostracize people with Hansen’s disease in lazar houses. In Pinel’s scheme, doctors also attained a new level of social power; their job at the asylum took on the same responsibilities of judging and policing that had previously been held by the courts and prison guards. In Foucault’s estimation, asylums were simply a new form of repression, disguised as progressive medical care.

Under the supervision of doctors, the medieval concept of “madness” was gradually pathologized into what we now understand as a range of psychiatric illnesses. This medical approach, however, is intrinsically tied to the structures of authority from bygone eras. Late 19th-century psychiatry, for example, depended on a quasi-magical authority that the psychiatrist held over their patients. This mystical relationship would later be exploited by Sigmund Freud when he invented psychoanalysis in the 1890s, even as he demystified other treatment structures.

Foucault concludes thoughts on madness as a kind of “nothingness” that “can only manifest itself by departing from itself” (106) by comparing two 18th-century European artists who, to him, captured this idea in their work. Spanish artist Francisco Goya explored the concept in his painting “The Madhouse,” and the French writer Donatien Alphonse François, the Marquis de Sade, did so in his novels Julliette and Justine. For Foucault, these works have little in common except “a certain movement that retraces the course of contemporary lyricism […], rediscovering the secret of unreason’s nothingness” (282).

 Both Goya and Sade express madness as a source of violence, which gives it power: “The nonbeing it once was now becomes the power to annihilate” (285). These works, Foucault argues, imbue “madness” with the destructive agency that it has in the work of modern artists. In the late 20th century, works that capture this destructive essence of “madness” reflect the world in which they were created, and call that world to account for its actions. This reverses the longstanding power dynamic by which the world—its social, religious, and political institutions—once judged and confined “madness.” Now, works that reflect society’s treatment of people deemed “mad” or the annihilating “madness” that leads to large-scale violence judge the society in which they were made.