A Crítica de Foucault à Medicina Psquiátrica

HUBERT L. DREYFUS

FOUCAULT'S CRITIQUE OF PSYCHIATRICMEDICINE*

ABSTRACT. From his earliest published work, Mental Illness and Personality(1954), to his last project, The History of Sexuality, Foucault was critical of thehuman sciences as a dubious and dangerous attempt to model a science ofhuman beings on the natural sciences. He therefore preferred existentialtherapy, which did not attempt to give a causal account of human nature, butrather described the general structure of the human way of being and itspossible distortions. Foucault focused his attack on psychiatry, which claimedto have an explanation of normal and abnormal functioning of the personalitymodeled on medicine. Freud typified for him this deep mistake which hetraced first to the Kantian understanding of human beings as transcendental/empirical doubles which must think their own unthought, and then later tothe gradually developing confessional practices which lead people in ourculture to try unsuccessfully to put all their desires into words so as toconform to the norms of psychoanalysis which in turn are based on anaccount of sexuality as a cause of personality. Foucault proposed his genealog-ical account of how our culture arrived at this view of man as sexual being asa form of therapy which was to help us free ourselves from this restrictiveself- interpretation.

Key Words: normal, mental illness, sexuality, psychoanalysis

I. GENUINE SCIENCES OF NATURE VS.PSEUDO-SCIENCES OF MAN

By the time Foucault began his History of Sexuality, he wasconvinced that the psychoanalytic account of human beings assubjects motivated by sexual desires that are constantly repressedand must be continually recovered, is both "dubious" and dan-

Hubert L Dreyfus^ Ph.D., Professor, Department of Philosophy, University of California, Berkeley,California 94720, U.S.A.

The Journal of Medicine and Philosophy 12 (1987) 311-333 . 1987 by D. Reidel Publishing Company.

at Universidade de S?o Paulo on July 28, 2010 http://jmp.oxfordjournals.org

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312 Hubert L Dreyfusgerous. Reading Foucault's history of how Western man arrived atthe practices that define him as a sexual being, the philosopheris bound to ask: What justifies Foucault's claim? There is adifference between explaining how a practice comes about andasserting or denying the validity of that practice. Does Foucaulthave an argument for his rejection of psychoanalytic theory and, ifhe does, does this argument lead to the rejection of all versions ofpsychotherapy? If not, what account of psychopathology and ofpsychotherapy would be immune to Foucault's critique? Is there akind of psychotherapy Foucault would positively recommend?Does he himself practice a kind of therapy?

The answer to the first of these questions is nearest the surfacein a work Foucault published two years after he received hisdegree in Psychopathology from the University of Paris. In thisearly work, entitled Mental Illness and Personality (1976a),1 Fou-cault distinguished anatomy and physiology, which offer medicine"an analysis that authorizes valid abstractions against the back-ground of organic totality" (p. 10), from psychiatry, where scientificanalysis has no place. Foucault argued that an abstract, theoretical,causal account of normal and abnormal function is possible inorganic medicine, but that a parallel scientific approach is impos-sible for psychiatry because the personality must be grasped not asa totality of functional components but as a unified interpretationor style of behavior.

The coherence of a psychological life seems . . . to be assured in some wayother than the cohesion of an organism; the integration of its segments tendstoward a unity that makes each possible, but that is compressed and gatheredtogether in each: this is what psychologists call, in the vocabulary that theyhave borrowed from phenomenology, the significant unity of behavior, whichcontains in each element dream, crime, gratuitous gesture, free association the general appearance, the style, the whole historical anteriority and possibleimplications, of an existence (Foucault, 1976a, pp. 1014).

These claims need explaining and defending. Explaining, be-cause Foucault is assuming an existential phenomenological con-ception of the personality and of psychiatry. Defending, becauselater Foucault holds that all disciplines, even natural science andmedicine, can make statements that are taken to be true or falseonly against a historically conditioned background of sharedpractices. Given his concern with "truth-effects" rather than truthclaims, it might seem that his early appeal to "valid abstraction


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Foucault's Critique of Psychiatric Medicine 313

and the determination of . . . real causality" (Foucault, 1976a; p.10) would have to be rejected by Foucault himself. Foucaultwould then no longer be able to distinguish psychoanalyticaltheory as a pseudo-science from valid theories in the naturalsciences, since no science could make valid causal claims.

Yet, even in The Order of Things, Foucault distinguishes thetruth from what is accepted as in the true/false business at aspecific time:

Mendel spoke the truth, but he was not dans le vrai (within the true) ofcontemporary biological discourse: it simply was not along such lines thatobjects and biological concepts were formed . . . . It is always possible to speakthe truth in a void; one would only be in the true, however, if one obeyed therules of some discursive "policy". . . (Foucault, 1976b, p. 224).

Since Foucault was interested only in the "dubious disciplines",the human sciences, however, he tends to overstate his caseconcerning the contextual dependence of truth claims, whileseldom discussing truth, as opposed to the practices that maketruth claims possible.

In those few places where he does discuss the truth of naturalscience, Foucault remains a philosopher of science in the traditionof his teacher, Georges Canguilhem, who seems to be some sort ofscientific realist. In an appreciation of the work of Canguilhem,Foucault writes: "In the history of science one cannot take truth asgiven, but neither can one do without a relation to the truth andto the opposition of the true and the false. It is this reference tothe order of the true and the false which gives to that history itsspecificity and its importance" (Foucault, 1985, p. 3).

The Comtean notion that positive science has "taken off" fromtraditional religion and metaphysics became Bachelard's "epistem-ological rupture". When, in The Archaeology of Knowledge, Foucault(1976b, p. 188) defines the thresholds of positivity, epistemologi-zation, scientiflcity, and formalization through which discursiveformations go, he is speaking of stages of the rationalization of thephysical sciences as seen by a long tradition of French philoso-phers from Comte to Duhem and Althusser. According to thisview, some sciences, such as physics, because their techniques ofinvestigation put them in touch with an independent causalreality, free themselves from the power practices in which theyoriginate, and gain autonomy and objectivity, while others, whosetechniques do not mesh with their objects, are stuck with meth-


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314 Hubert L Dreyfusods dictated not by their subject matter but by the power prac-tices under which they were developed. At the time of Disciplineand Punish, a relatively late work, Foucault still seems to hold thisview of the natural sciences:

What Great Observer will produce the methodology of examination for thehuman sciences? Unless, of course, such a thing is not possible. For, although itis true that, in becoming a technique for the empirical sciences, the investi-gation has detached itself from the inquisitorial procedure, in which it washistorically rooted, the examination has remained extremely close to thedisciplinary power that shaped it (Foucault 1977a, p. 226).

Foucault is interested in the non-autonomous human sciencesand the way they have remained involved with power. Therefore,he has nothing further to say about the automonomous naturalones. It seems reasonable to suppose, however, that Foucault hasretained his earlier view that the natural sciences have been ableto arrive at relative autonomy because they have found a level ofanalyses that authorizes valid abstractions corresponding to thenatural kinds and causal powers in the physical world.

Not only does Foucault note that the natural sciences haveachieved autonomy but, in the same passage, he implies that suchautonomy may be impossible for the sciences of man. Thissuggests that the natural sciences can be right about natural kindsin the physical and biological world, but there may be no naturalkinds for the human sciences to be right about. At one point in aninterview, Foucault asks himself: "Why should an archaeology ofpsychiatry function as an 'anti-psychiatry', when an archaeology ofbiology does not function as an antibiology?" (Gordon, 1980, p.192). And he answers with another question: "[I]s it not . . . thatpsychiatry is not on good terms with its own history, the result ofa certain inability on the part of psychiatry, given what it is, toaccept its own history?" (Gordon, 1980, p. 192).

What is it about psychiatry that makes it unable to accept itsown history? I will argue that Foucault thinks this inability has todo with the impossibility of valid causal theories in the humansciences and a consequent compromising involvement with power.My discussion will follow the order of Foucault's development,first taking up the special relation of the human sciences to causallaws and then considering the relation of psychiatry to power.

Foucault started out as a student of Heideggerian existentialpsychiatry. His first published work, a one hundred page introduc-


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Foucault's Critique of Psychiatric Medicine 315tion to Binswanger's Dreams and Existence (1954), begins bysetting out and defending Heidegger's account of human exis-tence, or Dasein, in Being and Time. In this account, there is nohuman nature. Rather, "human being" is a self-interpreting way ofbeing whose practices have enable it to act as if it had a wholeseries of different natures in the course of history. To understandHeidegger's claim, it helps to remember that, in Homeric times,there were ways of singing of heroes and so men could becomeheroes. Later, in Christian times, there were practices for cannon-izing saints so men could become saints. At the time of Homer,there could be no saints but only pathetic losers who let peoplewalk all over them, and, conversely, in Medieval times therecould be no heroes but only prideful individuals who disruptedsociety by denying their dependence on God. Or, to take anexample from Foucault's History of Sexuality, in Antiquity insome groups men took care of themselves by taking care theiractions were in keeping with the laws of health and society, whilein another, confessional practices produced a new type of manwho identified himself with his desires, and then, since his desiresmight be the disguised work of the devil, developed a hermeneu-tic of suspicion to ferret out their true meaning.

If there is no human nature, we can describe the structure ofself-interpreting beings, but we cannot have a psychology ascientific theory of psychic components, their causal powers, andtheir normal and abnormal functioning. So we are finally in aposition to understand Foucault's claim that physiology can giveus "valid abstractions" that allow "causal determinations", whereasthere can be no theory in psychiatry since what psychiatry muststudy is a "style, the whole historical anteriority and possibleimplications, of an existence" (Foucault, 1976a, p. 11).

On this view, we can have true, objective theories about DNA,human reproduction, sexual functions, etc., but there is no objec-tive answer to the questions, What is human nature? Are wesexual beings? etc. not because we do not yet know the answersto these questions, but because they are not the sort of questionsthat have objective answers. All one can have is a particularhistorical understanding of human nature, a self-interpretationembodied in the current social practices and in each individualsocialized into those practices.


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316 Hubert L. DreyfusII. THE COGITO AND THE UNTHOUGHT: SELF-ANALYSIS

AS INTERMINABLE

Later, Foucault argues that psychiatry is not only mistaken in ageneral way in trying to be a science of human nature but thatpsychoanalysis, as a child of its time, is mistaken in a particularway. Psychoanalysis seeks to be a science of a particular inter-pretation of human nature, viz., man. Man, according to Foucault,is a recent human self-interpretation in response to the collapse ofreligion and metaphysics. Kant accepted the finitude of humanreason and sought to make this very finitude the basis of man'spositive powers; "To make the limits of knowledge provide afoundation for the possibility of knowing" (Foucault, 1970, p.317). Thus, man, as defined by Kant, became both the source ofall meaning in the universe and a meaningless object in it. Indeed,it is precisely as finite that he is the source of all order. Allsciences of man are based on, and have to struggle with, thisdifficult idea. A science of the psyche based on this notion of manwill thus have a typical convoluted form. Since he is an opaqueobject in the world, man's own mental content is foreign andobscure to him, yet, as source of all meaning, he is "perpetuallysummoned towards self knowledge" (ibid., p. 323). If man is to beintelligible to himself, the unthought must ultimately be accessibleto thought and dominated in action, yet insofar as this unthought,in its obscurity, is precisely the condition of possibility of thoughtand action it can never be fully absorbed into cogito. Thus, "Themodern cogito . . . is not so much the discovery of an evident truthas a ceaseless task constantly to be undertaken afresh . . ." (Fou-cault, 1976a, p. 324). Foucault calls this structure, characteristicof any science of man's mind, the cogito and the unthought, andhe takes Freudian theory to be a perfect example of it.

In his psychological theorizing, Freud presupposed a Cartesian/Kantian conception of the mind. This epistemological conceptionof mind is roughly that the mind consists of a set of ideas,analogous to images or descriptions, which represent the outsideworld and may correspond or fail to correspond to what isactually out there in the world. At the culmination of this tradi-tion, Franz Brentano, who was one of Freud's teachers, claimedthat mental states such as perception, memory, desire, belief, etc.,are all "of" something or "about" something. Brentano held thatthis directedness or aboutness, called by him "intentionality", ischaracteristic of the mind and nothing else.


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Foucault's Critique of Psychiatric Medicine 317Freud accepted the intentionalist conception of mind as a set

of states directed toward objects by means of representations.However, the entire tradition from Descartes to Brentano hadmaintained that all intentional states must be conscious, whereasFreud learned from his work with hypnosis that not every mentalrepresentation was immediately accessible to reflection. Thus,Freud was led to introduce the notion of an unconscious, which,just like the conscious mind, was directed toward objects bymeans of representations, but whose representations were notdirectly accessible to the conscious subject. Yet it is these un-conscious representations that motivate us. Unconscious instinc-tual impulses, according to Freud, are directed via unconsciousideas. Libidinal energy has its effect on our behavior by cathechinga specific representation or idea of some object, which we thendesire for sexual gratification.

This intentionalist or epistemological conception of mind,joined with the idea that some mental contents can be uncon-scious, lead directly to Freud's conception of pathology andtherapy. Freud accounts for pathology by hypothesizing thatrepresentations that are deprived of consciousness remain causallyactive but are not integrated into the web of conscious mentalstates, and so manifest themselves to consciousness as symptoms.Thus the epistemological account of mind when used to accountfor pathology becomes a depth psychology concerned with repre-sentations buried in the unconscious.

Corresponding to this epistemological view of mind and patho-logy, we find an epistemological conception of the therapeuticprocess. In depth psychology, the basic problem is that somemental contents are unconscious, and not properly integrated intothe ego's overall set of representations. Therapy thus consists ofhelping the patient to uncover the hidden contents and to rein-tegrate them into his overall mental system. With this view oftherapy as the interminable task of searching out and bringing tolight the self's concealed motivations, Freud represents the cul-mination of the thought of the long line of thinkers who havebeen governed by that structure of the sciences of man whichdemands that one think the unthought.

Psychoanalysis stand as close as possible . . . to that critical function which, aswe have seen, exists within all the human sciences. In setting itself the task ofmaking the discourse of the unconscious speak through consciousness, psy-choanalysis is advancing in the direction of that fundamental region in which


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318 Hubert L Dreyfusthe relations of representation and finitude come into play (Foucault, 1976a,p. 374).

Thus, on Foucault's account, psychoanalytic theory turns outto be a perfect example not just of a (pseudo) science of humanbeings in general but, more specifically, an exemplary human(pseudo) science in which man's nature as finite is taken to beexplained by an unthought that must be, but can never be, Hillyrecuperated by consciousness.

At the time of The Order of Things, Foucault was under theinfluence of structuralism, as was the French psychoanalystJacques Lacan. Foucault therefore goes through some convolutedmoves to argue that Lacanian psychoanalysis, "occupies a privi-leged position" (1976a p. 373). It is somehow beyond the sciencesof man, because, in facing the primary processes of the uncon-scious, it comes upon what cannot be interpreted and brought toconsciousness gaps in language, unrepresentable desires "themute solidity of a thing, of a text closed upon itself. . ." (1976a, p.374). In the oracular prose of the period, Foucault explains:By following the same path as the human sciences, but with its gaze turned theother way, psychoanalysis moves towards the moment by definition in-accessible to any theoretical knowledge of man . . . at which the contents ofconsiousness . . . stand gaping, upon man's finitude. . . . [a] region whererepresentation remains in suspense . . . (Foucault, 1976a, p. 374).

Foucault follows Lacan's attempt to rehabilitate Freud. "Freud",he tells us, "was the first to undertake the radical erasure of thedivision between . . . the normal and the pathological, the com-prehensible and the uncommunicable, the significant and thenon-significant . . . (1976a, p. 361). Indeed, "nothing is morealien to psychoanalysis than anything resembling a general theoryof man. . . " (1976a, p. 376).

In his later work, however, when Foucault focuses on thesocial effects of the sciences of man rather than on their self-defeating attempt to recuperate the unthought into the cogito,he comes to see psychoanalysis not as a liberating step beyondthe human sciences, but as the culmination of a normalizing con-fessional technology developed by the early Christians. In thelectures and interviews reflecting the not yet published Confes-sions of the Flesh, Foucault argues that Christian confessional prac-tices produced a being he calls 'the man of desires'. This Christian


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Foucault's Critique of Psychiatric Medicine 319man identifed himself not with his public deeds but with hismost private intentions, desires, fantasies, and dreams. Moreover,since what one desired might well be forbidden and thus thedesire disguised, one had to be suspicious of one's desires andconstantly work to dredge up one's true motivations. Foucaultquotes a confession manual: "Examine . . . all your thoughts,every word you speak, and all your actions. Examine even untoyour dreams, to know if, once awakened, you did not give themyour consent. And finally, do not think that in so sensitive andperilous a matter as this, there is anything trivial or insignificant"(1978, p. 20). This is the motto of the hermeneutic subjects wehave all become.

In classical Freudian theory, since pathology arises from re-pressed unsatisfied desires returning as symptoms, health wouldconsist in constantly retrieving the repressed desires so as eitherto satisfy them, substitute other acceptable goals, or maturelyresign oneself to not being able to fulfill one's infantile and anti-social demands. But caught in the confessional practices thatunderly the structure of the cogito and the unthought, we cannever suceed. "We convince ourselves that we have never saidenough on the subject, that, through inertia or submissiveness,weconceal from ourselves the blinding evidence, and that what isessential always eludes us, so that we must always start out onceagain in search of it" (1978, p. 33). Thus, in principle, Freudiantheory advocates the interminable analysis of one's desires, fan-tasies, and dreams and so contributes to the practices that tend tomake everyone into self-normalizing subjects. Each person is ledto seek the truth about himself, and thus to assure that all hisactions and even his thoughts in every area of life do not deviatefrom what science has shown to be normal, healthy, and produc-tive.

Foucault does not deny that people's desires are importantaspects of their personality and that, on occasion, when, forexample, one's actions are self-defeating, it makes sense to askoneself what one really wants. He never had reason to retract hisremark at the end of Mental Illness and Personality, that

What has just been said is not intended as an a priori criticism of any attemptto circumscribe the phenomena of madness or to define a strategy of cure. Itwas intended simply to show a particular relation between psychology andmadness and a disequilibrium so fundamental that they rendered vain any


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320 Hubert L. Dreyfusattempt to treat the whole of madness, the essence and nature of madness, interms of psychology (Foucault, 1976a, p. 76).

What makes Freudian theory dangerous, according to Foucault,is that such self-inspection is not confined to a period of therapywhen dealing with a specific problem. Rather it is supposed tobe based on a science of the psyche that holds that relentlessself-inspection must be practiced as a permanent way of life ifone is to become and remain a mature and healthy human being.Freudian theory thus reinforces the collective practices of self-analysis that provide material to fill the dossiers of the humansciences and allow norms, based on an alleged science of humannature, to permeate every aspect of our lives. Acording to Fou-cault, this endless self-analysis, in which each private subject isurged to speak so as to make itself available to inspection andcorrection, has become not our cure, but our curse.

For Foucault, then, Freud's claim to have elaborated a scienceof the subject by understanding desire as sexual desire, and sexualdesire as a natural kind about which we can discover laws ofnormal development, functioning and causal effects, is unfounded.

The notion of "sex" made it possible to group together, in an artificial unity,anatomical elements, biological functions, conducts, sensations, and pleasures,and it enabled one to make use of this fictitious unity as a causal principle . . .(Foucault, 1978, p. 154).Moreover, late Foucault maintains that the sexual human natureto which this pseudo-science appeals is a power-construction.

Causality in the subject, the unconscious of the subject, . . . the knowledge heholds unbeknown to him, all this found an opportunity to deploy itself in thediscourse of sex. Not, however, by reason of some natural property inherentin sex itself, but by virtue of the tactics of power immanent in this discourse(Foucault, 1978, p. 70).

Power, for Foucault, means bio-power, the tendency to bringnorms, allegedly based on science, into every aspect of humanlife for ever greater enhancement and control. This tendency isdangerous according to Foucault not because it represses someaspect of our nature we haven't any nature but because itlimits freedom of personal choice, a desideratum he presumablycarries over from his early allegiance to existential philosophy.Not that Foucault supports freedom as constant flexibility and


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Foucault's Critique of Psychiatric Medicine 321self-overcoming for its own sake. Freedom, for Foucault, is free-dom from every universal norm, even this post-modern one. It isfreedom to give one's life the stability and uniqueness of a workof art. As Foucault said in his last interview: "The search for aform of morality acceptable by everyone in the sense that every-one would have to submit to it, seems catastrophic to me" ("LeRetour de la Morale," Les nouvelles, 28 June 1984, p. 37).

When the later Foucault approaches psychoanalysis, not justas a would-be-science of man, but as a power practice charac-teristic of modern Western society, he includes the Lacanian ver-sion of Freud. Even Lacan still assumes an ahistorical knowledgeof human nature, viz., that man's deepest desires can never besatisfied and that one must therefore accept the meaninglessnessof desire and of human existence. He, therefore, proposes atherapy based on the need to articulate what one can of theunthought so as to be liberated from it. In a 1977 interview withLacan's successor, Jacques-Alain Miller, Foucault points out thateven in Lacanian psychoanalysis "the subject is incited to producea discourse of truth about his sexuality which is capable of havingeffects on the subject himself" (Gordon, 1980, pp 215216).

Once we see why Foucault regards psychoanalysis as a dan-gerous pseudoscience, we are in a position to see why an accountof psychopathology free from a theory of normal functioning alongwith a therapy with other aims than liberating us from the sup-posed causal effects of repressed desires by requiring us to tell thetruth about the contents of our minds, were once, and might stillbe, acceptable to him.

III. EXISTENTIAL PSYCHOTHERAPY: BEYOND THESCIENCES OF MAN

Freudian theory is dubious and dangerous, not because whatFreud says about human nature and its norms are not true whilesome other theory might get it right, but because, since there is nohuman nature, the whole attempt to medicalize psychiatry ismisguided. But, then, we must ask: If the psychiatrist cannot havea causal theory, explaining normal and abnormal functioning, howcan he understand people and so help those with personalityproblems? Early Foucault attempts to answer this question byfirst showing how psychoanalytic concern shifted from an em-


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322 Hubert L. Dreyfusphasis on a causal theory of symptoms to a description of styles ofdefenses.

This notion of psychological defense is of major importance. The whole ofpsychoanalysis has centered around it. An investigation of the unconscious, asearch for infantile traumas, the freeing of a libido that supposedly existedbehind all the phenomena of the affective life, an uncovering of such mythicalimpulses as the death instinct psychoanalysis has long been just this; but it istending more and more to turn its attention to the defense mechanisms andfinally to admit that the subject reproduces his history only because heresponds to a present situation (Foucault, 1976a, p. 36).

Foucault cites with approval Anna Freud's The Ego and theMechanisms of Defense, and suggests that one could and shoulddescribe and treat styles of defenses as they show up in thepresent without regarding them as clues to internal unconsciouspathology, as if that were the real cause of the problem. "A styleof psychological coherence must be found that authorizes theunderstanding of morbid phenomena without taking as its refer-ential model stages described in the manner of biological phases"(Foucault, 1976a; pp. 41-42).

The proposal that one avoid pseudo-science by defining patho-logical patterns of behavior without seeking underlying causesleads Foucault to Ludwig Binswanger's existential phenomeno-logical psychiatry a form of diagnosis that is not based oncausal theory and a type of therapy that does not advocate ahermeneutic inspection of desire. Since existential phenomeno-logical psychiatry is now rather unfamiliar, we will need to con-sider briefly the different understanding of mind and realityunderlying the Freudian and the existential approaches.

We have seen that Freud presupposed a Cartesian/Kantianview of the mind. Philosophers such as Martin Heidegger andMaurice Merleau-Ponty, reacting against the Cartesian tradition,have developed an alternative model of the mind's relation toreality. This account is so radical that, strictly speaking, thesephilosophers do not refer to the mind at all. Rather they preferto speak of the way the whole human being is related to theworld. Indeed, even "relation" is misleading, since it suggests thecoming together of two separate entities human beings andthe world whereas these philosophers see mind and world asinseparable. So they are finally driven to replace the epistemologi-cal relation of subject and object with a way of being they call


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Foucault's Critique of Psychiatric Medicine 323"being-in-the-world" in which human-being or Dasein is a kind ofspace in which coping with other beings becomes possible.

This "ontological" view does not deny that human beings some-times have mental representations by which their minds aredirected toward objects. Rather, the ontologists assert that mentalrepresentations presuppose a context in which objects can showup and make sense. This context is provided by social practices(Heidegger, 1962, Chap. 4).2 The shared practices into which weare socialized provide a background understanding of what countsas objects, what counts as human beings, and ultimately whatcounts as real, on the basis of which we can direct our actionstoward particular things and people. For example, Christian prac-tices imparted an understanding of human beings as creatures ofGod with deep selves full of hidden desires and memories out ofreach of consciousness. These aspects of the self could be re-covered partially by confession, but only God could know themexhaustively. At the same time, Christianity introduced an under-standing of things as created by God, and thus full of significancethat solicited endless interpretation. This unified understandingof people and things, viz., that to be is to be a creature givenmeaning by God, was embodied in what Foucault came to call theculture's micro-practices. Such practices are picked up by sociali-zation, itself largely the result of identification and imitation, sothat this understanding need never be conscious or even uncon-scious. Heidegger calls this background understanding of what itmeans to be, which is embodied in the tools, language, andinstitutions of a society and in each person growing up in thatsociety, but which cannot be exhaustively represented in his/hermind, an understanding of being. Hence the name ontology.

A culture's understanding of being creates what Heidegger callsa clearing {Lichtung) in which entities can then show up for us.The clearing is neither on the side of the subject nor the object it is not a set of implicit and explicit beliefs nor a set of facts rather it contains both and makes their relation possible. It is anacquired context that both opens up and limits the kinds ofobjects we can deal with or, as Heidegger puts it what thingscan show up for us as.

Merleau-Ponty, following Heidegger, compares this clearing tothe illumination in a room. The illumination allows us to perceiveobjects, but is not itself an object toward which the eye can bedirected. He argues that this clearing is correlated with our bodily


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324 HubertL. Dreyfusskills and thus with the bodily stance we take toward people andthings. Each person not only incorporates his culture's under-standing of human beings and of objects, but also his sub-culture'sand family's variations on the current social practices. Thus, eachperson comes to have or to be his own embodied understandingof what counts as real, which is, of course, not private but is avariation on the shared public world.

This ontological as opposed to epistemological view of humanbeing leads to an alternative account of the unconscious, ofpsychopathology, and of therapy. Binswanger worked out andpracticed this alternative. He understood psychopathology as adistortion of the human clearing that makes it narrow and rigid.Binswanger was concerned with describing the style of a patient'sworld. For example, as Foucault explains in his introduction toBinswanger's book on dreams, he was not interested in the sym-bolic meaning of the content of dreams but in the personal style ofstructuring space and time that dreams reveal.

The analysis of the dream was not exhausted at the level of a hermeneutic ofsymbols; but, starting from an external interpretation which is still a kind ofdeciphering, one was to . . . arrive at an understanding of the existentialstructures (Foucault, 1955, p. 15).

Binswanger used the ontological structure of a patient's exist-ence rather than a causal, genetic account of intra-psychic forces,as a framework for constructing a narrative that was intended tocapture the developing pattern of a patient's life. Foucault explains:

It is a question of restoring, through his understanding, both the experiencethat the patient has of his illness (the way in which he experiences himself as asick or abnormal individual) and the morbid world on which this consciousnessof illness opens . . . . The understanding of the sick consciousness and thereconstitution of its pathological world, these are the two tasks of a phenomen-ology of mental illness (Foucault, 1976a, p. 46).

Binswanger's therapy consisted in helping a patient to becomeaware of his way of being-in-the-world and to assume responsi-bility for it. This itself was supposed to produce change, sinceaccording to Binswanger, becoming a person whose life could bedescribed as a case of sickness to be studied objectively is itself achoice of an inauthentic form of existence which repudiates itsfreedom. But Binswanger does not explain why it is hard for aperson to see the style of his life, nor how his therapy producesthis understanding.


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Foucault's Critique of Psychiatric Medicine 325Merleau-Ponty, who was one of Foucault's teachers, offers a

more plausible existential account of pathology that Foucaultseems to integrate into his account Binswanger. In Merleau-Ponty'sontological view, pathology occurs when a particular way a personrelates to some people or some objects becomes a way of relatingto all people and all objects, so that it becomes the form orstyle of all relationships, i.e., some aspect of the epistemologicalrelation of a subject to other persons and objects, which shouldtake place in the clearing, becomes a dimension of the clearingitself. Merleau-Ponty calls the shift from content to context,"generalization". Foucault uses jealousy as an example of suchgeneralization:

One has only to think of those jealous individuals who justify their mistrust,their interpretations, their delusional systematizations, by a meticulous genesisof their suspicions that seems to dilute their symptoms throughout theirexistence . . . They see in their morbid jealousy the deepest truth, the mostradical misfortune of their existence. They normalize it by referring it to thewhole of their previous life (Foucault, 1976a, p. 48).

When this happens, the person's world or clearing becomes re-stricted and rigid. The person suffers from a lack of possibilitiesthat he cannot understand and over which he has no control. Tohighlight the contrast with Freudian depth psychology, this onto-logical account of psychopathology as the expanding of contentinto context, might be called breadth psychology.

This is, of course, a non-representational version of the uncon-scious. Merleau-Ponty uses as an example of such a generalizedunconscious the case of someone who relates to each person as ifthe issue were one of determining who is inferior and who issuperior. In Merleau-Ponty's terms, inferior/superior, once an issuein the clearing, has become a dimension of the clearing. Merleau-Ponty uses the notion of context this time called "atmosphere" to explain why such a self-defeating stance is outside of thesufferer's awareness and control

An inferiority complex . . . means that I commited myself to inferiority, that Ihave made it my abode, that this past, thought not a fate, has at least a specificweight and is not a set of events over there, at a distance from me, but theatmosphere of my present. (Merleau-Ponty, 1962, p. 442).

On this ontological account, a child comes to encounter allsignificant figures as superior, for example, not because the repre-sentation of specific threatening others make him anxious and are


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326 Hubert L. Dreyfustherefore repressed and return in disguised form as symptoms andbelief in his inferiority. An unconscious belief that he is inferiorwould not adequately account for the pervasive style of hisbehavior nor his imperviousness to counter-arguments. Moreover,a belief, or a schema, does not explain how the person who has itbehaves with the appropriate style in each particular case. Forexample, if our patient simply believes he is inferior, or has a rulesuch as, 'Whenever asked to do something, claim one is notadequate for the job,' he would not know how to apply the rule toall specific situations, even when his wife asks him to take outthe garbage or when his boss suggests he deserves a promotion.3Yet it is clear that he will exhibit his unique style of inferioritybehavior in each of these situations and indefinitely many others.According to Merleau-Ponty's account, with which Foucaultwould surely agree, the patient's sense of inferiority is sedimentedinto his posture and other body-sets that structure his world, sothat he unthinkingly responds in a similar way to each newsituation. As Foucault puts a similar point:

Power relations can materially penetrate the body in depth, without depend-ing . . . on the mediation of the subject's own representations. If power takeshold on the body, this isn't through its having first to be interiorised inpeople's consciousness (Gordon, 1980, p. 186).

Even after an issue in the world, e.g., who is superior, hasbecome one of the dimensions of the clearing, however, a person'sworld is not completely static and one-dimensional. Tounderstand the last step to the closed world of pathology requiresexplication of one last ontological notion from Heidegger andMerleau-Ponty. Heidegger, in his later work, introduces the ideaof a particular event in the clearing or "Open" which focuses andstabilizes the cultural meanings already in the public practices. AsHeidegger (1971) puts it: "There must always be some being inthis Open . . . in which the openness takes its stand and attainsits constancy" (p. 61). He gives as an example the Greek templethat opens up and organizes a multi-dimensional world by high-lighting crucial issues that then become the locus of conflicts ofinterpretation, and the starting point of history. Heidegger'snotion of an event that gives constancy to a cultural clearingmight be called a cultural paradigm, for it has much in commonwith Thomas Kuhn's notion of a scientific paradigm, a particularexperiment or explanation that serves as a model of good science


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Foucault's Critique of Psychiatric Medicine 327and organizes the activities of researchers in a scientific commun-ity. Soren Kierkegaard (1941) emphasizes that a lover or a causeto which one is committed can serve the same function in anindividual's life.

Merleau-Ponty introduces a similar idea concerning the role ofparticular objects or events in an individual's life.It is necessary to have the ontological capacity . . . to take a being as arepresentative of Being . . . The fixation of 'character' [takes place] by invest-ment of the openness of Being in an entity and, henceforth, takes placethrough this entity. Any entity can be accentuated as an emblem of Being . . .(Merleau-Ponty, 1969, p. 270).

The emblem, as Merleau-Ponty calls the paradigmatic object, hasthe effect of reorganizing the background or clearing in which allcontents appear. Thus, even though it is an object we actuallyconfront, it performs the same function as the clearing itself.

Heidegger and Merleau-Ponty have noticed two closely relatedbut antithetical kinds of ontological entities. Heidegger's notion ofan event that gives constancy to a cultural clearing, but allowsmultiple interpretations, might be called a positive paradigm.Merleau-Ponty, on the other hand, is suggesting that there canalso be negative paradigms objects, person, or events that focusa person's world not by opening it up but by closing it down, thussubstituting a one-dimensional obsession for diversity, suspicionfor openness, and timelessness for history.

According to Foucault (1976a, p. 55), a change in structurerather than content, is what distinguishes the "morbid world"from the world of a "normal man". Foucault quotes Binswangerwith approval: "The validity of the phenomenological descriptionsis not limited by a judgment on the normal and abnormal"(1976a, p. 56). He then adds: "But the morbid manifests itself inthe course of investigation as the fundamental characteristic of thisworld . . . [T]his morbid existence is marked by a very particularstyle of abandoning the world: by losing the significations of theworld, by losing its fundamental temporality . . ." (1976a, p. 56).That is, the patient has no open future but is stuck in a pastclearing in which the same issue shows up again and again.

To help the patient out of his closed world, the therapist maytry to lead the patient to remember how things showed up beforea specific issue became one of the dimensions of his clearing. Thestructure of dreams could also be used to help break out of the


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328 Hubert L. Dreyfuscurrent closed world of the patient by showing that the worldonce had a more open style. Of course, any ordinary memory willshow the past as already colored by the current clearing, but therecan be a kind of spontaneous recall especially in dreams, in whichpast events are experienced as they were originally, not as theyhave been retroactively interpreted (Schachtel, 1959).4

Another way to get the patient to see he is stuck in a totalizinginterpretation is for the therapist to make it difficult for thepatient to fit the therapist into his world while at the same timecalling attention to the anomalies that arise when he tries. Ratherthan following Freud in using transference primarily in dealingwith specific resistances to uncovering the truth of specific de-sires, the existential therapist would work with transference as anoccasion for showing the patient the inappropriate coloring orstyle of his world by pointing out that he is reacting to thetherapist in a typical but inappropriate way. The therapist thususes the fact that he inevitably becomes an emblematic focus forthe one dimension through which the neurotic sees everything inhis world to call attention to this dimension and its limitations.

Even if the patient were thus led to recognize the coloring andcramptedness of his present clearing, however, he would be likelyto insist that a certain time in the past he had discovered that thisis how things really are for him, his "destiny" as Foucault (1976a,p. 48) puts it. Thus the therapeutic strategy for turning theontological back into the epistemological ultimately must under-mine the patient's current sense of reality. This is accomplishedby working with the patient to piece together an account of howthe patient's narrow version of reality developed through a seriesof accidental events and misunderstandings. The patient mustcome to realize that what he takes to be his "destiny" is notobjective reality but his own arbitrary interpretation.

Simultaneously, the patient must be lead to see the connectionbetween his interpretation of reality and his pain. The therapistthus tries to get the patient to see that what he takes to be un-changeable reality is really simply his particular and quirky story,and that this understanding has a high price. Such a "genealogy"of an individual's world will tend to undermine the patient'sconviction that his way of seeing things is the way things are andhave to be.

None of this would work, however, if every aspect of thepatient's behavior had been infected by his one-dimensional view.


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Foncault's Critique of Psychiatric Medicine 329For then the therapeutic, genealogical, reconstruction of the ar-bitrariness of the patient's sense of reality would be seen by thepatient merely as showing the strange and idiosyncratic route hefollowed in arriving at his truth. Fortunately, however, this neednot be his response. When a patient's world becomes totalizedand one-dimensional, other ways of behaving from earlier daysendure. These marginal stances, interpretations and practices arenot taken up into the one-dimensional clearing precisely becausethey are too fragmentary and trivial to be seen as important. Thetherapist must recover and focus these lost possibilities. Here, thetherapist as positive paradigm has a curative role.

Thus, without a causal theory of the functional components ofa personality and their normal and abnormal functioning, but withonly a description of human being as a space opened up byinterpretation, and a typology of possible distortions of thatclearing, the phenomenological therapist can give an account ofpsychological problems and offer a genealogical cure. No wonderFoucault favored existential, ontological psychiatry.3

IV. THE LIMITS OF ALL PSYCHO-THERAPIES

In spite of the attraction of phenomenological psychiatry, Foucault,in his early essay, holds that, like psychoanalysis, it can accountneither for why some people rather than others with seeminglysimilar experience get into psychological trouble nor for theparticular kinds of "madness" that are manifest in a given society.

It would be a mistake to believe that organic evolution, psychological history,or the situation of a man in the world may reveal these conditions. It is in theseconditions, no doubt, that illness manifests itself, that its modalities, its formsof expression, its style, are revealed. But the roots of pathological deviation, assuch, are to be found elsewhere . . . (Foucault, 1976a, p. 60).

In an anticipation of a theme that only emerges fully in his laterwork, Foucault already holds in his first book that the conditionsof the possibility of pathology lie in the social world. "The analysesof our psychologists and sociologists, which turn the patient into adeviant and which seek the origin of the morbid in the abnormal,are,. . . above all a projection of cultural themes" (1976a, p. 63).

Later Foucault fills this out. The ultimate form of alienation inour society is not repression but the constitution of the isolatedindividual subject to which all psychiatries contribute. Just as an


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330 Hubert L Dreyfusindividual, through a series of accidental historical interpretationsfocused in a series of paradigms, comes to have a one-dimensional,normalizing understanding of reality, in which every anomalymust finally be made to yield its truth and confirm his systematicinterpretation, so our culture, in its pursuit of objective truth andthe total ordering of all beings for the sake of efficiency, health,and productivity, focused in the paradigms of the panopticon andthe confessional couch, has reached a stage in which humanbeings can only show up as sexual individuals, each striving to bea normal subject so as to maximize his human potential.

Given our modern Western understanding of reality, in allaccounts of ourselves, whether they be pseudo-scientific or exis-tential, "Man has a relation with himself and inaugurates that formof alienation that turns him into homo psychologicus" (1976a, p.74). Until one realizes this, all forms of psychotherapy will eithercontribute to general social suffering, as Foucault thinks psycho-analysis does, or else provide only isolated and temporary "cures"in which an individual's narrowing of reality may be opened up,while the contradictions and normalizing closure of our everydaysocial practices continue to produce individual problems and ageneral malaise.

V. GENEALOGY AS SOCIAL THERAPY

But how can Foucault convince us of his view? Why can't wethink indeed, as creatures of our age, are we not forced tothink that after a long history of false starts we have finallylearned that human beings really do have a normative nature, anature that is sexual through and through, just as we havelearned that the heart is a pump and the brain is not a radiatorbut the seat of thought?

Foucault could easily deny the truth of psychoanalysis if hedenied all serious truth claims, but that would be a pyrrhicvictory. Yet once he has granted that some sciences can statethe truth, how can he deny truth to any would-be scienceexcept by entering a long and inconclusive empirical debate?There is only one other way, and Foucault takes it. Just as inexistential therapy, one does not try to argue the patient out ofhis interpretation of reality, but rather starts with the patient'sdistress, amplifies and focuses it, and then seeks to dislodge theunderstanding of being which is correlated with this distress. So,similarly, one does not seek a philosophical proof that our sexual


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Foucault's Critique of Psychiatric Medicine 331interpretation of ourselves is at bottom a social construction, onewrites genealogical histories.

The best way to see that things might be otherwise is to seethat they once were otherwise, and in some areas of life, still are.And to see how we developed our narrow view. Thus, followingNietzsche, Foucault sees his work as a genealogy, written to helpus derealize, and so move beyond, a certain constricted andsuffocating understanding of reality which has gradually emergedin the history of the West. Foucault does not think, any morethan Nietszche did, that such a genealogy will provide an instantcure, enabling the genealogist to step outside himself and hisculture. Foucault was always clear that what one chooses to lookat in the past, (e.g., Greek sexual practices), and what one findsacceptable and unacceptable (e.g., the Greek's relative lack ofinterest in a normative science of sexuality, on the one hand, buttheir obsession with penetration and submission, on the other),reflect one's own historical perspective. Historical therapy none-theless consists in loosening the grip of our current understandingof reality by letting us see how we got where we are, the cost ofour current understanding, and that things might be otherwise.Without stepping out of history or seeking a philosophicalgrounding for an objective truth, genealogy can show us the acci-dental status of our sense of who we are, and can sensitize us topractices still alive in our culture that have not been taken up intothe reigning understanding of being.

Foucault is practicing genealogical therapy on modernity atlarge. He is trying to historize, and so help dissolve, the "em-blemized", one-dimensional, closed, normalized view we have ofourselves as hermeneutic subjects, so as to ready us for thepossiblity of a new social paradigm with a new interpretation ofthe human self that could take up currently marginalized practicesand so open up our world rather than shut it down.6 Foucaultparaphrases and presumably agrees with Nietzsche: "Historicalsense has more in common with medicine than philosophy . . . Itstask is to become a curative science" (1977, p. 156).

NOTES

* This is a revised version of an article that appeared in PsychCritique, Vol. 2,No. 1 (1987), entitled 'Foucault's Therapy', on pages 65 through 83. Copyright by Ablex Publishing Corporation. Printed with permission.1 This volume was originally published by Presses Universitaires de France in


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332 Hubert L. Dreyfus1954. The English version is a translation of the revised second edition,published in French in 1962.2 For an elaboration of this interpretation, see Dreyfus (forthcoming).

3 This critique of the way a representational theory of the mind must try

unsuccessfully to account for styles of behavior is worked out in Dreyfus(1979).4 Schachtel discusses the way certain memories seem to evade schematization

and thus to evoke the original experience just as it was lived.3 Since Foucault only addresses the Lacanian revision of Freud, we can only

speculate about what he would say about other major post-Freudian psycho-analytic theories. We have seen that since ego psychology focuses more onstyles of defense than mental content Foucault finds it congenial. Objectrelations theory, which emphasizes pre-oedipal factors thus showing the limita-tions of a purely oedipal account, would also come closer to the ontologicalunderstanding of the self. Still, in their theories both these schools make causalclaims based on an alleged science of human nature which justifies an accountof normal and abnormal psychological function.

In actual practice, however, current psychoanalytic therapy when itconfronts the defenses of the patient or places emphasis on the transferencerelation rather than insight is compatible with Foucault's suggestion that oneshould focus on styles of defense. What needs to be radically questioned andrethought is the therapeutic role of expressing desires in words. One mustquestion Freud's representational account of content and the associatedaccount of causality modeled on biology.6 For a detailed account of Foucault's genealogical method, see Dreyfus and

Rabinow(1982).

REFRENCES

Dreyfus, H.: 1979, What Computers Can't Do, 2nd ed. Harper and Row, NewYork.

Dreyfus, H.: forthcoming, Being-in-the-world: A Commentary on Division 1 ofBeing and Time, M.I.T. Press, Cambridge, Massachusetts.

Dreyfus, H. and Rabinow, P.: 1983, Michel Foucault: Beyond Structuralism andHermeneutics. 2nd ed., University of Chicago Press, Chicago.

Foucault, M: 1955, Introduction to L. Binswanger, Le Reve et I'Existence, Descleede Brouwer, Paris.

Foucault, M.: 1970, The Order of Things, Harper and Row, New York.Foucault, M.: 1976a, Mental Illness and Psychology, Harper and Row, New

York. (To be reprinted by University of California Press in 1987.)Foucault, M.: 1976b, The Archaeology of Knowledge, Harper and Row, New

York.Foucault, M.: 1977a, Discipline and Punish: The Birth of the Prison, Pantheon,

New York.


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Foucault, M.: 1977b, 'Nietzsche, genealogy, and history', in D. F. Bouchard(ed.), Michel Foucault: Language, Counter-memory, Practice Selected Essaysand Interviews, Cornell University Press, Ithaca.

Foucault, M.: 1978, The History of Sexuality, Vol. 1, Pantheon, New York.Foucault, M.: 1984, L'Histoire de la sexualite, Vol 3: Le souci de soi, Gallimard,

Paris.Foucault, M.: 1985, 'La vie: L'experience et la science', Revue de Metaphysique et

de Morale, 1, 614.Foucault, M: 1986, The History of Sexuality, Vol. 2: The Uses of Pleasure,

Pantheon, New York.Gordon C (ed.): 1980, Power/Knowledge: Selected Interviews and Other Writings,

19721977 by Michel Foucault, Pantheon, New York.Heidegger M: 1962, Beingand Time, Harper and Row, New York.Heidegger, M.: 1961, The origin of the work of art', in Poetry, Language,

Thought, Harper and Row, New York.Kierkegaard, S.: 1941 Fear and Trembling, Princeton University Press, Prince-

ton.Merleau-Ponty, M.: 1962, Phenomenology of Perception, Routledge and Kegan

Paul, London, England.Merleau-Ponty, M.: 1969, The Visible and The Invisible, Northwestern Univer-

sity Press, Evanston.Schachtel, E.: 1959, Metamorphosis, Basic Books, New York.


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