History of the Human Sciences

http://hhs.sagepub.com Psychiatry as a political science: advanced liberalism and the administration of risk
Nikolas Rose History of the Human Sciences 1996; 9; 1 DOI: 10.1177/095269519600900201 The online version of this article can be found at: http://hhs.sagepub.com

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HISTORY OF THE HUMAN SCIENCES

Vol. 9 No. 2
1-

© 1996 SAGE (London, Thousand Oaks and New Delhi)

Psychiatry as a political science:

advanced liberalism and the administration of risk
NIKOLAS ROSE

INTRODUCTION
In London, at the end of 1992, a particular killing attracted considerable publicity
- a

TV documentary by the wife of the dead man, public grilling of the Secretary of State for Health, questions in Parliament, massive press publicity, calls for urgent action. Jonathan Zito was stabbed to death on an underground station with a screwdriver by a stranger. The victim was young, white, newly married, aspiring to a career as a professional musician, at the start of what promised to be a rewarding life with his family. The person who stabbed him, Christopher Clunis, was large, black, without employment, a discharged psychiatric patient with a long psychiatric history, living on his own in a supervised flat arranged for him by the social services but run by a private property organization. People living in the area of north London where the stabbing occurred had reported odd and threatening behaviour several times to the police in the days before the event, but the action that the police force had taken was half-hearted, haphazard and ineffective. Whilst many different professionals had been involved in caring for Christopher Clunis over his long history inside and outside psychiatric hospitals, hostels and prisons, it appeared that any care that they might have planned had broken down. Mr Clunis had been considered fit for discharge by the psychiatrists who were responsible for him during his last hospital admission, but he had stopped taking his drugs, he had missed appointments with his psychiatrists, his case had been passed between different local social workers but none of them had been successful in establishing regular contact, the police had failed to link recent reports of his disturbed behaviour with his previous record of

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home visit by the mental health assessment team two weeks before the murder had failed because none of those present had any idea what Mr Clunis looked like, and thus no one recognized him when he left his flat as they arrived. The subsequent official inquiry, which reported in February 1994, meticulously documented the parts played by innumerable professionals and experts over the five and a half years leading up to the death of Mr Zito: over 20 i consultant psychiatrists, forensic psychiatrists, duty psychiatrists from at least 11 hospitals; community psychiatric nurses, general practitioners and other medical workers from four health authorities; social workers, community workers, housing resettlement officers, emergency housing teams from three London boroughs; staff of various resettlement units, sheltered housing schemes and short-stay hostels; police officers from different police stations in at least two police authorities; prison officers from several prisons together with various lawyers and a host of supporting characters. Reading the report one loses count of the number of occasions when notes and files were mislaid, when messages between the different professional groups were lost or misunderstood, when professionals disappeared on holiday, on maternity leave, or to another job, or were off sick at a crucial point, when decisions were taken in almost complete ignorance of Mr Clunis or his history or on the basis of an entirely spurious version of his case. After telling this sorry tale, the conclusion of the inquiry could hardly be disputed: Mr Clunis was as much a victim of the mental health system as the young man he killed. The case led to calls in a number of directions. Mrs Zito argued passionately in her TV documentary for more funds for community care, more emergency beds in hospitals and more effective planning of discharges. Doctors used the case to protest the lack of resources, the pressure on beds, and hence their difficulty in carrying out their vocation of care and cure. SANE - a charity called Schizophrenia: A National Emergency founded about five years ago - deployed the case to support its argument that more hospital beds, more incarceration and tighter restrictions on discharge should be introduced. This position was graphically summarized in its poster featuring a long-haired, bearded and dishevelled young man with a caption that went, approximately, he thinks hes Jesus Christ, you think hes dangerous, they think hes fit to be discharged into the community. The Secretary of State used the case to press her argument for supervised discharge orders, compelling discharged patients to take their medication and comply with their aftercare plan under sanction of recall to hospital: she set her officials to work on the construction of new regulations, standards and monitoring procedures to govern the ways in which medical and other staff made and enforced plans for care in the community. This case illustrates something of the contemporary matrix of arguments around the problem of madness and mental health. This field seems contested, complex and dispersed, made up from diverse and contradictory logics. Madness

violence,

an

attempted

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figures variously as the sign of a community that doesnt care, as a threat to a community that naturally cares for itself, as an instance of the uncaring nature of a fiscally straightened state, as an object of pity and of fear. Whatever hope and trust is invested in other branches of medicine and other medical practitioners, psychiatry appears as a perpetually failing agency, failing in its claims to understand, its capacities to cure, its responsibilities for both individual care and social protection. But perhaps we can see, in this confused and contradictory picture, a kind of condensation of the new problems of government faced by nations like the UK and perhaps others - in this period after the welfare state. Elsewhere I have suggested that we are seeing the emergence of a range of new rationales and techniques of government that can be termed advanced liberal. I use government here in the sense developed by Michel Foucault - government as all those strategies, forms of thought and action, that seek to conduct the conduct of others. This perspective draws our attention to the fact that every attempt to conduct the conduct of others, and indeed to shape ones own conduct, contains a quantum of knowledge. At one and the same time, knowledge makes human conduct intelligible and constitutes certain forms of expertise as appropriate for knowing and acting upon it. Truths, explanations, categorizations and taxonomies, vocabularies and diagnoses concerning human beings individually and en masse are conditions for the governability of conduct. And government is dependent upon expertise. Those who profess specialist knowledge and esoteric skills have come to acquire a crucial role in helping to shape the problems that must be governed, in giving techniques for the conduct of their authority in relation to those who are their subjects, and in making up the relays that link programmes of government to the multitude of dispersed sites where conduct is to be judged, assessed, evaluated, understood and acted upon. Psychiatry has, since the 19th century at least, been intrinsically bound to problematics of government. Indeed the birth of psychiatry as a know how of conduct in the 19th century was part of a fundamental shift in our experience of ourselves in the west: the individuality and vitality of the human being became an object for a positive knowledge; authority acquired the obligation to act upon the conduct of human individuals in the light of positive knowledge; positive knowledges of what it was to be human began to shape the ethical regimes according to which individuals came to understand, judge and act upon themselves.3 Psychiatry, from this perspective, is intrinsically bound to the changing ways in which human beings have tried to govern themselves - not just to changing ideas or models of human nature, but to the changing ethical field within which such understandings of what it is to be human are linked to vocabularies and systems of judgement about conduct and to techniques for acting upon it to improve it. The term psychiatry is actually rather misleading. What one is dealing with here is an heterogeneous complex of contested relations among different

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professionals who claim to be able to identify difficulties of conduct in terms of a theoretical and practical knowledge of the vicissitudes of the psyche, and to act upon persons in the light of that knowledge. One sees not only a range of different varieties of psychiatrists, but also clinical psychologists, psychiatric social workers, psychotherapists, counsellors, occupational therapists, general practitioners as advisers on mental health and so forth. One of the most significant developments of our own century has been the proliferation of experts claiming such knowledge, and the infusion of heterogenous psy- judgements into the duties of other professionals such as teachers and lawyers. In particular, the emergence of clinical disciplines alongside medicine, especially clinical psychology, represents a significant mutation in expert authority. Contemporary strategies for the government of mental health involve novel relations and divisions among experts in mental pathology, novel ways of classifying and dividing those who are to be the subjects of expert attention, and novel relations between experts and others. They place responsibilities upon experts in a way that is significantly different from that under welfare and link expertise to the political apparatus in novel ways. These new responsibilities and relationships will form the topic of this paper / I suggest that psychiatry has a revised role in advanced liberal forms of government. Psychiatric experts are required to collaborate with other professionals in a diversity of practices and apparatuses for the administration of risk across the territory of the community. They are also obliged to participate in novel strategies for the management of exclusion. They are exhorted to adapt to the new logics of choice, empowerment and lifestyle management. And they are caught up
culture of blame, in which almost any unfortunate event becomes a tragedy which could have been avoided and for which some authority is to be held culpable. This places new political expectations upon the professionals of mental health. It also places new responsibilities upon those who are actual or potential subjects of psychiatry and creates new divisions between good and bad patients, clients and users in terms of a calculus of risk.
a

within

PSYCHIATRY AND ADMINISTRATION The new vocation for psychiatry should be understood, first of all, in terms of the formation of a new territory for psychiatry in the postwar period: community. As Robert Castel has argued, the policies of sectorization in France, of community mental health in the USA and of community care in the UK, irrespective of the specific political circumstances that produced them, shared a certain rationale - one of covering the maximum amount of ground, reaching the maximum number of people, through the deployment of a unified apparatus linked to the machinery of the state.5 Of course, the notion of community had emerged within a variety of different attempts to reconfigure the organizational

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form of

psychiatry. In the period immediately after the Second World War, community is proposed as the organizing theme for programmes for the reform of asylum psychiatry advocated by progressive psychiatrists: psychiatry should not be segregated from the places it serves, its institutions should be located in their communities, they should reach out into the community in terms of care for those who do not yet have to enter hospital, or those who are discharged from the hospital.6 At about the same time, the vocabulary of community becomes central to the critique of asylum psychiatry: the asylum should not be a place of incarceration but a therapeutic community - it will be this line that will later be developed by Franco Basaglia and others in Italy into a programme for the wholesale abolition of the asylum and its replacement by community mental health centres. Finally, over the course of the 1970s and 1980s, community, in the UK and the USA, emerges as the key term in a set of national political policies 8 and technologies. Thus, whatever the immediate political impulses behind the programmes for the closure of asylums, the emergence of the vocabulary of community as a way of seeking to understand and programme the proper field of operation of psychiatry indicates a shift in the rationalities underpinning the government of mental pathology and mental health. On the one hand, community psychiatry was a way for psychiatry to modernize itself: psychiatrists would respond to critiques of their custodial and controlling role by seeking to divest their activities of their anti-liberal and carceral features, sloughing these off to other forms of expertise so that psychiatry can become a liberal, open and curative medicine. But it was also an attempt to forge programmes that would simplify and reintegrate the disparate elements of the vocation that had taken shape for diverse forms of psychiatric expertise over the course of the 20th century. For present purposes, what is of particular interest in the emergence of the rationalities of community psychiatry is the novel role that is accorded to psychiatric experts: less that of curing illness than of administering pathological individuals across an archipelago of specialist institutions and types of activity, and simultaneously engaging in a prophylactic and preventative work of maximizing
mental health. There is nothing new in psychiatry assuming a predominantly administrative role - indeed one might say that it was out of an administrative demand that psychiatry began to form as a distinct complex of knowledges, techniques, experts and devices in the 19th century. Over its 150-year history, one can observe at least three distinct configurations in this administrative vocation: the asylum; degeneracy; and mental hygiene. Each problematizes the population in a different way. Each establishes a different grid of visibility for normal and pathological conduct. Each proposes new technologies for the regulation of conduct and a different vocation for experts. It is worth briefly delineating these three configurations, in order to appreciate the distinctiveness of community psychiatry and its current rationalities, techiques and obligations.

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?he Asylum
Robert Castel refers to the 19th century as the golden age of psychiatry.9 There was, he suggests, a coherence among the various dimensions of psychiatry - its theoretical codes, its institutional form, its technologies of cure, its constitutional mandate. The asylum was more than an institutional site; it was an assemblage of thought and action that held these elements together. For my purposes here, it is worth drawing out three elements from the much investigated story of the birth and spread of the asylum in 19th-century Europe and North America.&dquo; First, it was the asylum that made psychiatry possible, and not the other way round. For psychiatry becomes possible, in its modern form, only when a system of relations is established between a range of persons, conditions and judgements such that they can form the object of a single field of representation and intervention. The asylum made possible the visualization of madness that underpinned the nosographies and taxonomies that were so central to the formation of a positive science of madness, the techniques of case-taking, diagnosis and classification best represented in Esquirols Atlas or Bucknill and Tukes Manual of Psychological Medicine.&dquo; The asylum conferred upon the subjects of psychiatry that frail unity that lasted for so long - the walls of the institution rather than any leap of scientific imagination united the inconsolably sad, the religious fanatic, the hearer of voices, the deluded and the violator of norms of sexual propriety. It was in the confined and regulated space of the asylum that the dream took shape that a unified intellectual system might grasp the heterogeneity of madness and a unified technology might be deployed to cure it. The asylum, that is to say, institutionalized the boundaries of what we have today come to contemplate as mental illness at the same time as it conferred diagnostic powers and therapeutic authority upon those medical agents who control and organize the space of confinement. Second, it was in the asylum that the project of cure took the shape it would have for over a century: madness as a violation of norms of civility was to be cured when the mad person was restored to the status of free citizen.&dquo; Thus the psychiatrist, in the 19th century, was not merely an authority of enclosure exercising powers within the enclosed space of the institution - but was a technician of social order. The archipelago of asylums that spread throughout Europe were the other side of all those philanthropic projects for the civilization of the labouring classes, the domestication of female sexuality and the transformation of subjects into citizens who would regulate their own conduct according to norms of prudence, order, temperance, continence, responsibility and so forth. The asylum is thus linked to what Colin Gordon has termed the reciprocal disenchantment of transgression in which scandalous conduct becomes no more than the violation of a standard for civilized comportment of the self consequent upon individual pathology.&dquo; The mad person was placed among that gallery of figures who, in the second half of the 19th century,

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represented social danger; and all sorts of social danger came to be recast in the moral-medical vocabularly of madness. The asylum became one of the vast machines of morality invented in the 19th century, whose rationale was the production of citizens who could be free to the extent that they had taken the obligations of moral, prudent and self-responsible conduct into themselves.&dquo; Third, confinement in the asylum under a medical mandate reconciled a social demand with a constitutional obligation. The social demand was for a mechanism for the containment of socially scandalous behaviour that was not yet
criminal. Yet the citizen, over the course of the 19th century, was to be endowed with a range of legal and constitutional rights which prohibited confinement except for a breach of the law demonstrated in the ordinary courts of the land. Of course, the details of this reconciliation vary across different national contexts and juridical regimes. Nonetheless, as Foucault has put it, our current experience of madness unifies in the form of an illness that which was brought together first as the meeting point between the social decree of confinement of those who disturbed the tranquillity of family or street, and the judicial knowledge which designated the capacities of the subject as a legal entity and hence required a particular warrant for the deprivation of the liberty of a citizen. 15 The asylum was undoubtedly programmatically coherent and strategically versatile - the adoption of the asylum form so rapidly in so many different national contexts is evidence that, in the imagination of so many policy-makers, philanthropists and learned individuals, there was a politically salient problem to which it could appear as a solution. However, the 19th century was also a period of fundamental attack on legitimacy of the asylum complex along each of the dimensions of its activities. The status of mental medicine as knowledge was derided, the integrity of its practitioners was impugned, its capacity to cure was denied.6 As asylums became larger, rates of discharge reduced and scandals about illegitimate confinement multiplied. We are familiar, at least in outline, with the desperate remedies that were adopted, as madness, in the asylum and became increasingly understood as the symptom of a malfunctioning brain. Further, alongside the attacks on the project of asylum psychiatry, one sees the growth of other types of expertise in mental pathology over the 19th century, practised in other sites and directed to other problems of conduct. Problems arising in relation to women and the domestic space formed a particular object of concern. The household has, of course, for long been a key site for the problematization of conduct of one family member by others - one has only to think of the long history of the incarceration of errant daughters, undesired wives and unwanted parents in private asylums. But this 19th-century development is different. Phrenology, hypnosis, spiritualism and a range of other techniques provided the basis for a range of medical and quasi-medical specialisms concerned with nervous disorders, neurasthenia, hysteria and so forth, especially in relation to the troubles afflicting the wealthy, and the middling orders of society. Over this time one sees bitter contestations between the medical alienists

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and these predominantly non-medical ministrators to the soul.&dquo; Around the figure of the hysterical woman, psychiatry emerges as a key element in the regulation of domesticity, sexuality and conjugal relations. However, for present purposes, a different aspect of the 19th-century history of psychiatry needs to be emphasized: the emergence of a series of projects in which psychiatry sought a role in practices for the government of conduct outside the asylum, and in which the asylum as an institution was only one, though no doubt crucial, element. Links were formed between psychiatry and other reformatory institutions and practices - prisons, asylums for chronic inebriates, the apparatus for regulating the morally insane and moral imbeciles. Psychiatry made forays on to other institutional territory, particularly the courtroom. One sees here the beginning of the century-long conflict between psychiatric and legal technologies of judging and holding accountable.&dquo; Whilst the psychiatric dream of a wholesale transformation of criminal justice did not materialize, psychiatry did make significant inroads into the legal process in disputes over homicides of public figures (McNaghten, etc.) and over female homicides (infanticide, etc.) and one sees the beginnings of the process whereby the criminal will gradually cease to be a purely legal subject, and become the subject of a particular pathological personality.9

Degeneracy
however, in the last decades of the 19th century that psychiatrists were first to make a general claim as to the significance of their science for the administration of the population as a whole in the interests of national well-being. Central to this claim was the vocabulary of degeneracy.2 The grammar of degeneracy, not only in France but also in the UK and the USA, became the key way of rendering intelligible a whole series of figures who appeared to threaten social order, especially in the towns - syphilitics, imbeciles, paupers, criminals, gamblers, idiots, drunkards, vagrants, the mad, the unemployable, the tubercular. Within the analytic of degeneracy, all these appeared as different forms of expression of an underlying pathology of constitution. This pathology was probably acquired by amoral conduct (drunkenness, masturbation) which weakened constitution, and was amenable to prevention and control but not to treatment. Not only was pathological constitution passed down family lines, but it worsened in each generation. Some evolutionary optimists thought that sterility was the eventual result of this generational transmission, thereby rendering the social problem ultimately self-limiting, though nonetheless significant in terms of immediate action. For others the reverse was true - degenerates were promiscuous, bred rapidly and irresponsibly, and hence posed a threat to overall quality of the race. There were certainly many differences in the ways in which degeneracy was understood in France, Italy, the USA and the UK. But the notion that insanity
It was,

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9
a wider social pathology operated as a kind of a priori of the of individuals were not of political thought: pathologies merely medical but were indicative of a wider social the malaise; population must, at significance in In be understood bio-medical terms. root, Britain, those who sought to of into a full-scale develop conceptions degeneracy project of eugenics were to encounter the limits set by constitutional doctrines of individual liberty. They were to be opposed by the majority of doctors who favoured a more positive strategy for enhancing the quality of the race through hygienic improvements. Nonetheless the significance of this reactive and segregative political rationality for psychiatry in the first half of the 20th century should not be underestimated in arguments for labour colonies, for the segregation of the feeble-minded and for the analytics of poverty. And it is worth reminding ourselves that it was not merely Jews, homosexuals and gipsies who were the object of the murderous racial purification carried out by the Nazis in Europe, but also the mad, the imbeciles and the degenerate. Indeed up until the 1950s in the USA, under the influence of powerful eugenicist psychiatrists, mental defectives were subject to compulsory sterilization and segregation in many states, and the mad were confined in appalling and destructive conditions: the segregationist rationale cannot easily be consigned to a comfortably distant period of prejudice. For our present purposes, however, the significance of the role played by the bio-medical themes of decline, degeneracy in political thought is slightly different. It is in establishing a new grid of perception which blurred the boundaries between frank madness, confined in the asylum, and the nervous disorders disrupting domestic and conjugal relations. The frontier between the reasonable and responsible citizen and the mad person ceased to be clear, the identity of those who were mad ceased to be evident, and while the borderlands between sanity and madness were previously considered virtually deserted, they were now revealed to be occupied by a huge population of petty criminals, delinquent juveniles, prostitutes, political agitators, unemployables and the like. Even if eugenics had not been discredited through its associations with policies of racial purification and mass destruction carried out in Nazi Germany, the tactics of confinement and sterilization for those on this borderline hardly measured up to the task of prevention which now seemed to confront psychiatry: the confined space of the asylum could no longer appear as the ideal solution to a problem which now appeared virtually co-terminous with that of modem mass society itself.

was an

element in

Mental Hygiene
It is in this context that one can see the mental hygiene movement that developed in the USA, in France and in the UK in the 1920s and 1930s as arising out of attempts to invent a more positive and social vocation for psychiatry: a set of prophylactic and preventative strategies for acting upon the population prior to

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10

the emergence of social danger in order to minimize the chances of this danger arising or to reduce its severity. The codes and mechanisms of psychoanalysis, and a range of other dynamic psychologies and therapies, provided the means by which psychiatry was able to address itself to a range of new problems that were offered to it - not of madness but of social inefficiency and unhappiness. The surfaces of emergence for this new dispensation of psychiatry lay in the novel human machines that had begun to proliferate, where individuals were gathered together under a regime of management, their behaviour marshalled in the service of institutional aims, their conduct assessed in relation to organizational norms: the army, and the problem of shell shock during and after the First World War; the courtroom, and the issue of juvenile delinquency in the early decades of the 20th century; the school, and the problems for pedagogy posed by minor problems of truancy, lying, absenteeism, tantrums and the like; the factory, and the damage to productivity resulting from industrial accidents, fatigue, inefficiency. It is here that a new social vocation for psychiatry was bom, one where psychiatric expertise claimed a role in relation to the management of social ineptitude and inefficiency in all social institutions. This new dispensation operated according to neither the boundaries of reason and unreason, nor those of civility and scandal. The new programmes for psychiatry envisaged it as a non-custodial project with positive aspirations: the production and maintenance of social normality and competence.&dquo; In the grammar of mental hygiene, inefficiencies of conduct of almost any sort were consequences of minor mental disturbance. If not treated, these minor mental disorders would get worse and lead to frank insanity, with all the consequent danger, misery and social cost. However, these inefficiencies were amenable to treatment if caught early, and similarly amenable to prevention by the installation of a proper regime in the factory, the school, the army, but especially the home. In the strategies of mental hygiene, the asylum was not only irrelevant but actually an obstacle. The stigma of madness associated with the asylum discouraged early treatment - hence the demand for the establishment of clinics and hospitals where voluntary admission could lead to treatment (of which the Maudsley hospital in the UK was one of the first). Later the same thinking was embodied in the shift in terminology from lunacy to mental illness and from asylum to mental hospital - the first of many attempts to bring mental medicine into contact with general medicine and apply the same principles of
treatment.
was the application of strategy that had been used with in the social hygiene movement. The object of psychiatric attention had shifted: the pathological individual was relocated in a nexus of relationships which might lead to disorder or might prevent it.22 The mode of explanation of pathology no longer proceeded in terms of an inherited constitutional defect exacerbated by personal immorality or other exciting causes, handed on to progeny. For the minor disturbances at least, the line ran

hygiene physical problems

Mental

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11

from childhood experience of familial emotional relations, namics of the psyche, to maladjusted conduct exacerbated

hygiene in school, factory, army, or elsewhere, into a pathology that was fundamentally preventable. Each institutional locus thus became not only a potentially damaging source of mental ill-health, but also an opportunity for prevention and for early diagnosis and treatment. Child psychiatrists would reach out into the ordinary homes of ordinary citizens through popular books and radio broadcasts, and would educate and instruct parents in the adoption of regimes to ensure mental normality and adjustment in their offspring. Industrial psychologists would train managers and employers in recognizing the signs of maladjustment in employees, and in the requirements of a mentally hygienic industrial regime. Social workers became case-workers, with a new role in linking up the home, the school, the court and the clinic, the playground and the street around the focus of the individual case; the person with his or her biography and family was now to be the object of documentation and professional supervision. A new normalizing scrutiny and evaluation spread into the school, the army, the factory and elsewhere. From this point on, almost every violation of institutional and social norms of conduct would be accorded a psychological meaning, not so much to be judged, but to be understood. The new imperatives were: investigate, assess, prescribe, treat.
Community

through the dyby poor mental spiral of mental

against this background that the distinctiveness of community as a new territory for psychiatry can best be understood. The dream of community psychiatry in the UK - outlined in any number of policy documents, White Papers and so forth - was of the community as a single complex organizational space that would mirror, in administrative form, the complexity and diversity of the problems of mental ill health and the populations it embraced:
It is

children and adolescents with psychological problems ... assessment and treatment of adults whose conditions require short-term admission to hospital and for the longer term treatment, including asylum, of those for whom there is no realistic alternative... places in hospitals and... hostels, sheltered housing, supported lodgings ... for adults with a mental illness needing residential care outside hospital, together with an adequate range of day and respite services ... co-ordinated arrangements between health and social services, primary health care teams and voluntary agencies for the continuing health and social care of people with a mental illness living in their own homes or in residential facilities [including] domiciliary services, support to carers and the training and education of staff working in the
...

community.23

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12

Psychiatry would reintegrate its disparate aspects into an administrative network which would bring together the diverse subjects with which it now dealt alcoholics, offenders, disturbed children, pathological parents, as well as those suffering acute or chronic mental distress - the diverse sites in which it operated hospitals, clinics, hostels, homes, schools, mental health centres, social workers visits, general practitioners surgeries - and the diverse professionals who staffed psychiatrists, primary care workers, nurses, occupational therapists, psychotherapists, clinical psychologists and so forth - into a coherent community care system. The dream of psychiatry was to become a discipline of mental health.24 Within such a discipline, psychiatric professionals would have an additional role. They were not simply to cure or to contain, but to administer persons across this system, to make diagnoses which would be performative in the sense that they would determine where an individual would be directed within this archipelago of sites of professional-client interaction - halfway houses, concept houses, day-care centres, day hospitals, etc. As this new diagram of psychiatry begins to take shape, madness itself changes its significance. As mental ill-health, madness becomes fully disenchanted, little more than the lack of the capacity to cope with the exigencies of a world outside the asylum. Where madness is inability to cope, cure reciprocally becomes restoration of the capacity to cope, and the role of therapeutic professionals undergoes a parallel transformation. Professionals now are required not so much to cure, as to teach the skills of coping, to inculcate the responsibility to cope, to identify failures of coping, to restore to the individual the capacity to cope, and to return the individual to a life with which he or she can
it
-

cope.

PSYCHIATRYS NEW VOCATION

I
a

suggested

earlier that the

political vocation

of

psychiatry

was

undergoing

mutation, and that this could be understood by locating psychiatry in relation to

range of strategies of government that I have termed advanced liberal. For present purposes, advanced liberal strategies of government include the

following elements: extending market rationalities - contracts, consumers, competition - to domains where previously social, bureaucratic, or professional logic reigned; governing at a distance by formally separating activities of welfare professionals from apparatuses of central and local state, and governing them by budgets, laws, audits, targets, standards, codes of practice and the logics of consumer demands; making individuals and communities themselves interested in their own government in the sense that they should take responsibility for their own present and future welfare and for the relations which they have with experts and institutions.&dquo; Clearly the psychiatric domain poses a number of difficulties for such a logic given not only the presumed incapacity of psychiatric

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13

take responsibility for their own conduct, but also because of the elements of social protection which have been allocated to psychiatry over the last hundred years. Nonetheless, some of the characteristics of the contemporary psy- complex become intelligible when placed within the context of these changing political rationalities. A useful starting-point is the notion of risk.26 Robert Castel, in a paper which I have already drawn upon extensively, has argued that we have recently witnessed, within psychiatry, a shift from dangerousness to risk.2 Whilst dangerousness is a property of the concrete individual, risk, Castel suggests, is a combination of factors which are not necessarily dangerous in themselves: age of mother, type of family background, job record, type of housing.... We might extend this analysis further. We have seen the emergence of a notion of risk as a way of making intelligible and manageable a whole series of difficulties in our contemporary experience, from those of organizational management, through loss of work, to ill-health or criminal victimhood. The language of risk is indicative of a shift towards a logic in which the possibility of incurring misfortune or loss in the future is neither to be left to fate, nor to be managed by a providential state. Problems previously understood in other ways are recoded in the language of risk. New zones of intervention become visible and risk management is added to the responsibilities of individuals and authorities. Understood in this sense, the notion of risk enables us to highlight a number of related features of the contemporary vocation of psychiatry. The first concerns the way in which the subjects of psychiatry are delineated. Pat OMalley has recently drawn attention to the rise of what he terms a new prudentialism.28 This is a mode of thinking and acting in which individuals are increasingly held responsible for the management of their own fate and that of their families through a kind of calculation about the future consequences of present actions - a bringing of the future into the present and making it calculable and hence, in our dreams at least, manageable.29 Risks are to be identified, assessed, calculated, reduced, insured against by the prudent individual citizen, by the effective professional, or by the well-managed organization.3 Under the political rationalities and social devices of welfare, of which the paradigm is social insurance, the individual was to be bound into a nexus of social citizenship, social solidarity and mutual interdependency - a technology which was as much about inculcating a certain ethical relation of self to itself (contractual obligation, thrift, responsibility, regularity of contributions, etc.) as about securing the social against the dangers consequent upon loss or interruption of earnings, sickness, old age, etc. In the new regime of risk management, planning for the future becomes added to the responsibilities of active and enterprising individuals and families. They must now think of their present conduct in terms of risks to be calculated, averted and secured against. And they are surrounded by new experts: not administrators of social existence but advisors of personal risk. Individuals are invested with the responsibility to manage their own risk and to

subjects to

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14

take responsibility for failures to manage it. Risk management, in this sense, becomes a technique of the prudent self with simultaneous reconfiguration of logics of responsibility and censure. In terms of government, new relations take shape between technologies for the government of others and the modes in which human beings are to understand and govern themselves. What is the significance of this shift for the organization of psychiatry? I suggest that risk criteria (especially the division between high risk and low risk) underpin a revised set of dividing practices, dividing the prudent from the imprudent self, the self able to manage itself from the self who must be managed by others. The subjects of psychiatry are no longer unified by their institutional confinement, and the visibility which confinement conferred upon them, but by the fact that they are unable to manage themselves prudently in the matrix of encounters outside the asylum. Failures of management of the self, lack of skills of coping with family, with work, with money, with housing, are now all, potentially, criteria for qualification as a psychiatric subject. Even dangerousness is now recast; no longer is it construed as an essentially anti-social pathology lurking in the heart and soul of the individual, but rather it is the calculation of a combination of evidence about past conduct and professional judgements bearing upon the likelihood of failures to exercise the capacities of self-control and self-mastery over ones impulses towards others or feelings towards oneself. Level of risk has become the key criterion for intervention. The duty of self-management also provide a basis for new divisions within the subjects of psychiatry themselves. These divide between those good subjects of psychiatry who are medicine compliant, keep appointments, are able to assess their coping performance in a way that aligns with the assessment of professionals, and those who do not play the game of community care. The psychiatric subject thus lies at the junction of the self-managed world of the affiliated and the twilight world of the excluded. The ordered world of social problems is displaced by a new fragmented world of the excluded, in which there is a multiplication of categories of marginal persons such as the lone parent, the drug abuser, the alcoholic, the single homeless. This empire of the risky and the at risk becomes the space for the operation of a multitude of new professional organizations, quasi-governmental outfits, self-help groups and private profit-making institutions. The formation of this new spatial and ethical territory of exclusion, and the image of the excluded to which it is attached, is bound up with a new role for experts in relation to the marginalized. Hence one finds the use of all the psychological techniques of responsibilization in so many of these sites. Professionals become tutors - sometimes gentle, sometimes harsh - in the arts of self-management: keep your appointments, take your medicine, dont get drunk or violent - or you will lose your place in this project. The will to cure becomes little more than the inculcation of a particular type of relation to the self - prudent self-management, making contracts and abiding by them, setting reachable targets

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15

and achieving them, learning skills of management of everyday life. In the UK, at least, this new relation between experts and their clients is linked to the vicissitudes of the notion of empowerment. Empowerment has mutated from a term utilized by clients and advocates in the challenging of professional power to become part of the obligations of the responsible professional. Experts are now taught the techniques by which they can empower their clients, by which is meant according them the capacities for managing their own lives by way of acceptable logics of life-strategy. A whole range of types of intervention upon the capacities of the subject is now rearticulated in these terms. Particularly notable is the way in which behavioural techniques are no longer viewed as coercive and heteronomous incursions upon the subjectivity of the individual, but are widely deployed by doctors, clinical psychologists and psychiatric nurses as well as social workers and many others, as means for the re-empowering of the disempowered self, (re)-equipping the self with the skills necessary for autonomous coping with the tasks of conducting a prudent life of freedom and choice. A second feature of the new mentalities of risk is also significant in relation to psychiatry. This is the way in which the notion of risk reshapes the obligations of psychiatric professionals: risk management and risk reduction, as logics for professional action, have come to supplement or replace other forms of professional action and judgement. The dream of the early years of sectorization and community care was of a kind of hygienist utopia, which placed great faith in the powers of psychiatrists to devise measures of prevention, to diagnose conditions which did occur, to allocate them to treatments, to contain, moderate and even cure mental illness, in conjunction with a whole variety of other professional groups and in a wide range of specialist sites. While this dream of a rational, all-embracing and centrally directed system of mental health care still persists, these totalizing aspirations have become somewhat discredited - no doubt as much for their own pretensions and failures as for reasons of political ideology and pragmatism. It is true that the programmatics constructed in terms of risk sometimes appears to share this vision of total elimination of the accidental. Thus, according to a recent document on risk in the National Health Service, Whether considering a brain damaged baby, the administration of the wrong drug, the absence of fire fighting equipment, the lack of training in lifting techniques, or inadequacy of fire fighting equipment, it is morally indefensible to say &dquo;It was just one of those things&dquo; if it was possible to foresee and prevent the incident from happening - even once. 31 But the challenge of risk management, as it terms itself, is a challenge to each individual professional rather than to the abstract rational qualities of some overarching system. Risk management - the identification, assessment, elimination, or reduction of the possibility of incurring misfortune or loss - is to become an integral part of the professional responsibility of each expert; government of risk is to take place through a transformation of the subjectivity of each professional.

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16

Risk management also extends to the act of diagnosis.32 Previously, schematically, one might say that there was a kind of division of labour in the management of the mad person - diagnosis and treatment was the responsibility of the doctor, care and control was the responsibility of the nurse, assistance was the responsibility of the social worker. The clinical diagnosis by the psychiatrist was the fulcrum of this division of labour, even if, on the territory of the community, the actual management of the patient was to be undertaken by other experts and in other sites. Diagnosis by a medically qualified expert was thus a condition of entry to the territory of psychiatry and was performative, mandating a certain regime of drugs, detention or referral to a particular specialist institution, and so forth. However, new forms of diagnosis have emerged that challenge the pre-eminent role of the doctor. To quote Castel again: The site of diagnostic synthesis is no longer that of the concrete relationship with a sick person, but a relationship constituted among the different expert assessments which make up the patients dossier.33 The psychiatrist here loses his or her master-status as the locus of judgement. And judgement is, in any event, carried out only partially in medical terms. Diagnosis comes to operate also in terms of a variety of other forms of expertise about such matters as employment history, family life, coping skills, capacity to cook, shop and manage money, as well as information on past conduct and dangerous behaviour. Whilst the psychiatrist may formally remain in charge of the case - although even this is in doubt with the nomination of key workers from other disciplines - the terms of psychiatric judgement are no longer clinical (or even epidemiological, as Castel suggests) but what one might term quotidian: to do with the management of the everyday. The case of Christopher Clunis exemplifies this shift. The role of the psychiatric diagnosis in the management of this case was significant but restricted. Drug-induced psychosis, schizophrenia and other diagnostic categories were assigned by various medics at different points. However, the key question asked of the psychiatrist again and again was a different one: what should be done with this person, should he be sent to this institution or to that, to this hostel or that sheltered housing scheme, back into the community or back into prison? The logic of prediction comes to replace the logic of diagnosis - and this is a logic at which the psychiatrist can claim no special competence. What is at stake is the classification of the subjects of psychiatry in terms of likely future conduct, their riskiness to the community and themselves and the identification of the steps necessary to manage that conduct. And within this rationale, the medical institution is redefined - no longer a place of cure, it becomes little more than a container for the most risky until their riskiness can be fully assessed and controlled. Hence the multidisciplinary team, so beloved of the programmers as the solution to so many problems, emerges less out of the recognition of the diagnostic and curative significance of different sorts of clinical and social expertise, than out of the attempt to answer the administrative question: what is to be done and how can we decide.

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17

On the new territory of psychiatry, it thus appears that one is seeing a subordination of the medical to the administrative function of expertise. Richard Ericson has recently argued that police have become primarily knowledge workers and that their trade is now increasingly constituted by a knowledge of risk and risk management, through a meticulous collection and correlation of information - police as advisers to other agencies on the nature of risk, the riskiness of communities, areas and activities, and the means of avoiding and managing risk.34 Perhaps one might say that the functions of social protection previously accorded to psychiatry have now been reconfigured in somewhat similar terms: psy-professions are allotted the role of ensuring community protection through the identification of the riskiness of individuals, actions, forms of life and territories. Hence the increasing emphasis on case conferences,

multidisciplinary teams, sharing information, keeping records, making plans, setting targets, establishing networks for the surveillance and documentation of the patient on the territory of the community. Of course there is nothing particularly novel about the application of the logic of risk to the problem of pathological conduct. The notion of a risk register that has been proposed in the UK, on which all patients who have entered psychiatric hospital under a section of the Mental Health Act would be recorded, reactivates a pattern that has already been applied to child abuse for some two decades without notable success. We are certainly a long way from the position described by Castel, in which a general system for risk prediction of child abnormalities is proposed, upon which would be recorded a whole array of factors whose
connection with these abnormalities is abstract and statistical - age of mother, nationality, previous history of illness and so forth - and where a certain combination of such factors will set off an automatic alert and result in the despatching of a social worker to see the mother-to-be. Of course it is true that the new technologies of information-recording and coordination embody the possibilities of new modes of surveillance. Unlike the forms of individualization which were born in the 19th-century asylum - and the prison, school and hospital - these are not dependent upon the visibility conferred by the institution. Rather, material gleaned from a whole variety of sources, designated by diverse experts as risk factors, may be brought together to individualize a subject in terms of the likelihood of future offending, mental breakdown, child abuse, or whatever. But I am not convinced that the future lies in the totalization of these modes of surveillance, with the prospect of the prophylactic assignation and guidance of individuals to certain paths in a kind of rationalized dystopia. Rather, it seems to me, it is more likely that risk assessment and risk management will be enjoined upon individual professionals, governing them at a distance from the formal political apparatus, with the prospect held out of legal or other sanctions if they fail to take the proper steps to ensure that all risks are investigated, accounted for and weighed in the balance. The course of an illness may be unpredictable and operate according to an organic or esoteric logic for

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18

which neither the doctor nor the patient can be held accountable. But community protection may nonetheless be ensured by administrative rather than clinical means: by adding the administrative obligations of coordination, information, planning and so forth to the obligations of each professional involved. Of course, as the case of Christopher Clunis illustrates, techniques of administration that rely upon the coordination and evaluation of information and the initiation of timely preventative intervention are always failing. But failure does not lead to the abandonment of the dream of secure administration of troublesome sectors of the population according to a logic of normalization, risk reduction and neutralization, though this is certainly the lesson drawn by some. Nor does it lead to the demand for a rationalized national system of total surveillance, though others certainly raise this as a hope or a fear. Rather, it leads to demands for more information to be noted in better files, for more coordination between different professionals, for tighter standards, codes of conduct and so forth. Thus, speaking in August 1994 in the light of a report into homicides committed by discharged psychiatric patients, the UK Junior Minister of Health declared: The aim of our policy is to ensure a seamless chain of care around the discharged psychiatric patient in the community.35 But the response of his government was to seek not to reinvent the coordinated machinery of welfare psychiatry, but to develop procedures, targets, standards, audits, evaluations and the like. These would aim to establish mechanisms for control of professionals which would not bind them into a centrally directed bureaucracy, but would nonetheless shape and regulate their actions and decisions and hold them accountable for their consequences. This is, therefore, not a zero sum game - in this new psychiatric order, both subject and expert are to be regarded as responsible, playing their part in the strategy of reducing risk and minimizing harm under threat of sanction and within the disciplines imposed by a plethora of practices of blame.

CONCLUSION
It might be thought that in this over-general and schematic account I have chosen

oddly, for our contemporary field of mental health comes into being, above all, when it is suggested that the danger posed by frank insanity is but a tiny proportion of that vast cost in social inefficiency and personal unhappiness attributed to the psycho-neuroses. To redress this emphasis would require another paper. For the present, I would just say that, first, it is on the issue of community protection rather than the maximization of health through prophylactic means that our present problematizations of madness have come to turn. And second, that the rationalities of risk assessment, risk management and risk minimization have become features of our current experience of madness that are not confined to a small sector of the psychiatrized population. A few words in conclusion. The asylum conferred a certain unity upon the

my focus

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19

subjects of psychiatry and upon the project to underpin that institutional and moral unity with a unified system of knowledge. Whole libraries of psychiatric taxonomies are the legacy of that quest. The unity conferred by the territory of the community and the rationales of risk is less accessible to such utopian dreams of a totalized theory or taxonomy of madness, and to the claims for a single source of authority which go along with them. Perhaps, then, the current proliferation of claims to expertise in care in the community is not only an inevitable consequence of professional ambitions but arises from the diverse forms of visibility and manageability which appear in this new territory. For on the community many others, and not merely professionals, appear able to make a claim to knowledge and status - as, for example, in the assaults on psychiatry mounted by voluntary organizations made up of lay persons, frequently parents or relatives of users. And, more particularly, it is within this configuration that a
power may be accorded to those who are users, consumers, or survivors of psychiatry, as manifested in the growth of organizations of recipients of psychiatric ministrations in so many different countries. Thus the very
new

and contestability of knowledge which community psychiatry embodies and intensifies is not wholly without progressive possibilities. For if all others can claim their portion of expertise, so, perhaps, can those who have for so long been denied a voice in the system which governs them: the subjects of psychiatry themselves. Further, the disenchantment of transgression associated with the birth of the asylum transformed the subject of psychiatry into a case, a pathological entity suffering from an internal moral, psychological, or biological fault. This was linked to the elaboration of a series of technologies of cure that sought to access and transform that internal space by moral, chemical, psychological, or physical means. Perhaps the very superficiality of many of the new technologies of behavioural management, the demands that they place upon themselves for the active involvement of the users of psychiatry in the games of power that would manage them, opens up new possibilities for the contestation of psychiatric expertise. Like the logics of choice which inform so many advanced liberal strategies of management, they open new two-way relations between authorities and the subjectivities of those they would govern, relations that open new spaces for contestation and amplify the possibilities for legitimate disputation of

uncertainty

professional judgement. One is tempted to be less optimistic about the new open logics of surveillance and freedom under obligation that have replaced the confinement of the asylum. It was not only that the asylum, despite its overwhelmingly negative history, provided some scope at the margins for experimentation with regimes that would be less judgemental and more caring than those to which we have become accustomed in the forms of madness that now pass for normality. The management of populations in terms of communities of risk blurs the division symbolized by the walls of the asylum.36 We can all be allocated to risk

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20

may indulge in behaviour like drunk driving which poses risks to others as well as to ourselves, require guidance from experts as to how we should manage our lifestyle in order to reduce its riskiness. Practices of recording, accounting, monitoring, collecting and acting upon information in relation to risk have consequences for the values of liberty, democracy and civil rights which have been much discussed. But as Jonathan Simon has recently pointed out, perhaps more significant are the costs of the transformation of security into a value in its own right. In reconceptualizing accidents and misfortunes as calculable risks, and in holding professionals and politicians to account when these events occur, we allow all cultural practices to be vivisected at the micro-level and give our experts the duty of defining and managing them in order to eliminate or minimize any possible features that might prove dangerous.&dquo; It is not that these strategies and devices for total security will ever succeed in their ambitions. But rather, what one should be concerned about are the forms of life and the logics of culpability to which those obligations and ambitions are attached.

categories,

Goldsmiths
NOTES

College, University of London,

UK

Versions of this paper have been given at the Centre for Psychotherapeutic Studies, University of Sheffield, March 1994, and the Institute for the History and Philosophy of Science and Technology, University of Toronto, April 1994. This version was prepared for a Society for the Social History of Medicine conference, From Mental Illness to Mental Health, held at Sheffield, September 1994 and a conference on the History of the Human Sciences, at Melbourne, September 1994. Thanks to all for their comments and to Nigel Parton for letting me read his forthcoming work on risk in social work prior to publication. The ideas in this paper are heavily indebted to the work of Robert Castel.
1 Richie, Dick and Lingham (1994). 2 Rose and Miller (1992); Rose (1994a). 3 Rose (1994b). 4 I have derived many of the ideas in this paper from

a stimulating paper by Robert Castel (1991). 5 ibid.: 294. 6 This was the line taken by those who had been active in the mental hygiene movement in the interwar period and in wartime psychiatry. See in particular the report of the World Health Organisation under the chairmanship of John Bowlby. Also significant here was the role of major foundations such as Rockefeller. 7 On the work of Franco and Franca Basaglia and their colleagues, see Lovell and

8 See the reports of the 1950s. 9 Castel (1988).

Scheper Hughes (1987). Ministry of Health and the Chief Medical Officer during the

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21 10 11 12 13 14 15 16 17

A number of the points that follow are derived from Rose Esquirol (1838); Bucknill and Tuke (1869).

(1992).

Foucault (1961: especially Ch. 4). Gordon (1992). Cf. Markus (1993). Quoted in Rose (1992:146). Cf. Castel (1988); Scull (1993). Judith Walkowitz provides a detailed discussion of discussion of the history of hysteria, see Veith (1970). 18 Cf. Smith (1981).

one

example (1992).

For

19 Pasquino (1991). 20 Pick (1989). 21 On the mental hygiene movement, see the discussion in Rose (1985). 22 Cf. Armstrong (1983). I discuss this further in Rose (1985). 23 Caring for People (1989: 55). This rationale was first laid out comprehensively in the 1975 White Paper Better Services for the Mentally Ill. 24 Rose (1986). 25 Rose (1994a). 26 Note that this way of understanding the salience of risk calculations in our present is

rather different from that entailed in Ulrich Becks proposition that we live in a risk society (Beck, 1991). While this paper was in proof, I read some recent work by Nigel Parton which makes similar arguments in relation to the current obsessions with risks in social work and their role in the blaming system (Parton, 1996).

Castel (1991). OMalley (1992). While the new prudentialism shares many features with the forms of prudentialism advocated in the 19th century, the differences lie in at least three features: the novel forms of autonomization of the subjects of risk; the role of market-based insurantial expertise; the new objectives of prudentialism in terms of lifestyle maximization. 29 Hacking (1992). 30 For an example of this logic applied to the health service itself, see NHS Management
27 28

31 32

33 34

(1993). See also Parton (1996) for a discussion of the Risk Initiative undertaken by the Social Services Inspectorate. ibid.: ii. One could also argue that diagnosis itself has today become a matter of probabilities. It is no longer solely a question of the identification of a condition according to a fixed and categoric taxonomy. Diagnosis itself becomes statistical: a matter of describing a concatenation of indicators, co-occurring in certain regular patterns. No doubt the statisticalization of diagnosis goes back at least to the emergence of the social psychiatries in the middle decades of this century, and the psycho-epidemiologies of the 1960s and 1970s. Nonetheless, the conduct of diagnosis in probabilistic terms is entirely amenable to its new role - to make predictions as to the future course of events with a view to developing expert strategies for administering the subjects in a way that minimizes their riskiness. Castel (1991: 282). R. Ericsons paper delivered to a workshop on Radically Rethinking Regulation, University of Toronto, Centre for Criminology, April 1994.
Executive

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22 35

John Bowis, Junior Health Minister, radio interview, BBC Today programme, Radio

4, 17 August 1994. 36 Cf. Cohen (1985). 37 Simon (1994:38). BIBLIOGRAPHY

Armstrong,

D.

(1983) The Political Anatomy of the Body. London: Cambridge

University Press.
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Caring for People: Community Care in the Next Decade and Beyond. Cm 849. London:
HMSO.

Castel, R. (1988) The Regulation of Madness: The Origins of Incarceration in France ,

trans.

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Cambridge: Polity. Effect: Studies in Governmentality .

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Castel, R. (1991) From Dangerousness to Risk, in G. Burchell, C. Gordon and P. Miller

(eds)

The Foucault

Hempstead, Herts:

Crime, Punishment and Classification. Cambridge: Polity. Esquirol, J. E. D. (1845) Des maladies mentales considérées sous les rapports médical, hygiénique et médico-légal. Paris: Baillière. Foucault, M. (1961) Histoire de la folie à lâge classique. Paris: Plon. Gordon, C. (1992) Histoire de : la folie an Unknown Book by Michel Foucault, in A. Still and I. Velody (eds) Rewriting the History of Madness. London: Routledge. Hacking, I. (1992) The Taming of Chance. Cambridge: Cambridge University Press. Lovell, A. and Scheper Hughes, N., eds (1987) Psychiatry Inside Out: Selected Writings of Franco Basaglia. New York: Columbia University Press. Markus, T. (1993) Buildings and Power: Freedom and Control in the Origins of Modern Building Types. London: Routledge.
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Pick, D. (1989) Faces of Degeneration: a European Disorder, c.

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23

Rose, N. (1992) Of Madness Itself: Histoire de la folie and the Object of Psychiatric

History, in A. Still and I. Velody (eds) Rewriting the History . of Madness London: Routledge. Rose, N. (1994a) Government, Authority and Expertise under Advanced Liberalism, Economy and Society 22(3): 273-99. Rose, N. (1994b) Medicine, History and the Present, in C. Jones and R. Porter (eds) Reassessing Foucault: Power, Medicine and the Body. London: Routledge. Rose, N. and Miller, P. (1992) Political Power beyond the State: Problematics of Government, British Journal of Sociology 43(2):172-205. Scull, A. (1993) The Most Solitary of Afflictions: Madness and Society in Britain
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IL:

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Chicago

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