1-9 Discipline and recovery: A Foucauldian perspective on schizophrenic discourse
Schizophrenia in popular American discourse is often portrayed as the most chilling of the mental disorders. While mental illness in general is stigmatized, schizophrenia provokes the most dramatic images of madness: hallucinations, paranoia, delusional beliefs, and catatonic patients stretched out in rigid stupor all leap to mind. Though there has been great advancement in the cultural understanding and acceptance of disorders like depression and anxiety, these are seen as ‘gentle,’ everyday sorts of illnesses from which schizophrenia remains in stark contrast. Both advertisements for psychotropic medications as well as psychology textbooks softly persuade consumers that their own fathers, lovers, or even themselves may have experienced depression, but for schizophrenia there are no such lullabies: they are the last bastion of the truly “insane.” Recovering from schizophrenia is seen in the most mainstream of psychiatric communities as an unfunny joke (McGuire, 2000); and in the more progressive, a dim, future hope.
Though there are obligatory nods in diagnostic descriptions to recovery from schizophrenia, it is readily acknowledged in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) IV Text Revision that “the course is typically chronic” (DSM-IV-TR, 2000, p. 307). Schizophrenia is also characterized as a genetic or “brain disorder,” (“schizophrenia,” 2009) typically limiting not only the kinds of treatment, but also the perceived possibility of a cure. Though treatment options are ventured, these are generally viewed as containing, rather than curative measures (ibid) and the view of the person experiencing a schizophrenic break quickly moves from situational to permanent, a matter of being.
In Discipline and Punish, Michel Foucault ventures a brief genealogy of the prison system and its subjects. Therein, he introduces two very important concepts in the evolution of the prison: the move from punitive to disciplinary power, and the distinction that is created between the “offender” and the “delinquent.” To paraphrase briefly: while the offender is tried only for his crime, the delinquent is tried for his life, and turned into a kind of permanent offender by the system that purports to assist him. While Foucault does not explicitly draw them here, his conceptions of the delinquent and offender are ripe with parallels to the categorization and organization of mentally ill persons. The present discussion will focus on these concepts and illuminate how the schizophrenic patient represents a ‘psychological delinquent:’ one who is forged by and continuously at the behest of the psychological system of power and knowledge as a chronic offender. By examining the different “truths” produced about the nature of schizophrenia cross-culturally, we can challenge the bio-medical view championed in the West and explore other explanations for why schizophrenia is so often a chronic disorder in certain cultures.
I will follow Foucault’s advisement that it is misguided to question the supposed failures of a system and instead examine the ways in which those failures are actually succeeding in constructing and creating something in the service of the same system. Foucault posits that in studying techniques of power, it is ill-advised to focus “on their ‘repressive’ effects alone… but [must] situate them in a whole series of their possible positive effects” (Foucault, 1975/1995, p. 23). Taking this up, I will explore the ways in which psychological system in the United States, while it fails to help people distressed from schizophrenia, succeeds in producing an entire class of psychological delinquents, thus defining the “external frontier of the abnormal” (Foucault, 1975/1995, p. 180), and subsequently creating a need for itself in society.
The truth(s) about schizophrenia
I will first briefly examine what constitutes a diagnosis of schizophrenia. According to the DSM IV-TR schizophrenia is classed as a psychotic disorder and primarily characterized by hallucinations, delusions and “bizarre” thinking. The diagnosis also includes the possibility of other positive symptoms such as “disorganized speech, grossly disorganized or catatonic behavior” (DSM-IV-TR, p. 297) and negative symptoms such as a lack of affect, “poor eye contact and reduced body language,” “decreased fluency or productivity of speech,” and/or an “inability to initiate and persist in goal directed activities” (DSM-IV-TR, p. 301). While these are the criteria that must be met in order to make the diagnosis, it would be short-sighted indeed to say that these symptoms alone comprise the discourse around schizophrenia. Rather, two extremely important elements must be examined in order to form a more holistic picture of schizophrenic discourse in the United States: cause and course.
While the DSM, by design and rule, cannot comment on disease etiology, a quick look through the “schizophrenia” section of any classroom psychological text will reveal a discussion of decreased brain tissue, increased basal ganglia, lessened cerebral blood flow, enlarged ventricles, glutamate hypotheses and, most commonly, the dopamine hypothesis. In the simplest of terms, the hypothesis states that schizophrenia is the result of too much dopamine in the brain, either because of “excessive levels of synaptic dopamine, or from excessive postsynaptic sensitivity to dopamine” (Breedlove, Rosenzweig, & Watson, 2007 p. 491). The evidence for this (in humans) has been constructed, in part, accidentally—Parkinsonian patients who were administered a dopamine increasing drug too frequently began to show symptoms of schizophrenia—and in part retroactively, as drugs that suppress dopamine production or binding seem to lessen the positive symptoms of schizophrenia (ibid). These drugs, called neuroleptics, continue to be the most common kind of treatment for persons diagnosed with schizophrenia (ibid). While the DSM does not offer speculations on etiology of any sort, it is clear from even a casual survey of the literature, and the standard course of treatment – brain chemical alteration – where the trouble is suspected to lie. Schizophrenia in the West is conceived of as a largely, if not wholly, neurological impairment.
It is perhaps precisely this medical-genetic explanation that leads recovery expectations for schizophrenic patients to be so bleak. While the DSM notes that the “course may be variable” (p. 308) in schizophrenia, it quickly follows up that “complete remission… is probably not common in this disorder,” (p. 309) and that the course “is typically chronic” (p. 307). The National Institute for Mental Health characterizes schizophrenia as a “chronic, severe, and disabling brain disorder” for which “there is no cure” (“schizophrenia,” 2009). The American Psychological Association admits that “at the most optimistic of times…perhaps 10 to 20 percent of those with schizophrenia might achieve recovery” (McGuire, 2000). And just what does “recovery” even mean? Part of the problem of reporting schizophrenia recovery statistics is that ‘recovered’ often means “doing better, but still mentally ill” (Unger, 2009).
In keeping with the rhetoric of ‘no cure, but treatment’ schizophrenia is often likened to a physical disability – though a double amputee can never return to his exact way of walking prior to his injury, he can have a wheelchair, prosthetics, or other devices that will aid his movement. However, no matter how smooth the use of these supplements, the person will never be characterized as a walking person with two legs again and he is, in this sense, permanently disabled (or at least, permanently lacking legs) (Unger, 2009). Likewise, the poor recovery rate from schizophrenia is said to be correlated to its etiology. Because schizophrenia is conceived as the result of a physical problem that cannot be permanently altered, the person who is diagnosed, even at their healthiest of times, will always carry the problem and, more likely than not, even their healthiest of times will bear its mark. This focus on the physical, on the “brain disorder” that is schizophrenia quite naturally leads to a sense of permanence: one does not “have” schizophrenia, like one might a cold, or a bad mood, rather, one is schizophrenic. The problem’s longevity is the fault of the problem itself.
Or is it? By 1960 the dramatic and debilitating characterization of schizophrenia and other psychotic disorders (such as psychosis and schizoaffective disorder) had caught the interest of the World Health Organization (WHO), which began taking steps to conduct a series of studies on global occurrences of schizophrenia. The first of the ground-breaking WHO studies, the International Pilot Study on Schizophrenia (IPSS) recruited roughly 1200 patients meeting diagnostic requirements in nine different nations and compared the course, treatment, and outcome of their mental illnesses (Jablensky & Sartorius, 2008). This preliminary study answered WHO’s first major question – there were, in fact, patients displaying characteristically similar presentations of schizophrenia or psychosis at each one of the centers around the world.
Intrigued, WHO launched a follow up study to assess the feasibility of tracking these schizophrenic/psychotic patients over a more longitudinal course. This follow up study not only demonstrated that it was possible to re-connect with these patients in a rigorous and consistent manner, but also found something quite unexpected: in the two year gap between the IPSS and follow up, the course of the selected patients was quite variable – 37% were still psychotic, 31% were symptomatic but not psychotic, and 32% were entirely asymptomatic (Hopper, Sartorius, Harrison & Janca, 2007). There was also a great amount of variability from one center (nation) to the next. Patients in Nigeria and India showed the best overall outcomes, with less than ten percent falling into the ‘worst outcome’ category, while Denmark, the United States, China, and Czech Republic had the worst overall outcomes (Jablensky & Sartorius, 2008). One immediate congruency leapt out at WHO researchers: patients in developing nations seemed to fare much better, on average, in the course and outcome of their schizophrenia than schizophrenic patients in developed nations. Despite analyzing variables such as the patient’s specific symptoms, environment, onset and others, no one factor seemed to be significant enough to account for the difference.
Vexed, WHO undertook yet another study, tightening their methods, tools, and design and expanding their population to include anyone meeting diagnosis from any public service or welfare agency (i.e., not simply psychiatric offices but prisons, religious centers, healers and other community centers) for the Determinants of Outcomes for Severe Mental Disorders study (DOSMeD) (Jablensky & Sartorius, 2008). This study used 12 nations and 1379 patients, and once again found that patients in developing countries tended to have a much milder course of illness, with 56% of patients in developing nations being characterized as mild, versus 39% in developed nations (Hopper, Sartorius, Harrison & Janca, 2007).
Intriguing as these findings were, they were still only preliminary for WHO, who then set out to test the longitudinal cohesion of these initial theses in the now famed International Study on Schizophrenia (ISoS). Following three of the IPSS cohorts for 26 years and seven of the DOSMeD cohorts for 15 years, WHO researchers located as many living members of each cohort as possible and conducted stringent testing at two and five year marks. Of the incidence group (those who had been followed since the first psychotic episode) 56% were fully “recovered” – having no symptoms of their previously diagnosed psychotic disorder currently or in the past two years. Of the prevalence group (those who had entered into the study on a second or later psychotic break), 60% were recovered. (Hopper, Sartorius, Harrison & Janca, 2007). Most astonishingly, the percentage of people who met “excellent” or “good” criteria on one measure (Global DAS) in developing countries was twice the percentage of those in developed countries (53% versus 24%) (Hopper & Wanderling, 2000).
So it would seem the “truth” about schizophrenia, is actually “truths.” While the Western medical model asserts that the disorder is a “chronic, severe, and disabling brain disorder” (“schizophrenia,” 2009), it appears that for vast chunks of the world, this particular truth is not descriptive of schizophrenia or even accurate. Despite the ascendency of the bio-medical model, evidence based and irrefutable, WHO, and its worldwide cohorts, refute this constructed truth. Schizophrenia, it appears, may not be chronic, severe, or even a brain disorder. How then can we account for these provocative findings? If the truth about schizophrenia isn’t necessarily true, why do we keep reporting it? Why do we continue to hospitalize, medicate, and tell our schizophrenic patients that they will likely never recover?
Power/knowledge in psychiatry
In the opening chapter of Discipline and Punish, Foucault outlines his goals for the book, one of which is to not consider the history of the prison and the history of the human sciences independently from each other but rather to discern if there is “some common matrix” between them (Foucault, 1975/1995, p. 23). This “common matrix” is in fact, the very practice of power and knowledge as one in the same. As Foucault goes on to illuminate: “the technology of power [is] the very principle both of the humanization of the penal system and of the knowledge of man” (ibid).
In his genealogy, Foucault details an expansion of the judging panel to include psychiatrists and psychologists who can hand down (in addition to the offender’s sentence) “judgments of normality, attributions of causality, assessments of possible changes, anticipations as to the offender’s future” (Foucault, 1975/1995, p. 20). It is the psychiatric system that was able to implement and speak with authority to what is ‘normal’ and with it, “the norm [which] introduces, as a useful imperative and as a result of measurement, all the shading of individual differences” by which persons can then be categorized, diagnosed, made abnormal (Foucault, 1975/1995, p. 184). This examination, and subsequent “shading” of the person, is only made possible by the introduction of the psychiatric gaze and diagnosis, and Foucault notes that the “moment when the science of man became possible is the moment when a new technology of power” became possible (Foucault, 1975/1995, p. 193). This technology of power is what Foucault terms disciplinary power.
In the works of Foucault, power takes on a new definition beyond that of the colloquial: it is “no longer repressive, but productive; does not say no but yes; does not prevent, but invent” (Caputo & Yount, 1993, p. 8). Foucault also admonishes that power “cannot be localized in a particular type of institution,” rather “[w]hat the apparatuses and institutions operate is, in a sense, a micro-physics of power” (Foucault, 1975/1995, p. 26). The “micro-physics” of power is one of Foucault’s most important concepts, fundamental to an understanding of the connection between power and knowledge, and how the psychiatric system exerts power/knowledge over patients.
Foucault wants to disengage the notion of power from the material thought of possession, in which power is something one has or does not have. Rather, Foucault posits that we ought to conceive of power “not as a property but as a strategy,” as something that is “exercised rather than possessed” (Foucault, 1975/1995, p. 26). Secondly, Foucault argues that everyone exercises power; if power is something one ‘does’ rather than one ‘has,’ we can take away the privilege of power and recognize that “these relations [of power] go right down into the depths of society” (Foucault, 1975/1995, p. 27). And it is the relations that are key; for Foucault, wherever there are humans, there are power relations. Power is in the mundane, the everyday, the small practices, the ways in which we talk, gesture and look at each other, in the “dispositions, manoeuvres [sic], tactics, techniques, [and] functionings” (Foucault, 1975/1995, p. 26) of every person, every day. Finally, and perhaps most salient to the present discussion:
power produces knowledge….[and] power and knowledge directly imply one another…there is no power relation without the correlative constitution of a field of knowledge, nor any knowledge that does not presuppose and constitute at the same time power relations (Foucault, 1975/1995, p. 27).
Foucault posits that within any system, including the psychiatric system, knowledge does not beget power but knowledge is power, or rather “[k]nowledge is what power relations produce in order to spread and disseminate all the more effectively” (Caputo & Yount, 1993 p. 9). And, as power and knowledge directly imply each other, “without power, no ‘truth’ could be brought forth at all” (ibid).
Foucault delineates the difference between punitive power and contemporary disciplinary power in several ways that are congruent with the operations of the psychiatric system. Firstly, he notes that disciplinary power “refers individual actions to a whole that is at once a field of comparison, a space of differentiation and the principle of a rule to be followed” (Foucault, 1975/1995, p. 182). In psychiatry, we can liken this to the truth-producing diagnostic manual. An individual’s symptom is immediately made sensical within the larger field of mental health, and the mental health field depends on a highly convoluted diagnostic system to aid it. Within this system, the individual’s actions are compared to others in the “normal” group, to others within various illnesses, and to others within his own diagnostic category to determine his exact shade, the particular strand of his disease (“differential diagnosis” [DSM-IV-TR, 2000]). A diagnosis at once refers to itself and to all the diagnoses it is not, and in and of its own constitution as an abnormal trait makes note of the “power of the Norm” (Foucault, 1975/1995 p. 184).
Disciplinary power also “differentiates individuals from one another,” (Foucault, 1975/1995, p. 182) differential diagnosis being perhaps one of the most common practices of the psychological community. Indeed, every new edition of the DSM continues to grow, burgeoning with new distinctions, differentiations, slight variances in how abnormal one might be. Foucault draws a contrast between disciplinary power and judicial punishment, which operates only with the “permitted and the forbidden,” or, in the present discussion, the sane versus the insane. As opposed to this binary system, the DSM has an ever-increasing diagnostic system of differentiation to discipline patients within their specific categories. These categories then are dependent on a system of “non-observance, that which does not measure up to the rule departs from it” (Foucault, 1975/1995, p. 178). Foucault writes that “the power of normalization imposes homogeneity; but it individualizes by making it possible to measure gaps, to determine levels, to fix specialties,” in short, to separate each one from the next (Foucault, 1975/1995, p. 184).
Also characteristic of disciplinary power is that it “measures in quantitative terms and hierarchizes, in terms of value, the abilities, the level, the ‘nature’ of individuals” (Foucault, 1975/1995, p. 183). This is shown again quite clearly in the process of diagnosing itself. By saying this behavior is a symptom of illness and this is not, then further subdividing each diagnosis into specially characterized parts (paranoid schizophrenia, catatonic schizophrenia, disorganized schizophrenia, etc) and then assigning each subdivision a possibility of mild, moderate, or severe, a hierarchy is immediately and obviously set in place. Not only are the characteristics and levels of disease ferreted out from deep inside the person, but they are measured on any number of tests, tools, and questionnaires to rate the level of abnormality.
The disciplinary power of psychiatry then “introduces, through this ‘value-giving’ measure, the constraint of conformity that must be achieved” (Foucault, 1975/1995, p. 183). In other words, normalcy is defined by an absence of the symptoms laid forth as abnormal. By valuing asymptomatic behavior and devaluing symptomatic, by even creating what is a “symptom,” the psychiatric system exerts disciplinary power by creating truth as to what normality is and what the patient must do and become in order to be accepted. For the patient “all behavior falls into the field between good and bad;” symptomatic or not (Foucault, 1975/1995, p. 180). Lastly, disciplinary power must define for its subjects “the external frontier of the abnormal,” (ibid), that is, the truly crazy. If there is a standard of normalcy to point to, so must there be an absolute of abnormalcy, and it is here where the schizophrenic patient lies: the worst of all offenders, the frightening conclusion of a continued path down aberrancy.
Before we begin a discussion of how the schizophrenic person constitutes a psychological delinquent, we must of course define the term as Foucault particularly uses it. As Discipline and Punish is a text about punitive and penal history the language is used accordingly, but we will find that with relatively little modification, the same terms apply richly to the psychiatric system and its subjects. Though Foucault hints at such an analysis – “one might understand both how man, the soul, the norm or abnormal individual have come to duplicate crime” (Foucault, 1975/1995, p. 24) – we will explore this in greater detail and extend the ways in which psychiatric and penal power/knowledge not only imply and form each other, but also mimic the concept of delinquency within their structures.
In Foucault’s discussion “crime” is used to denote an offense—in particular, one against the laws of society—whereas in psychiatry we can define a crime as an offense against the laws of normalcy in society. Hallucinations would be criminal, to be sure, but also an act of crying inappropriately in public, washing one’s hands too often, having beliefs that are “bizarre” or not shared by society – all these represent crimes against the normal, against the law of the ordinary. Anyone who commits such a crime, in Foucauldian language, is an offender: that is, quite plainly, one who offends. An offender breaks society’s rules (be they laws or normalizing judgments) by his offense and, if caught, will be tried and punished.
We can liken this character within the psychiatric system to a mildly depressed or anxious person. While depression and anxiety are certainly quantifiable and diagnosable disorders that depart from the norm in some way, they are the “little everyday disorder” (Foucault, 1994, p. 182) that is a singular crime, merely uncomfortable for society to witness. Too much worrying, too much crying, too much sleeping—all are subject to the “normalizing gaze” (Foucault, 1975/1995, p. 184) of the psychiatric judges, but not matters of much concern, overall. With a little therapy, or a quick psychoactive regime, these crimes will be swiftly judged (diagnosed) and punished (treated) into oblivion, assumed unlikely to occur again. These kinds of “crimes” are thought to be of a generally less severe nature, and brought on more readily by context – like the thief who steals to feed his family, so can the depressed person who recently lost his job hardly be fundamentally to blame for his crime.
The delinquent, on the other hand, represents a new invention of a person, a sort of substitute for the offender. The delinquent differs from the offender chiefly in that “it is not so much his act as his life that is relevant in characterizing him” (Foucault, 1975/1995, p. 251). The delinquent is a person to be known, wholly and biographically, as a fundamentally “dangerous individual” (Foucault, 1994, p. 178). As opposed to the offender, whose offense stands on its own, apart from the essential character of the one who commits it, the creation of the delinquent “establishes the ‘criminal’ as existing before the crime and even outside it” (Foucault, 1975/1995 p. 252). Hand in hand with this biographical distinction is the difference that the delinquent “is not only the author of his acts… but is linked to his offence by a whole bundle of complex threads (instincts, drives, tendencies, character)” (Foucault, 1975/1995, p. 253). The delinquent’s entire life is put on trial with his offense, and then, in the evidence of his life, he is jailed within the offense itself, his very life and being betraying him as not just the perpetrator of a crime, but as in his essence, criminal. Foucault writes that in the new disciplinary power “[i]t is no longer simply: ‘Who committed it [the crime]?’ But: ‘How can we assign the causal process that produced it? Where did it originate in the author himself?’” (Foucault, 1975/1995, p. 19)
The delinquent is also an unnatural person, a creative fiction invented by the disciplinary system itself. The delinquent replaces the offender with his crime and instead stands with the “little soul of the criminal, which the very apparatus of punishment fabricated” (Foucault, 1975/1995, p. 255). While anyone may offend, given the right set of circumstances, a delinquent is a perpetual offender, an offender who has been subjected to the judging and individualizing of the psychiatric panel, and has come up as not just offending, but offensive. The delinquent is an offender who has been put through the “essentially corrective” (Foucault, 1975/1995, p. 179) paces of the disciplinary system and come out the other end marked, crippled, unable to do anything but offend, unable to live any truth but the truth that he is, and always will be, a delinquent. The recidivism of the delinquent is a key characteristic to which we will return, and Foucault delineates several points as to how the prison “cannot fail to produce delinquents” (Foucault, 1975/1995, p. 266) who will then of course, need to be imprisoned again. In as much as it is true that “the prison fabricates delinquents, it is that it brings them back, almost inevitably” (Foucault, 1975/1995, p. 255).
The schizophrenic delinquent
How then, as has been suggested, does the schizophrenic patient constitute this secondary character of the delinquent? Firstly, and most poignantly, is the production, the fabrication, of the chronic schizophrenic by the psychiatric system. As the delinquent is manufactured by the prison system of examination, normalizing judgment and punishment to ever return to it, so too is the schizophrenic patient created as a constantly recurring nuisance, a chronic creature for the psychiatric system to keep ‘rehabilitating.’ We see this in the very language of reference itself – where there are depressed persons, or anxious persons, there is, in contrast, a schizophrenic. Though the shift may seem negligible or meaningless, language is one of the subtle, corrective forms that disciplinary power uses – the person with schizophrenia is rebuked, she does not have schizophrenia, she now is schizophrenic. We can liken this to Foucault’s description of the delinquent: “for a long time the criminal had been no more than the person to whom a crime could be attributed… today the crime tends to be no more than the event that signals the existence of a dangerous element” (Foucault, 1994).
The psychotic break may be the crime, but it is only the signaling of something already broken in the schizophrenic. This “dangerous element” will then be borne out over the course of the schizophrenic person’s life; as we have seen from the WHO studies, shockingly few American patients ever recover from schizophrenia, though this is not a biological fact. Rather it is a truth, a discourse that is foisted upon the schizophrenic person through “clinicians who imagine a hopeless future” and treat their patients so that “ultimately the patient learns of this” (Scheflen, 1981, p. 17).
When the schizophrenic person enters into the hospital (almost invariably the course of action for someone experiencing a first time psychotic break, either willingly or forcibly), they are subject to “certain rites of passage” (Scheflen, 1981, p. 24). These are commonly some form of “compliance with ward rules” and always that the person “must achieve ‘insight’ or an acceptance that he or she is mentally ill” (ibid). This ‘insight into illness,’ still championed in most every area of mental health treatment, is akin to the “confession” of religious practice that Foucault parallels in the psychological community (Foucault, 1976/1978). Here the patient is required to come into agreement, collusion, with the very people who are keeping her (often forcibly) in the hospital.
The patient cannot say to the doctor “I am not experiencing psychotic symptoms, I am no longer schizophrenic, I would like to go home,” even if she is telling an observable truth (Rosenhan, 1973). Even a patient who is non-psychotic will be turned away, forced to take anti-psychotic medication, and likely not released until they have ‘insight,’ until they confess their fundamental criminality and realize that they are and always will be sick (ibid). Even in DSM diagnostic criteria, we see that a diagnosis of schizophrenia can be met by a mixture of various symptoms “that have been present for a significant portion of time during a 1-month period (or for a shorter time if successfully treated)” (DSM-IV-TR, 2000, p. 298, italics added). Here we see that a person can be diagnosed for having a psychotic experience, even if it has stopped and they are not experiencing any symptoms, belaying the very fundamentally chronic conception of schizophrenia.
There is also significant evidence from the WHO studies and others (e.g. Whitaker, 2001; Breedlove, Rosenzweig & Watson 2007) that the very medication being given to schizophrenic patients not only has devastating side effects, but may contribute to their continuing psychosis. In addition to their neurological effects, we can also consider the continuing effect neuroleptics have in terms of power/knowledge: when the patient is given a medical treatment, they are informed it is because they have a medical disorder—a brain disorder to be specific, the kind of thing that is not in the habit of merely passing through. Foucault comments that “starting in the eighteenth century human existence, human behavior, and the human body were brought into an increasingly dense and important network of medicalization that allowed fewer and fewer things to escape” (Foucault, 1994, p. 135). This medicating and other “rites of passage” are supposedly performed in the interested of helping the patient but instead “tend to maintain a dependency upon family, staff members and institutionalization and to confirm mental health conceptions” (Scheflen, 1981, p. 24-25). The very process that purports to heal in fact does quite the opposite, creating a need, a deficiency, a dependency for life, where there were previously only a handful of troubling symptoms. The medicalizing discourse, subsequent treatment, insight into illness and labeling language all serve to form the schizophrenic as a chronic being, a delinquent.
Sadly, both the schizophrenic and the delinquent share a future that will be forever marked by the crime. Foucault relates the story of a young man who, upon being released from prison could not work, live or eat; his passport marked with his sentence and his options for work and housing restricted, he eventually took to crime again and of course, wound back up in the prison (Foucault, 1975/1995, p. 267-268). The schizophrenic person is branded by his ‘crime’ in a very similar way:
The diagnosis of schizophrenia accompanies the patient and colors his management in each facility of the network. If a patient with such a diagnosis goes to a medical facility, his credibility is suspect when he complains about symptoms. When he seeks to leave the umbrella, the diagnosis will adversely affect his ability to obtain a job (Scheflen, 1981, p. 26).
So we see that, like Foucault’s delinquent, the schizophrenic is a creature fashioned by the psychiatric community itself and prone to recidivism (which does not occur in other systems, as the WHO studies show us) and one who is marked and dependent on the disciplinary system.
The schizophrenic person is also a delinquent insofar as “it is not so much his act but his life that is relevant” and he is “defined by variables which at the outset at least were not taken into account” (Foucault, 1975/1995, p. 251). Endless amounts of schizophrenia-related research can attest to this with their quests into the schizophrenic’s background: Was her mother inconsistent, or her father absent? Was she a loner in school or did she hold childhood ‘magical beliefs’ too long? Did her twin grown up to be schizophrenic too?
When Rosenhan conducted his now famous study using confederates—perfectly ordinary undiagnosed individuals who got themselves admitted to psychiatric hospitals under the audiological auspices of hearing ‘thud’—he found something quite startling: the confederates’ backgrounds were suddenly adapted to fit the illness their diagnosis belayed. Though none of the confederates had actually had a psychotic experience, or any diagnosable illness, and though they behaved normally once admitted to the hospital, their behavior and past lives were altered in reverse to meet the present circumstances. “Patient histories” that had never raised alarm when told at cocktail parties to colleagues or whispered in lovers’ ears were suddenly indicative of every kind of psychotic feature the person was now ‘known’ to have (Rosenhan, 1973).
As Scheflen writes “[t]he practices and outcomes maintain and verify the preexisting conceptions” (Scheflen, 1981 p, 17, italics original). All the pieces of the patient’s life are suddenly tied together in a neat, supportive package that reinforces the present notion – as they are sick, so they always were sick. Thus, like the delinquent, the schizophrenic is tied, inexorably, to her ‘crime’ by “the whole system of relationships that link the act to the interests, the plans, the character, the inclinations, and the habits of the subject” (Foucault, 1994, p. 188).
Whom does the schizophrenic delinquent serve?
And so the question is begged – why do all this? Why convince the person experiencing schizophrenia, through language, through insight, through medicine, through her life and future themselves, that she cannot ever become well again? Whom does it benefit? Here we can follow Foucault directly. Firstly, it clearly benefits the system itself. By creating a class of perpetual delinquents, there will always be a need for psychiatric hospitals to house them, therapists to soothe them, pharmaceuticals companies to normalize them. Like the prison, the psychiatric system invents delinquents and thusly succeeds in making itself “natural and legitimate” (Foucault, 1975/1995, p. 301), genuinely necessary for societal functioning. By employing the truth of chronic schizophrenia, all realms of the mental health community get to keep each patient, each customer, for a lifetime rather than a scant few years. Everyone in psychiatry gets funding for more institutions, more research, and more clinical trials, because everyone in society knows that they are needed.
Secondly, delinquency acts as “an agent for the illegality of the dominant group” (Foucault, 1975/1995, p. 279). It is the schizophrenic to whom all the depressed, anxious, and obsessive-compulsive patients can look to with a sigh of relief. The schizophrenic diagnosis is the “external frontier of the abnormal” (Foucault, 1975/1995, p. 180) that lessens all other diagnoses in comparison. As Foucault explains, “while differentiating itself from other popular illegalities, delinquency serves to keep them in check” (1975/1995, p. 279). The schizophrenic person keeps the depressed or anxious one from going ‘too far’; she heralds what may happen, but is not yet happening. Or, as Scheflen paraphrases “So what is the moral? I think it is this: ‘Obey. Mind your p’s and q’s. Develop your character or else.’ ‘Or else what?’ ‘Or else you too may become psychotic’” (1981, p. 15). The schizophrenic is the boogeyman to whom the psychiatric community can point to as they hand out anti-depressants to their more benign subjects – see what happens if you don’t let us help you?
Similarly, while the schizophrenic delinquent serves to differentiate and check other ‘crimes of normalcy,’ she also serves to define madness for the general population. Schizophrenia is characterized as a “public disorder,” (Breedlove, Rosenzweig & Watson, 2007, p. 482) wherein the sufferers often end up on the streets and, regardless of where they are, their active symptoms are so dramatic as to be instantly visible to all. They serve as visual cautionary tales to the masses: this is what madness is. We can point to it, see it, hear it, and be safe from it. Scheflen writes that “deviance is critical for maintaining social cohesion and for exemplifying the desirable stereotypes of our traditions. How does one teach a boy to be clean without dirty boys to point to? How do we define social norms without public instances of deviation?” (1981, p. 15). By defining madness, the schizophrenic person defines normalcy as well. Schizophrenics are the “shameful class” (Foucault, 1975/1995, p. 182) that exists to be the lowest and the worst, the example that will keep everyone else being normal through a terrifying social “lore”:
[T]his lore [about schizophrenia] is used to frighten children and adults. It is part of the indoctrination to the moralities of obedience and self-control. So our conceptions of schizophrenia not only arise from the nature of our social order, but also serve to maintain it (Scheflen, 1981, p. 16, italics original).
So we see the neat, biological picture of chronic schizophrenia is ultimately a ball of yarn to be unwound. Though there does seem to be a biological element to the disorder, the WHO studies show us quite plainly how this is not the whole picture. Following Foucauldian analysis, a look at the discourse and power/knowledge of the psychiatric system provides us with another set of possible explanations. Perhaps the discourse of chronic and genetic schizophrenia has as much to do with the creation of the schizophrenic as a delinquent as it does with empirical science. The fabrication of the schizophrenic delinquent through medicalizing discourse and treatment, labeling, insight into illness, branding of the future and intertwining of the past creates a positive and productive knowledge of schizophrenia. By making a person with schizophrenia into a schizophrenic, a delinquent, the disciplinary system makes itself necessary to society, checks other mental illnesses, and defines an “external frontier” of madness (Foucault, 1975/1995, p. 181) for society at large.
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