Review by Burcu Alkan
From his seminal Madness and Civilization (1964) to his later studies on various structures of power, Michel Foucault’s works have instigated a diverse and often contentious set of reactions in many fields. However, John Iliopoulos’s book is not yet another work that argues for or against Foucauldian thought or just another history of psychiatry. The History of Reason in the Age of Madness: Foucault’s Enlightenment and a Radical Critique of Psychiatry (Bloomsbury, 2018) scrutinises the concept of reason as defined by the Enlightenment thinkers and the corresponding changes in psychiatry over the past centuries through Foucault’s meticulous analysis of both. It is an in-depth and highly-informed engagement with Foucault’s oeuvre. Iliopoulos goes beyond the all-too-familiar uses and misuses of the Foucauldian approach and clarifies many misreadings and misinterpretations.
He first positions Foucault’s critique of Enlightenment by underlining that Michel Foucault is “neither [an] anti-Enlightenment thinker who rejects reason and truth” nor does he prescribe to a simplistic “notion of the triumph of rationality” as a resolved, finished product (p. 2). Instead, he is concerned about the relationship between reason and rationality, the limits of that relationship, and what that relationship and its limitations say about the ways in which people relate to reality. Forms of rationality, Iliopoulos explains, “are forms of conduct and a structuring of reality based on reason as a principle of knowledge and action. Forms of rationality constitute the implementation of reason in everyday affairs” (p. 4). Disregarding their distinction as such turns the Enlightenment ideas into self-righteous purveyors of truth.
Given the necessity of such a distinction and the complications that arise from its lack, Iliopoulos spends the first couple of chapters in setting the foundation straight. In the first chapter, he asks the Kantian question of “What is Enlightenment?” and proposes it as being essentially, “the age of critique” (p. 7). About the intrinsic dangers of self-righteousness that underlie the “blackmail of the Enlightenment,” Iliopoulos explains: “Rationality is reason as principle of knowledge, necessary for grasping and manipulating reality, which does not cover the entire field of human experience and when it attempts to extend its powers to domains beyond its limits, undermines itself by falling into arbitrariness and irrationality. The courage to recognize these limits and the rigour to demarcate them belong to the reflective properties of reason” (p. 5). In this context, Iliopoulos examines the impact of Kant’s “Anthropology” on the conception of madness and the limits of psychiatry in the eighteenth century. The acknowledgement of the boundaries in the comprehension of madness enabled the “alienists” to see beyond the normative pressures of rationality. Yet, when the proto-psychiatrists prescribed to the necessity of defining issues incomprehensible to rationality through the lenses of rationality and “incorporate[d] tenets of positivism” into their work, they lost their “scientific rigour” (p. 17).
In the second chapter, Iliopoulos extends his analytical evaluation of Foucault’s work to both philosophical and psychiatric applications of phenomenology. He notes: “Phenomenology is the offspring of a primordial confrontation between reason and madness, the direct derivative of this fundamental tension, which created the rational phenomenological subject capable of contemplating the sick consciousness” (p. 28). Foucault’s analysis of madness and psychiatry through phenomenology maintains a distanciation from external theories, perceptions, and presumptions and focuses on what the manifest reality of “madness” reveals. Such a consideration of madness transcends and transgresses the established truth regimes that limit understanding, as madness itself poses its own truth regime against normative rationalities. The mad consciousness does not have a distorted perception of truth but a unique relationship with it, that is, its own truth regime. An example of this is shown through how the hallucinating person never confuses the voices of the “real” world with the voices that only they hear. Accordingly, madness becomes a category of truth in itself, “an epistemological problem” as it clashes with “the exoteric forms of knowledge,” “the diagnostic truth” that determine and categorise madness (pp. 44-45).
In the third chapter, Iliopoulos moves to the basics of discourse analysis as an examination of how “forms of rationality, infiltrate, make up and organize power relations and their effect in the way reality is perceived” (p. 30). The historicity of Foucault’s approach distinguishes his work from a simplistic relativisation of the experiencing subject, and thus, from direct phenomenological interpretations. The “subjects and objects emerge simultaneously as a result of truth procedures specific to a given historical period” (p. 47) and the said truth procedures are always in a complex relationship with ethics, politics, and jurisprudence. Consequently, for Foucault, the perception of madness and the development of psychiatry from the eighteenth century onwards have been contingent upon the “three modalities of truth”: politics, science, and ethics, and their tension-laden encounters. Whether it is the public hygiene requiring those who do not fit the normative regulations of society to be kept away or the jurisprudential necessities of differentiating between the “real criminals” and those who are “mentally ill,” psychiatric medicine bears immense power and intense pressure.
Accordingly, the fourth chapter brings the debates to Foucault’s critique of the politics of power, discipline, and abuses of psychiatry. It discusses his engagement with anti-psychiatry and his analysis of ethico-politics concerning psychiatric medicine. Although Foucault appreciates the contributions of anti-psychiatric debates, he is not necessarily an advocate. He argues that certain forms of rationality created correlated structures of power through logical truth-regimes that were needed, produced, and disseminated within societies. Yet, he rejects monolithic interpretations of power that identify it only with sovereignty, oppression, and prohibition. He establishes a critical distance with anti-psychiatric movements that maintain only a negative and domineering power model. Hence, he proposes “an anonymous, multiple, pale, colorless power” (p. 83), that of discipline. Psychiatric discourse has been in flux due to a drive to become a reliable scientific enterprise and a dependable forensic field. As much as it was prone to abuses of power, it was also geared towards preventing such abuses by malingerers and aimed at safeguarding the vulnerable. Such complexity and complications mark Foucault’s meticulous historical critique of psychiatry not only as an institution but also as an evolving field and discourse.
The fifth and sixth chapters look at the nineteenth century as a critical threshold in the history of psychiatry before it was medicalised in the contemporary sense with the inclusion of biology, pharmacology, and neurosciences. They focus on two distinct but interrelated subjects: an ailment, hysteria and a model of treatment, psychoanalysis. Under the pressure of external truth-regimes, psychiatry was strained to establish reliable epistemological foundations in order to prove its medical status. The body became “both the foundation of perceived reality and the object of this reality as a set of biological processes, […] the unequivocal source of a knowledge […] not only diagnostic but also prognostic” (p. 109). As madness was not demonstrable anatomically and psychiatry was up against the “somatocracy” of positivism, neurology provided the needed material for a medical identity, engendering neuropsychiatry. However, certain types of “madness,” particularly hysteria resisted such classifications and continued to challenge the position of psychiatry as a branch of medicine. The hysterics demonstrated symptoms of neurological disorders but these symptoms lacked references in the nervous system. Charcot’s application of hypnosis further problematised the situation, as neurological symptoms without anatomical correspondence could also be instigated exogenously through suggestion. Still, Charcot’s technique proved to be a name-making method by enabling the differentiation of “real” neurological symptoms from “simulated” ones.
The nineteenth century became a stage for the clashes between two separate truth regimes within psychiatry: the “dominant scientific truth regime […] that is guided by rationality” and “that has become increasingly positivist” in handling mental illness and the “marginalized truth regime that tests madness” guided by reason and “establishe[d] a relationship with otherness” (p. 125). Psychoanalysis brought their conflict-ridden antagonism into an undeniable focus by weaving back and forth between them and creating its own unique space in the process. Freud proposed psychoanalysis as a medical and psychological practice, expanding the realm of psychiatry but challenged its established structures by means of inverting its diagnostic model. Psychoanalysis employed a traditional medical conception of truth, i.e. the notion of crisis. However, instead of looking for the kernel of truth in the patient’s mind, it focused on the presence of falsity and illusion to simulate crisis and thus render it accessible to a possibility of comprehension. Iliopoulos maintains that Foucault’s analysis was not an attempt at invalidating psychoanalysis as a scientific method but a genealogical study to locate it “in Western rationality and to assess the type of truth that it articulates in relation to psychiatry” (p. 126). What Foucault sees is not an epistemological weakness but “a unique type of discourse that can critique psychology itself as well as historical analysis” (p. 133).
The History of Reason ends with a brief chapter discussing the psychiatrists as intellectuals, showing “how their epistemological status can question current security-oriented rationality” (p. 153). It is an intense and informative book that traces the history of psychiatry through its philosophical veins. Moreover, it is a reconsideration of the threshold between modernity and postmodernity, a fluid space that bears the potential to bring together the critical enterprise of the Enlightenment and the radical edge of the postmodern. It is a reminder of the alertness necessary in critical thinking, a warning regarding the pitfalls of Enlightenment rationality that ignores its dialogue with reason. Yet, it also encourages a renewed faith in critique a la Enlightenment, as John Iliopoulos revisits the potential in Foucault’s work in navigating that fluid, liminal space.