the open asylum of the world; or how deinstitutionalization helped to drive everyone mad

As ever SC Hickman hits the nail on the head and sums up one of my abiding concerns, you could say obsessions, motivating the creation of this blog:

“[W]e have all become patients in an open sanatorium under the dominion of overlords who have become both our managers, therapists, and mad entrepreneurs of a sociopathic society”.

This is the basic insight from which to begin anything. The world is an open asylum and we are all lunatics. Perhaps it was always thus, this chattering, hallucinating and delusional organism with its neurological illusions, reifications, the religious psychoses that Max Stirner brilliantly and brutally imploded under the heading of Idee Fixe, a name that covered both psychosis and what we now know as obsessive-compulsive disorder (Bifo’s autonomisms; Gurdjieff’s mechanical man).

Yet as Foucault showed there is madness and there is madness. At some point, Foucault cites the 18th century Great Confinement, we began to differentiate the sane and the rational from the insane and the irrational. The distinction is like all partitions a separation and a point of contact, an interface that touches both the sane and the mad. At stake in the History of Madness, Abnormal, and the Lectures of Psychiatric Power is certainly the fate of the mad and their enmeshment in an emergent web of power-knowledge, but it is also the production of a self-certain rationality from which the seductive doubt, the temptation to ask “is this all a delusion generated by some malign demon?” has been vanished. The exclusion through confinement of the mad is the exclusion through disappearance of this terrible doubt. So it is that on one side of the asylum walls we could point unproblematically to the sane by virtue of the obvious insanity of the inmates.

Then came the movements of deterritorialization that Deleuze notes in the Postscript on Societies of Control. Of particular interest to us for the investigations of the psychopathologies of contemporary society are his remarks on how the deterritorializing movements plays out in relation to a medical system that psychiatry is not exempt from but is acutely symptomatic:

These are the societies of control, which are in the process of replacing disciplinary societies. “Control” is the name Burroughs proposes as a term for the new monster, one that Foucault recognizes as our immediate future. Paul Virilio also is continually analyzing the ultrarapid forms of free-floating control that replaced the old disciplines operating in the time frame of a closed system. There is no need to invoke the extraordinary pharmaceutical productions, the molecular engineering, the genetic manipulations, although these are slated to enter the new process. There is no need to ask which is the toughest regime, for it’s within each of them that liberating and enslaving forces confront one another.  For example, in the crisis of the hospital as environment of enclosure, neighborhood clinics, hospices, and day care [/b] could at first express new freedom, but they could participate as well in mechanisms of control that are equal to the harshest of confinements.

Foucault’s analysis of the asylum is an analysis of the disciplinary regime of power that operates via a founding violence of exclusion and containment. In the asylum we deposited our mad, our catatonics, our “retards”, our masturbaters, homosexuals, unmarried and too young mothers, and whoever else seemed ill disposed to live in good society. The asylum had its walls and its controlled access- usually an entrance that could only function as an exit to the psychiatrists and asylum attendants or the dead.

It is too much to talk about the period of deinstitutionalization in what is essentially a comment. Let’s run through some of the basic points necessary to speak of what we are talking about when we conjure up this hoary and cumbersome term.

The process of deinstitutionalization is readily understood as a negative movement and relation in reference to the carceral treatment of the insane within the enclosure of the asylum walls. More than the actual decanting of bodies from the great madhouses it refers specifically to the policies that brought this movement about. Specifically it name the closure of the enclosures. Once the last few patients had been ejected from the asylum the old system of huge storehouses for the mad were shut down, closed up, and in many cases simply left to rot as weird reminders of this more barbaric age.

The psychiatric systems and the states that backed them would have us believe that this was the result of an enlightened policy inspired by humanist values and a recognition of the dignity of the life of the inmate-turned-patient. For instance in reflecting on the deinstitutionalization movement an academic historian of psychiatry, Palmero, is able to claim that

[The leaders of society became attentive to this humane problem, and they decided, helped by a chain of discoveries of major antipsychotic and antidepressant drugs and in the United States by a concomitant shift of the financial burden from the states to the federal government, to tear down the old asylums and rapidly discharge the chronic to their families or to halfway houses and homes for the elderly (HCE164-165).

It is not unusual to see deinstitutionalization discussed in terms of the overall shift towards a new humanitarian consciousness in operation throughout society. In the United States deinstitutionalization began in 1955 and gathered momentum alongside the emergence of various human and civil rights campaigns that would use the claims of such rights as moral leverage on the powers that be. Typically the response of these powers is represented as a softening of the heart and a profound new awareness of the misery and suffering being metered out in the asylum system. Pity the poor madman and weep for the hysterical woman locked up all these years and subjected to restraint, dire living conditions, the mixed cruelties of deprivation, neglect and abuse, the barbarism of enforced electro-shock treatment and all those old mechanisms of torture redeployed as therapeutic machines.

Similarly, under Jimmy Carter’s Presidency a commission into psychiatric treatment could produce statements of such humanitarian finery, such as putting forward

]the objective of maintaining the greatest degree of freedom, self-determination, autonomy, dignity, and integrity of body, mind, and spirit for the individual while he or she participates in treatment or receives services.

But Palmero reveals more than the humanitarian image of psychiatric policy is usually willing to show those who don’t look too closely. The major issues are revealed as the shift of funding for the old, crumbling and significantly over populated asylum system. The buildings were literally coming apart and in any one asylum there could be thousands of inmates whose bodies required fed, watered, cared for, medicated and housed. The behemoth was simply to expensive to keep going when the burden fell to the federal government. The first cause of the new psychiatric humanitarianism was capital concerns rather than a new awareness of the dignity of madmen. The psychiatric asylum generated no value and cost a hell of a lot. Antithetical to the basic operational axioms of capitalism, the system had to go.

Palmero also highlights what could be seen as the leading determinant of psychiatric deinstitutionalization with the passing mention of the discovery of new antipsychotics.

First and chief among these was the discovery of chlorpromazine. Better known as Thorazine (USA) or Largactil (UK) chlorpromazine is still used today. The difference between its use in the 1950s-60s and today is that then it was seen as a revolutionary chemical and a genuine medical discovery, while these days it is seen as an horrific and retrograde drugs that should be taken off the market. I recently had the misfortune of tapering someone off of chlorpromazine much to their relief, in order to replace that drug with a new “atypical” antipsychotic (Olanzapine) in order to manage the voices they were hearing. That person’s attitude to chlropromazine- a drug that was helping to suppress torturous voices that blamed them for a sibling’s death- was that it is a torture and should be removed from the market.

Chlorpromazine is a dopamine antagonist. This means that it blocks the the uptake of dopamine neurotransmitter at the post-synaptic junction absorption site. First synthesized in December of 1951 the molecule has a [i] very [/i] tumultuous history. One of the chief extra-molecular and extra-neurophysiological effects of chlorpromazine has been to work in conjunction with findings from studies on cocaine induced psychoses to bolster evidence from a “chemical imbalance” theory of schizophrenia known as the “dopamine theory”. Like all chemical imbalance theories it has gathered nothing in the way of genuine evidence and has plugged into the social morality of illness that reduces psychopathology to the personal and interiorised level of individual neurochemistry, which the individual is themselves largely responsible for managing. Just as the serotonin hypothesis of depression has been revealed as a fraud, disowned even by orthodox psychiatry, and blamed on the lies and advertising manipulations of psychopharmaceutical companies, so to the has the dopamine hypothesis received critical attention. Interested readers will find a wealth of criticism, most notably for me in David Healy’s The Creation of Psychopharmacology and Joanna Moncrieff’s recent Bitter Pills: The Troubling Story of Antipsychotic Drugs.

Capital and state fuse with the discovery and deployment of the molecule by French laboratories. Chlorpromazine allowed for the transfer of large numbers of chronic schizophrenics to be transferred out of the asylum and hospital setting and into “the community”- a place that in psychiatric parlance is defined exclusive by its negative relation to the clinical setting. The drug produced a viable answer to the question of the management of the insane. At roughly the same time imipramine, the first antidepressant, was also being developed and marketed for the management of the neurotic symptoms, while highly addictive benzodiazipines were freely being dished out to all and sundry, not being known or cared about as addictive at that time.

For all the talk of Deleuze and Guattari about the molecular revolution and Foucault about the microphysics of power here was a genuine molecular and microphysical phamarco-molecular revolution taking place in the internment and treatment of the mad who could now be known as genuinely “mentally ill”. In conjunction with the rise of private insurance companies who refused to pay out on lengthy treatments, these molecular compounds would play a decisive role in destroying the brief and glittering period of psychoanalytic dominance within American psychiatry. The drugs themselves would allow for the production of increasing specificity in diagnostic populations (later demanded by United States law) and would thus serve as the molecular basis for the emergence of the biopsychiatric era.

“Beware the molecular!” Baudrillard had exhorted in his book critical of all micro-molecular-libidinalizing, and here we can see that he was more right than he knew. The revolutionary molecules really did provide symptom management and relief and in many astonishing cases it was chlorpromazine that brought people out of decades long catatonic states. This is why we no longer see catatonia except rarely in severe depressions. The drugs worked. The molecules were liberated and liberated the bodies of the sick from their exclusion-containment in the asylum allowing them passage into the community among their fellow human beings. It also produced dreadful side effects such as tardive dyskinesia which turned people into waxy and pliable sculptures or set their tongue lolling around their oral cavity uncontrollably, extreme fidgetting agitation that prompted countless suicides, and the now well known neuroleptic malignancy syndrome. This last side effect is, like all the others, really a direct effect of the functioning of the chemical on the brain. Unlike the others it also ends with death.

The great liberation announced by chlorpromazine isn’t such a straightforward liberation. It is in fact a reterritorialization of the neural communication systems. It is also the reterritorialization of the regimes of the management of the mentally ill.

In The Creation of Psychopharmacology David Healy explains that

focusing on whether chlorpromazine cured any psychoses or emptied asylums completely misses the larger picture, even in countries such as Japan, where the asylum population grew dramatically during the chlorpromazine era. The important issues lie in the new realm of behavioral control that chlorpromazine opened up and the new mapping of social problems for which it laid the basis.

Of course in the story I am presenting I have largely left out the campaigns of the antipsychiatric and ex-patient or psychiatric survivors movement. This is not intended to minimize the occupations, protests, demonstrations and experiments in treatment and care that these movements spear headed, but simply because I am attempting to shift the perspective to emphasize the role played by the very real and very material psychoactive molecules themselves. At the very moment that the molecular metaphor swept across the plane of critical thought it was actual molecules that were laying down the possibility of a society of control that is also a society of stimulation. I will hopefully return to the question of the antipsychiatric movements in a future post because in demanding the closure of the asylums they also played a fundamental role in laying the conditions for the society of control. While it is not my object of scrutiny here we could well imagine an essay that told this same story from the inverse perspective, thereby reckoning a Trontian history of psychiatric power wherein the patient and her allies are the determinant forces. Indeed, as we will see below, it is often they themselves who demand the diagnoses and the drugs that go with them.

Chlorpromazine produced a population ready to be reprogrammed through the then still lo-fi behavioural modifications platforms. What we have seen since the ejection of the patient from the asylum into the community is the injection of the asylum into the community. This is what is meant by the deterritorialization of the asylum. It pierces the walls of the asylum and gushes out into the world in order to mingle with it, spread its forms of knowledge and its techniques and practices, to make its language [i]the[/i] language that we speak, and, finally, to be found by critical thought as the terminology and tool that it is necessary to repurpose once again for the dubious task of our liberation. If not our liberation then the capacity to make life livable once again. If not to make life livable then perhaps to finally apply its newest knowledge and techniques to finally have done with it.

Today the psychotherapeutic and behavioural programming systems that once operated exclusively on the mad are to be found everywhere. As the patients moved into the world so to did the psychiatrists who know found themselves in (too few and perennially underfunded) community based hospitals and clinics, or in private practice. Later they would appear on TV and become celebrities, driven by the glamour of psychoanalysis and Hitchcock. Advertising in the USA would also drive or simulate consumer demand for all the new cocktails. Today the psychiatrist or the psychotherapist is to be found in every place of employment and increasingly in ever school as policy across the Anglo-American world has become that of “early intervention” into sub-clinical and “ultra high risk” people. The development of a stress-vulnerability model of psychopathology that was also intended to be liberating has been shackled to a practice of identifying ’em young and before they’re even sick, monitoring them, sticking them on some psychoactive prophylactic. As behavioural programs spread and the organization of society gets more chaotic, unsettled, and generally psychopathogenic children are seen as having more behavioural issues, and parents and colleagues and every unemployed or overworked or whatever the fuck else we’re getting shit on with person gets angry and so has an “anger management problem” or a personality disorder or whatever else.

In the UK the last Labour administration introduced the Improving Access to Psychological Therapies program in which the cheap and easier to train and deliver cognitive behavioural therapy, and today increasingly mindfulness based approaches, became rapidly and widely wheeled out. Along side this the self-help industry exploded while non-neurotypical groups bonded and (as with Persistent Demand Avoidance) banded together to call for new diagnoses and treatments, especially around autism and aspberger’s syndrome.

There is no time to go into the separate developments in mental hygiene and the articulations that came from the Menninger’s and other psychiatrists about producing a state of mental health for the entire population, a theme picked up today in UK with the governments use of “the nudge” with its Behavioral Insights Team.

Meanwhile following deinstitutionalization, psychiatry had come to work long-term with only the most chronic and treatment resistant individuals. These chaotic and non-compliant patients would be placed on to compulsory treatment orders. These CTOs were intended as short-term measures only to be made use of with a small number of cases but Joanna Moncrieff (in “How Can Community Treatment Orders Still be Justified?”) has shown that in the UK alone thousands upon thousands of these orders have been placed on people. CTOs are legally compelling orders placed on individuals who are noncompliant with medication and other therapeutic requirements. They mandate that at this time on this day so many days a week the patient will be in this location so as to receive a long-lasting slow release “depot” injection of antipsychotic medications or be subject to an immediate section. To be sectioned is the same as the American term “to be committed”. One is thus forcibly treated by injection with molecules that sedate, disorient, confuse, shorten the lifespan and one has one’s liberty at all times under threat. You don’t go to the hospital (which at any rate has no beds or staff, if you did need genuine sanctuary), the hospital comes to you.

The asylum walls are now inside one’s blood stream in the microscopic form of antipsychotics or antidepressants or antianxyolitics. It is in the automatisms of speech and the mechanicity of our therapeutic thinking. It is in our every behaviour that has become the sign of some psychic malady or another to be rectified with pills, therapies or self-help books, yoga or meditation or acupuncture. We’re all addicts or else we’re all anorexics. We’re depressed when we’re sad and we’re depressed with we’re grieving and we’re depressed when we’re heartbroken.

In a sense this is true: we really are more depressed, anxious, and post-traumatic than ever before. We live in a world so noxious that our only capacity is to go mad to some degree. But as I said at the opening, there is madness and there is madness.

We have always been invested in some politics of carving up the mad and the sane. The distinction has always been spurious, always just a marker of how far one has stumbled from the capacity to cope or from the consensus hallucinations of everyday life. These consensual hallucinations can be personological in form and would include all those fictions of neurology such as our sense of self or personhood, our sense of agency, our orientation to our environment as if we were naive realists, or whatever else you want to name of that order.

They can be social too. But usually they are both. The personological illusion was necessary for the development of the individualist ideology that capitalism came to depend on. We see that they form a mutually reinforcing and reciprocal system of delusions that are necessary for the maintenance of human life as it has been lived up to this point. The madman as the abnormal man is the one who steps outside of this and threatens the whole order, whether it be by dint of a neurological-informational divergence from the others or because he is sick to fucking death of the life of work and consumption he has been given.

Perhaps it would be better to make a distinction of our own. The neurological illusions can properly be called hallucinations and each one of us can rightly be seen as the lunatics that we are. We can follow Baudrillard in naming the social illusions [i] simulations [/i]. It is departing from the simulations that really gets you noticed. It is only then that the deterritorialized asylum machinery gear up.

It is easy for me to sit and say the deterritorialized asylum exists. I am a psychiatric nurse who is read in psychiatric history and practice. I work in addictions where I see these processes occurring. I see it in myself and my friends and my partner and her son. I have taken in recent months to looking at the world this way: it is a great open asylum and I am one of the attendants or nurses who patrol the destructured wards. How does that change things? Every behaviour becomes evidence of pathology. Yet not every pathology is evidence of distress or dysfunction. I also see my own delusional positioning as the diagnostician and the one who provides care: it is the insanity of the one who looks on the madness of others. But I too am a patient in this vast and disembodied mobile asylum.

Yet this observation comes into contact with what I have begun to call the generalized victimology of the left. It is as JG Ballard said in an interview that

Along with our passivity, we’re entering a profoundly masochistic phase — everyone is a victim these days, of parents, doctors, pharmaceutical companies, even love itself. And how much we enjoy it. Our happiest moments are spent trying to think up new varieties of victimhood…

And nowhere is this more evident than in our self-diagnostic moments, a society that demands new diagnoses, and a left that revels in its post-traumatic and depressive condition, demanding safer spaces without risk and trigger-warnings that despite the best of intentions perpetuate the avoidant coping styles that prolong the traumatic condition.

The popular use of community treatment orders (CTOs) for instance seem to have been largely celebrated by people I’ve come into contact with as ways of keeping people out of hospital but also of getting them swiftly back in when they become dangerous or unwell (although the two seem conflated in most instances). The CTO is championed then as a way of overcoming the heavily, and rightly, critiqued regime of incarceration. To my mind this is far too quick a move. Yes, people are out of hospital and into their own homes or crisis houses…yes, they can go shopping, make friends, have a drink, go for a walk but they still remain under psychiatric control.

Essentially the CTO is a modified, toned down and mobile version of a Section. The disciplinary, incarceral regime is effectively conflated with the world beyond it, reaching even in to the home, making the clinical and the intimate, the institutional and the own, overlapping, interpenetrative, commensurable. If disciplinary societies affixed a body in a particular space, subjected it to a specific gaze or discursive power and thus subjectivised it in a particular way (in the Asylum, psychiatric authority, ‘mad’) then the society of control no longer needs to do this; like a network power spreads itself over everything, operates everywhere, becomes a great circulatory system without avatars of authentic responsibility and, as Baurillard says, finally disappears. It doesn’t require to keep you in one place, to make you go past checkpoints between sharply defined places and pass through different forms of power; now it merely monitors your flows, regulates your movement, acts not as jailer but as security guard, not as authoritarian but as a hyperconcerned paranoid agency. Better still it gets you to do it on its behalf.

For some time I have been toying with the idea of correcting Giorgio Agamben’s essay “The Camp as the nomos of the earth”. The truth is that the camp remains isolated, it remains disciplinary, whereas the asylum has become generalized. To see the logic at play here one merely needs to watch the first few episodes of the TV show Wayward Pines before the ridiculous reveal and disappointing reveal, or to watch the first season of The Leftovers.

In reality though we are far from the first generation to notice that the world has become an open asylum. In the [i] Genealogy of Morals [/i] Nietzsche had already said that for ‘too long the earth has been a madhouse’. Indeed this is one of Nietzsche’s abiding concerns. Where Stirner would diagnose every metaphysics as a psychosis it would be this later German who would really drive home the insanity of the self-lacerating guilt and bad conscience of bourgeois morality.

For Nietzsche the blame rests with this slave morality and the resentment that it has produced. He sought an escape from all this in the liberating violence of nihilism and the transvaluation of values that could produce a higher, nobler, aristocratic and Dionysian morality of joyful affirmation of life. All that is a lovely thought but he too would fall into the disappearance of dementia, the final undoing of the neuro-personological illusion.

I don’t pretend to have answers to the problem. Having spent a long time protesting it I now find myself in agreement with the politics of escape and passivity that Franco Berardi puts forwards. If we are madmen then let us see what we can do with our madness. If we are passive then let’s push that passivity even further. If we have resentments then perhaps the way of overcoming is the wrong way to go, maybe we should accelerate that resentment. The ex-patient turns militant, she looks elsewhere for her care and refuses to countenance cure. She looks for ways to evade capture and in a strategy of hyper-conformism she either mimics the healthy minded or else she simulates the symptoms in a spiral inflations and hyperboles.

She accepts her condition but refuses to see herself as mad at all. “If I am sick it is you who has made me sick and you who must help me, but I do not wish to be cured and you are powerless to cure me, tell me what it the matter, I don’t listen when you speak”.

The mad must embrace their madness if they are to live; or else let them put themselves to death. Between these two options lies the murky world of withdrawal and of disappearance.

In my research on suicide I am pulled along by two distinct thoughts. The first is a statement: whatever the proximal and distal causes, whatever the personal circumstances or intersectional position in class society of the suicide, she always ultimately issues a challenge to society. This challenge always takes one fundamental form: THE ACCUSATION. This accusation can be modified in its circumstances: you worked us to death; you cut pushed me to this point; you left me alone and without any support, care or compassion.

Each accusation has its sense. I believe the sense is generic and amounts to saying:  this life isn’t good enough to go on living, it is you who has failed.

The second orienting thought is really a question. Is it possible that one could approach suicide and dwell in the space of suicidal ideation without ever falling into the abyss of suicidal intent. That is, can one stare at, accept and embrace a voluntary death without actually dying. This might make it possible to make sense of Heidegger’s abstract formulations on being-towards-death and connect them up to the stoic practices of suicide. Seneca might prove to be particularly relevant here.

If it is possible to say that the asylum is the nomos of our age, that we are all mad and that the world has become an open asylum, then we are struck by one disquieting secret. It is the secret that every suicide has always known. It is the secret known also by the pessimist philosophers. Like our asylum it is also deterritorialized, an open secret that we all know but refuse to acknowledge (again, see Wayward Pines [). It is the secret that far from being insane, the suicide is the only sane one left among us.

apologies for lack of reference, written in a hurry, got to get outside on the bike.

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2 Comments

  1. Reblogged this on synthetic zero and commented:

    The world is a lunatic asylum and we are all insane. There is not a single one who is not a lunatic. The nurses and the doctors who come with prescription pad and medication at ward rounds are the highest holiest fools of them all.

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