Nikolas Rose - Psychiatry as a Political Science - Advanced Liberalism and the Administration of Risk

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History of the Human Sciences

DOI: 10.1177/095269519600900201 1996; 9; 1 History of the Human Sciences

Nikolas Rose administration of risk

Psychiatry as a political science: advanced liberalism and the

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1-

Psychiatry as a political science:advanced liberalism and the

administration of risk

NIKOLAS ROSE

HISTORY OF THE HUMAN SCIENCES Vol. 9 No. 2

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

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 Secretaryof State for Health, questions in Parliament, massive press publicity, calls forurgent action. Jonathan Zito was stabbed to death on an underground stationwith 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 bea rewarding life with his family. The person who stabbed him, ChristopherClunis, was large, black, without employment, a discharged psychiatric patientwith a long psychiatric history, living on his own in a supervised flat arranged forhim by the social services but run by a private property organization. Peopleliving in the area of north London where the stabbing occurred had reported oddand 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 andineffective. Whilst many different professionals had been involved in caring forChristopher Clunis over his long history inside and outside psychiatric hospitals,hostels and prisons, it appeared that any care that they might have planned hadbroken 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 hispsychiatrists, his case had been passed between different local social workers butnone of them had been successful in establishing regular contact, the police hadfailed to link recent reports of his disturbed behaviour with his previous record of



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violence, an attempted home visit by the mental health assessment team twoweeks before the murder had failed because none of those present had any ideawhat Mr Clunis looked like, and thus no one recognized him when he left his flatas they arrived.The subsequent official inquiry, which reported in February 1994, meticu-

lously documented the parts played by innumerable professionals and expertsover the five and a half years leading up to the death of Mr Zito: over 20consultant psychiatrists, forensic psychiatrists, duty psychiatrists from at least 11 ihospitals; community psychiatric nurses, general practitioners and other medicalworkers from four health authorities; social workers, community workers,housing resettlement officers, emergency housing teams from three Londonboroughs; staff of various resettlement units, sheltered housing schemes andshort-stay hostels; police officers from different police stations in at least twopolice authorities; prison officers from several prisons together with variouslawyers and a host of supporting characters. Reading the report one loses countof the number of occasions when notes and files were mislaid, when messagesbetween the different professional groups were lost or misunderstood, whenprofessionals disappeared on holiday, on maternity leave, or to another job, orwere off sick at a crucial point, when decisions were taken in almost completeignorance of Mr Clunis or his history or on the basis of an entirely spuriousversion of his case. After telling this sorry tale, the conclusion of the inquirycould hardly be disputed: Mr Clunis was as much a victim of the mental healthsystem 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 bedsin hospitals and more effective planning of discharges. Doctors used the case toprotest the lack of resources, the pressure on beds, and hence their difficulty incarrying out their vocation of care and cure. SANE - a charity called

Schizophrenia: A National Emergency founded about five years ago - deployedthe case to support its argument that more hospital beds, more incarceration andtighter restrictions on discharge should be introduced. This position wasgraphically summarized in its poster featuring a long-haired, bearded anddishevelled young man with a caption that went, approximately, he thinks he’sJesus Christ, you think he’s dangerous, they think he’s fit to be discharged intothe community. The Secretary of State used the case to press her argument forsupervised discharge orders, compelling discharged patients to take theirmedication and comply with their aftercare plan under sanction of recall tohospital: she set her officials to work on the construction of new regulations,standards and monitoring procedures to govern the ways in which medical andother staff made and enforced plans for care in the community.

This case illustrates something of the contemporary matrix of argumentsaround the problem of madness and mental health. This field seems contested,complex and dispersed, made up from diverse and contradictory logics. Madness



3

figures variously as the sign of a community that doesn’t care, as a threat to acommunity that naturally cares for itself, as an instance of the uncaring nature ofa fiscally straightened state, as an object of pity and of fear. Whatever hope andtrust is invested in other branches of medicine and other medical practitioners,psychiatry appears as a perpetually failing agency, failing in its claims tounderstand, its capacities to cure, its responsibilities for both individual care andsocial protection.

But perhaps we can see, in this confused and contradictory picture, a kind ofcondensation of the new problems of government faced by nations like the UK -and perhaps others - in this period ’after the welfare state’. Elsewhere I havesuggested that we are seeing the emergence of a range of new rationales andtechniques of government that can be termed ’advanced liberal’.’ I use

’government’ here in the sense developed by Michel Foucault - government as allthose strategies, forms of thought and action, that seek to conduct the conduct ofothers. This perspective draws our attention to the fact that every attempt toconduct the conduct of others, and indeed to shape one’s own conduct, containsa quantum of knowledge. At one and the same time, knowledge makes humanconduct intelligible and constitutes certain forms of expertise as appropriate forknowing and acting upon it. Truths, explanations, categorizations and taxo-nomies, vocabularies and diagnoses concerning human beings individually anden masse are conditions for the governability of conduct. And government isdependent upon expertise. Those who profess specialist knowledge and esotericskills have come to acquire a crucial role in helping to shape the problems thatmust be governed, in giving techniques for the conduct of their authority inrelation to those who are their subjects, and in making up the relays that linkprogrammes of government to the multitude of dispersed sites where conduct isto be judged, assessed, evaluated, understood and acted upon.

Psychiatry has, since the 19th century at least, been intrinsically bound toproblematics of government. Indeed the birth of psychiatry as a ’know how’ ofconduct in the 19th century was part of a fundamental shift in our experience ofourselves in ’the west’: the individuality and vitality of the human being becamean object for a positive knowledge; authority acquired the obligation to act uponthe conduct of human individuals in the light of positive knowledge; positiveknowledges of what it was to be human began to shape the ethical regimesaccording to which individuals came to understand, judge and act uponthemselves.3 Psychiatry, from this perspective, is intrinsically bound to thechanging ways in which human beings have tried to govern themselves - not justto changing ideas or models of human nature, but to the changing ethical fieldwithin which such understandings of what it is to be human are linked tovocabularies and systems of judgement about conduct and to techniques foracting 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



4

professionals who claim to be able to identify difficulties of conduct in terms of atheoretical and practical knowledge of the vicissitudes of the psyche, and to actupon persons in the light of that knowledge. One sees not only a range ofdifferent varieties of psychiatrists, but also clinical psychologists, psychiatricsocial workers, psychotherapists, counsellors, occupational therapists, generalpractitioners as advisers on mental health and so forth. One of the most

significant developments of our own century has been the proliferation ofexperts claiming such knowledge, and the infusion of heterogenous ’psy-’judgements into the duties of other professionals such as teachers and lawyers. Inparticular, the emergence of ’clinical’ disciplines alongside medicine, especiallyclinical 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 ofclassifying and dividing those who are to be the subjects of expert attention, andnovel relations between experts and others. They place responsibilities uponexperts in a way that is significantly different from that under welfare and linkexpertise to the political apparatus in novel ways. These new responsibilitiesand relationships will form the topic of this paper / I suggest that psychiatry hasa revised role in ’advanced liberal’ forms of government. Psychiatric experts arerequired to collaborate with other professionals in a diversity of practices andapparatuses for the ’administration of risk’ across the territory of the com-munity. They are also obliged to participate in novel strategies for the

management of exclusion. They are exhorted to adapt to the new logics ofchoice, empowerment and lifestyle management. And they are caught upwithin a culture of blame, in which almost any unfortunate event becomes a’tragedy’ which could have been avoided and for which some authority is to beheld culpable. This places new political expectations upon the professionals of’mental health’. It also places new responsibilities upon those who are actual orpotential subjects of psychiatry and creates new divisions between good andbad patients, clients and users in terms of a calculus of risk.

PSYCHIATRY AND ADMINISTRATION

The new vocation for psychiatry should be understood, first of all, in terms of theformation of a new territory for psychiatry in the postwar period: ’community’.As Robert Castel has argued, the policies of ’sectorization’ in France, ofcommunity mental health in the USA and of community care in the UK,irrespective of the specific political circumstances that produced them, shared acertain rationale - one of ’covering the maximum amount of ground, reaching themaximum number of people, through the deployment of a unified apparatuslinked to the machinery of the state’.5 Of course, the notion of community hademerged 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 reformof asylum psychiatry advocated by progressive psychiatrists: psychiatry shouldnot be segregated from the places it serves, its institutions should be located intheir communities, they should reach out into the community in terms of care forthose who do not yet have to enter hospital, or those who are discharged from thehospital.6 At about the same time, the vocabulary of community becomes centralto the critique of asylum psychiatry: the asylum should not be a place ofincarceration but a therapeutic community - it will be this line that will later bedeveloped by Franco Basaglia and others in Italy into a programme for thewholesale abolition of the asylum and its replacement by community mentalhealth centres.’ Finally, over the course of the 1970s and 1980s, community, inthe UK and the USA, emerges as the key term in a set of national political policiesand technologies. 8

Thus, whatever the immediate political impulses behind the programmes forthe closure of asylums, the emergence of the vocabulary of community as a wayof seeking to understand and programme the proper field of operation ofpsychiatry indicates a shift in the rationalities underpinning the government ofmental pathology and mental health. On the one hand, community psychiatrywas a way for psychiatry to modernize itself: psychiatrists would respond tocritiques of their custodial and controlling role by seeking to divest their activi-ties of their anti-liberal and ’carceral’ features, sloughing these off to otherforms of expertise so that psychiatry can become a liberal, open and curativemedicine. But it was also an attempt to forge programmes that would ’simplify’and reintegrate the disparate elements of the vocation that had taken shape fordiverse forms of psychiatric expertise over the course of the 20th century. Forpresent purposes, what is of particular interest in the emergence of the ration-alities of community psychiatry is the novel role that is accorded to psychiatricexperts: less that of curing illness than of administering pathological individualsacross an archipelago of specialist institutions and types of activity, and simul-taneously engaging in a prophylactic and preventative work of maximizingmental health.

There is nothing new in psychiatry assuming a predominantly administrativerole - indeed one might say that it was out of an administrative demand thatpsychiatry began to form as a distinct complex of knowledges, techniques,experts and devices in the 19th century. Over its 150-year history, one canobserve at least three distinct configurations in this administrative vocation: theasylum; degeneracy; and mental hygiene. Each problematizes the population in adifferent way. Each establishes a different grid of visibility for normal andpathological conduct. Each proposes new technologies for the regulation ofconduct and a different vocation for experts. It is worth briefly delineating thesethree configurations, in order to appreciate the distinctiveness of communitypsychiatry 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 Therewas, he suggests, a coherence among the various dimensions of psychiatry - itstheoretical codes, its institutional form, its technologies of cure, its constitutionalmandate. The asylum was more than an institutional site; it was an assemblage ofthought and action that held these elements together. For my purposes here, it isworth drawing out three elements from the much investigated story of the birthand 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 wayround. For psychiatry becomes possible, in its modern form, only when a systemof relations is established between a range of persons, conditions and judgementssuch that they can form the object of a single field of representation andintervention. The asylum made possible the visualization of madness that

underpinned the nosographies and taxonomies that were so central to theformation of a positive science of madness, the techniques of case-taking,diagnosis and classification best represented in Esquirol’s Atlas or Bucknill andTuke’s Manual of Psychological Medicine.&dquo; The asylum conferred upon thesubjects of psychiatry that frail unity that lasted for so long - the walls of theinstitution rather than any leap of scientific imagination united the inconsolablysad, the religious fanatic, the hearer of voices, the deluded and the violator ofnorms of sexual propriety. It was in the confined and regulated space of theasylum that the dream took shape that a unified intellectual system might graspthe heterogeneity of madness and a unified technology might be deployed to cureit. The asylum, that is to say, institutionalized the boundaries of what we havetoday come to contemplate as mental illness at the same time as it conferreddiagnostic powers and therapeutic authority upon those medical agents whocontrol and organize the space of confinement.

Second, it was in the asylum that the project of cure took the shape it wouldhave for over a century: madness as a violation of norms of civility was to becured 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 atechnician of social order. The archipelago of asylums that spread throughoutEurope were the other side of all those philanthropic projects for the civilizationof the labouring classes, the domestication of female sexuality and thetransformation of subjects into citizens who would regulate their own conductaccording to norms of prudence, order, temperance, continence, responsibilityand so forth. The asylum is thus linked to what Colin Gordon has termed ’thereciprocal disenchantment of transgression’ in which scandalous conductbecomes no more than the violation of a standard for civilized comportment ofthe self consequent upon individual pathology.&dquo; The mad person was placedamong that gallery of figures who, in the second half of the 19th century,



7

represented social danger; and all sorts of social danger came to be recast in themoral-medical vocabularly of madness. The asylum became one of the vastmachines of morality invented in the 19th century, whose rationale was theproduction of citizens who could be free to the extent that they had taken theobligations of moral, prudent and self-responsible conduct into themselves.&dquo;

Third, confinement in the asylum under a medical mandate reconciled a socialdemand with a constitutional obligation. The social demand was for a

mechanism for the containment of socially scandalous behaviour that was not yetcriminal. Yet the citizen, over the course of the 19th century, was to be endowedwith a range of legal and constitutional rights which prohibited confinementexcept for a breach of the law demonstrated in the ordinary courts of the land. Ofcourse, the details of this reconciliation vary across different national contextsand juridical regimes. Nonetheless, as Foucault has put it, our current experienceof madness unifies in the form of an illness that which was brought together firstas the ’meeting point between the social decree of confinement’ of those whodisturbed the tranquillity of family or street, and the ’judicial knowledge whichdesignated the capacities of the subject as a legal entity’ and hence required aparticular warrant for the deprivation of the liberty of a citizen. 15The asylum was undoubtedly programmatically coherent and strategically

versatile - the adoption of the asylum form so rapidly in so many differentnational contexts is evidence that, in the imagination of so many policy-makers,philanthropists and learned individuals, there was a politically salient problem towhich it could appear as a solution. However, the 19th century was also a periodof fundamental attack on legitimacy of the ’asylum complex’ along each of thedimensions of its activities. The status of mental medicine as knowledge wasderided, the integrity of its practitioners was impugned, its capacity to cure wasdenied.’6 As asylums became larger, rates of discharge reduced and scandalsabout illegitimate confinement multiplied. We are familiar, at least in outline,with the desperate remedies that were adopted, as madness, in the asylum andbecame increasingly understood as the symptom of a malfunctioning brain.

Further, alongside the attacks on the project of asylum psychiatry, one sees thegrowth of other types of expertise in mental pathology over the 19th century,practised in other sites and directed to other problems of conduct. Problemsarising in relation to women and the domestic space formed a particular object ofconcern. 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 tothink of the long history of the incarceration of errant daughters, undesired wivesand unwanted parents in private asylums. But this 19th-century development isdifferent. Phrenology, hypnosis, spiritualism and a range of other techniquesprovided the basis for a range of medical and quasi-medical specialismsconcerned with nervous disorders, neurasthenia, hysteria and so forth, especiallyin relation to the troubles afflicting the wealthy, and the middling orders ofsociety. Over this time one sees bitter contestations between the medical alienists



8

and these predominantly non-medical ministrators to the soul.&dquo; Around the

figure of the hysterical woman, psychiatry emerges as a key element in theregulation 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 inwhich psychiatry sought a role in practices for the government of conductoutside the asylum, and in which the asylum as an institution was only one,though no doubt crucial, element. Links were formed between psychiatry andother reformatory institutions and practices - prisons, asylums for chronicinebriates, the apparatus for regulating the morally insane and moral imbeciles.Psychiatry made forays on to other institutional territory, particularly thecourtroom. One sees here the beginning of the century-long conflict betweenpsychiatric and legal technologies of judging and holding accountable.&dquo; Whilstthe psychiatric dream of a wholesale transformation of criminal justice did notmaterialize, psychiatry did make significant inroads into the legal process indisputes over homicides of public figures (McNaghten, etc.) and over femalehomicides (infanticide, etc.) and one sees the beginnings of the process wherebythe criminal will gradually cease to be a purely legal subject, and become thesubject of a particular pathological personality.’9

DegeneracyIt was, however, in the last decades of the 19th century that psychiatrists werefirst to make a general claim as to the significance of their science for theadministration of the population as a whole in the interests of national

well-being. Central to this claim was the vocabulary of degeneracy.2° Thegrammar 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 whoappeared to threaten social order, especially in the towns - syphilitics, imbeciles,paupers, criminals, gamblers, idiots, drunkards, vagrants, the mad, the un-employable, the tubercular. Within the analytic of degeneracy, all these appearedas different forms of expression of an underlying pathology of constitution. Thispathology was probably acquired by amoral conduct (drunkenness, mastur-bation) which weakened constitution, and was amenable to prevention andcontrol but not to treatment. Not only was pathological constitution passeddown family lines, but it worsened in each generation. Some evolutionaryoptimists thought that sterility was the eventual result of this generationaltransmission, thereby rendering the social problem ultimately self-limiting,though nonetheless significant in terms of immediate action. For others thereverse was true - degenerates were promiscuous, bred rapidly and irrespon-sibly, and hence posed a threat to overall quality of the race.

There were certainly many differences in the ways in which degeneracy wasunderstood in France, Italy, the USA and the UK. But the notion that insanity



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was an element in a wider social pathology operated as a kind of a priori ofpolitical thought: the pathologies of individuals were not merely of medicalsignificance but were indicative of a wider social malaise; the population must, atroot, be understood in bio-medical terms. In Britain, those who sought todevelop conceptions of degeneracy into a full-scale project of eugenics were toencounter the limits set by constitutional doctrines of individual liberty. Theywere to be opposed by the majority of doctors who favoured a more positivestrategy for enhancing the quality of the race through hygienic improvements.Nonetheless the significance of this reactive and segregative political rationalityfor 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 andfor the analytics of poverty. And it is worth reminding ourselves that it was notmerely Jews, homosexuals and gipsies who were the object of the murderousracial purification carried out by the Nazis in Europe, but also the mad, theimbeciles and the degenerate. Indeed up until the 1950s in the USA, under theinfluence of powerful eugenicist psychiatrists, mental defectives were subject tocompulsory sterilization and segregation in many states, and the mad wereconfined in appalling and destructive conditions: the segregationist rationalecannot 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 slightlydifferent. It is in establishing a new grid of perception which blurred theboundaries between frank madness, confined in the asylum, and the nervousdisorders disrupting domestic and conjugal relations. The frontier between thereasonable and responsible citizen and the mad person ceased to be clear, theidentity of those who were mad ceased to be evident, and while the borderlandsbetween sanity and madness were previously considered virtually deserted, theywere 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 ofracial purification and mass destruction carried out in Nazi Germany, the tacticsof confinement and sterilization for those on this borderline hardly measured upto the task of prevention which now seemed to confront psychiatry: the confinedspace of the asylum could no longer appear as the ideal solution to a problemwhich now appeared virtually co-terminous with that of modem mass societyitself.

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



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the emergence of social danger in order to minimize the chances of this dangerarising or to reduce its severity. The codes and mechanisms of psychoanalysis,and a range of other dynamic psychologies and therapies, provided the means bywhich psychiatry was able to address itself to a range of new problems that wereoffered to it - not of madness but of social inefficiency and unhappiness. Thesurfaces of emergence for this new dispensation of psychiatry lay in the novelhuman machines that had begun to proliferate, where individuals were gatheredtogether under a regime of management, their behaviour marshalled in theservice of institutional aims, their conduct assessed in relation to organizationalnorms: the army, and the problem of ’shell shock’ during and after the FirstWorld War; the courtroom, and the issue of juvenile delinquency in the earlydecades of the 20th century; the school, and the problems for pedagogy posed byminor problems of truancy, lying, absenteeism, tantrums and the like; thefactory, and the damage to productivity resulting from industrial accidents,fatigue, inefficiency. It is here that a new ’social vocation’ for psychiatry wasbom, one where psychiatric expertise claimed a role in relation to the

management of social ineptitude and inefficiency in all social institutions. Thisnew dispensation operated according to neither the boundaries of reason andunreason, nor those of civility and scandal. The new programmes for psychiatryenvisaged it as a non-custodial project with positive aspirations: the productionand maintenance of social normality and competence.&dquo;

In the grammar of mental hygiene, inefficiencies of conduct of almost any sortwere consequences of minor mental disturbance. If not treated, these minormental disorders would get worse and lead to frank insanity, with all the

consequent danger, misery and social cost. However, these inefficiencies wereamenable to treatment if caught early, and similarly amenable to prevention bythe installation of a proper regime in the factory, the school, the army, butespecially the home. In the strategies of mental hygiene, the asylum was not onlyirrelevant but actually an obstacle. The stigma of madness associated with theasylum discouraged early treatment - hence the demand for the establishment ofclinics and hospitals where voluntary admission could lead to treatment (ofwhich the Maudsley hospital in the UK was one of the first). Later the samethinking was embodied in the shift in terminology from lunacy to mental illnessand from asylum to mental hospital - the first of many attempts to bring mentalmedicine into contact with general medicine and apply the same principles oftreatment.

Mental hygiene was the application of strategy that had been used withphysical problems in the social hygiene movement. The object of psychiatricattention had shifted: the pathological individual was relocated in a nexus ofrelationships which might lead to disorder or might prevent it.22 The mode ofexplanation of pathology no longer proceeded in terms of an inheritedconstitutional defect exacerbated by personal immorality or other excitingcauses, handed on to progeny. For the minor disturbances at least, the line ran



11

from childhood experience of familial emotional relations, through the dy-namics of the psyche, to maladjusted conduct exacerbated by poor mentalhygiene in school, factory, army, or elsewhere, into a spiral of mental

pathology that was fundamentally preventable. Each institutional locus thusbecame not only a potentially damaging source of mental ill-health, but also anopportunity for prevention and for early diagnosis and treatment. Childpsychiatrists would reach out into the ordinary homes of ordinary citizensthrough popular books and radio broadcasts, and would educate and instructparents in the adoption of regimes to ensure mental normality and adjustmentin their offspring. Industrial psychologists would train managers and employersin recognizing the signs of maladjustment in employees, and in the require-ments of a mentally hygienic industrial regime. Social workers becamecase-workers, with a new role in linking up the home, the school, the court andthe 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 ofdocumentation and professional supervision. A new normalizing scrutiny andevaluation spread into the school, the army, the factory and elsewhere. Fromthis point on, almost every violation of institutional and social norms ofconduct would be accorded a psychological meaning, not so much to bejudged, but to be understood. The new imperatives were: investigate, assess,prescribe, treat.

CommunityIt is against this background that the distinctiveness of community as a newterritory for psychiatry can best be understood. The dream of communitypsychiatry in the UK - outlined in any number of policy documents, WhitePapers and so forth - was of the community as a single complex organizationalspace that would mirror, in administrative form, the complexity and diversity ofthe problems of mental ill health and the populations it embraced:

... children and adolescents with psychological problems ... assessmentand treatment of adults whose conditions require short-term admission tohospital and for the longer term treatment, including asylum, of those forwhom there is no realistic alternative... places in hospitals and... hostels,sheltered housing, supported lodgings ... for adults with a mental illnessneeding residential care outside hospital, together with an adequate rangeof day and respite services ... co-ordinated arrangements between healthand social services, primary health care teams and voluntary agencies forthe continuing health and social care of people with a mental illness living intheir own homes or in residential facilities [including] domiciliary services,support to carers and the training and education of staff working in thecommunity.23



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Psychiatry would reintegrate its disparate aspects into an administrative networkwhich would bring together the diverse subjects with which it now dealt -alcoholics, offenders, disturbed children, pathological parents, as well as thosesuffering acute or chronic mental distress - the diverse sites in which it operatedhospitals, clinics, hostels, homes, schools, mental health centres, social workers’visits, general practitioners’ surgeries - and the diverse professionals who staffedit - psychiatrists, primary care workers, nurses, occupational therapists,psychotherapists, clinical psychologists and so forth - into a coherent ’com-munity 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 theywould determine where an individual would be directed within this archipelagoof sites of professional-client interaction - halfway houses, concept houses,day-care centres, day hospitals, etc. As this new diagram of psychiatry begins totake shape, madness itself changes its significance. As mental ill-health, madnessbecomes fully disenchanted, little more than the lack of the capacity to cope withthe 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 oftherapeutic professionals undergoes a parallel transformation. Professionals noware required not so much to cure, as to teach the skills of coping, to inculcate theresponsibility to cope, to identify failures of coping, to restore to the individualthe capacity to cope, and to return the individual to a life with which he or she cancope.

PSYCHIATRY’S NEW VOCATION

I suggested earlier that the political vocation of psychiatry was undergoing amutation, and that this could be understood by locating psychiatry in relation toa range of strategies of government that I have termed ’advanced liberal’. Forpresent purposes, advanced liberal strategies of government include the

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



13

subjects to take responsibility for their own conduct, but also because of theelements of social protection which have been allocated to psychiatry over thelast hundred years. Nonetheless, some of the characteristics of the contemporarypsy- complex become intelligible when placed within the context of thesechanging 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 recentlywitnessed, within psychiatry, a shift from dangerousness to risk.2’ Whilst

dangerousness is a property of the concrete individual, risk, Castel suggests, is acombination of factors which are not necessarily dangerous in themselves: age ofmother, type of family background, job record, type of housing.... We mightextend this analysis further. We have seen the emergence of a notion of risk as away of making intelligible and manageable a whole series of difficulties in ourcontemporary experience, from those of organizational management, throughloss of work, to ill-health or criminal victimhood. The language of risk isindicative of a shift towards a logic in which the possibility of incurringmisfortune or loss in the future is neither to be left to fate, nor to be managed by aprovidential state. Problems previously understood in other ways are recoded inthe 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 ofrelated features of the contemporary vocation of psychiatry. The first concernsthe way in which the subjects of psychiatry are delineated. Pat O’Malley hasrecently drawn attention to the rise of what he terms a ’new prudentialism’.28This is a mode of thinking and acting in which individuals are increasingly heldresponsible for the management of their own fate and that of their familiesthrough a kind of calculation about the future consequences of present actions - abringing of the future into the present and making it calculable and hence, in ourdreams at least, manageable.29 Risks are to be identified, assessed, calculated,reduced, insured against by the prudent individual citizen, by the effectiveprofessional, or by the well-managed organization.3° Under the politicalrationalities and social devices of welfare, of which the paradigm is social

insurance, the individual was to be bound into a nexus of social citizenship, socialsolidarity and mutual interdependency - a technology which was as much aboutinculcating a certain ethical relation of self to itself (contractual obligation, thrift,responsibility, regularity of contributions, etc.) as about securing the socialagainst the dangers consequent upon loss or interruption of earnings, sickness,old age, etc. In the new regime of risk management, planning for the futurebecomes added to the responsibilities of active and enterprising individuals andfamilies. They must now think of their present conduct in terms of risks to becalculated, averted and secured against. And they are surrounded by newexperts: not administrators of social existence but advisors of personal risk.Individuals are invested with the responsibility to manage their own risk and to



14

take responsibility for failures to manage it. Risk management, in this sense,becomes a technique of the prudent self with simultaneous reconfiguration oflogics of responsibility and censure. In terms of government, new relations takeshape between technologies for the government of others and the modes in whichhuman 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 theimprudent self, the self able to manage itself from the self who must be managed byothers. The subjects of psychiatry are no longer unified by their institutionalconfinement, and the visibility which confinement conferred upon them, but bythe fact that they are unable to manage themselves prudently in the matrix ofencounters outside the asylum. Failures of management of the self, lack of skills ofcoping with family, with work, with money, with housing, are now all,potentially, criteria for qualification as a psychiatric subject. Even dangerousnessis now recast; no longer is it construed as an essentially anti-social pathologylurking in the heart and soul of the individual, but rather it is the calculation of acombination of evidence about past conduct and professional judgements bearingupon the likelihood of failures to exercise the capacities of self-control andself-mastery over one’s impulses towards others or feelings towards oneself. Levelof 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 ofpsychiatry’ who are ’medicine compliant’, keep appointments, are able to assesstheir 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 subjectthus lies at the junction of the self-managed world of the affiliated and the twilightworld of the excluded. The ordered world of ’social problems’ is displaced by anew fragmented world of the excluded, in which there is a multiplication ofcategories of marginal persons such as the lone parent, the drug abuser, thealcoholic, the single homeless. This empire of the risky and the ‘at risk’ becomes thespace for the operation of a multitude of new professional organizations,quasi-governmental outfits, self-help groups and private profit-making insti-tutions.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 forexperts in relation to the marginalized. Hence one finds the use of all thepsychological techniques of responsibilization in so many of these sites.Professionals become tutors - sometimes gentle, sometimes harsh - in the arts ofself-management: keep your appointments, take your medicine, don’t get drunkor violent - or you will lose your place in this project. The will to cure becomes littlemore than the inculcation of a particular type of relation to the self - prudentself-management, making contracts and abiding by them, setting reachable targets



15

and achieving them, learning skills of management of everyday life. In the UK, atleast, this new relation between experts and their clients is linked to the vicissi-tudes of the notion of empowerment. Empowerment has mutated from a termutilized by clients and advocates in the challenging of professional power tobecome part of the obligations of the responsible professional. Experts are nowtaught the techniques by which they can empower their clients, by which ismeant according them the capacities for managing their own lives by way ofacceptable logics of life-strategy. A whole range of types of intervention upon thecapacities of the subject is now rearticulated in these terms. Particularly notable isthe way in which behavioural techniques are no longer viewed as coercive andheteronomous incursions upon the subjectivity of the individual, but are widelydeployed by doctors, clinical psychologists and psychiatric nurses as well associal workers and many others, as means for the re-empowering of the disem-powered self, (re)-equipping the self with the skills necessary for autonomouscoping 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 ofpsychiatric professionals: risk management and risk reduction, as logics forprofessional action, have come to supplement or replace other forms of pro-fessional action and judgement. The dream of the early years of sectorization andcommunity care was of a kind of hygienist utopia, which placed great faith in thepowers of psychiatrists to devise measures of prevention, to diagnose conditionswhich did occur, to allocate them to treatments, to contain, moderate and evencure mental illness, in conjunction with a whole variety of other professionalgroups 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 asmuch for their own pretensions and failures as for reasons of political ideologyand pragmatism.

It is true that the programmatics constructed in terms of risk sometimesappears to share this vision of total elimination of the accidental. Thus, accordingto a recent document on risk in the National Health Service, ’Whether con-sidering a brain damaged baby, the administration of the wrong drug, theabsence of fire fighting equipment, the lack of training in lifting techniques, orinadequacy 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 incidentfrom happening - even once’. 31 But the challenge of risk management, as it termsitself, is a challenge to each individual professional rather than to the abstractrational qualities of some overarching system. Risk management - the identifi-cation, assessment, elimination, or reduction of the possibility of incurringmisfortune or loss - is to become an integral part of the professional responsi-bility of each expert; government of risk is to take place through a transformationof the subjectivity of each professional.



16

Risk management also extends to the act of diagnosis.32 Previously, schem-atically, one might say that there was a kind of division of labour in themanagement of the mad person - diagnosis and treatment was the responsibilityof the doctor, care and control was the responsibility of the nurse, assistance wasthe responsibility of the social worker. The clinical diagnosis by the psychiatristwas the fulcrum of this division of labour, even if, on the territory of thecommunity, the actual management of the patient was to be undertaken by otherexperts and in other sites. Diagnosis by a medically qualified expert was thus acondition of entry to the territory of psychiatry and was performative,mandating a certain regime of drugs, detention or referral to a particular specialistinstitution, and so forth. However, new forms of diagnosis have emerged thatchallenge the pre-eminent role of the doctor. To quote Castel again: ’The site ofdiagnostic synthesis is no longer that of the concrete relationship with a sickperson, but a relationship constituted among the different expert assessmentswhich make up the patient’s dossier.’33 The psychiatrist here loses his or her’master-status’ as the locus of judgement. And judgement is, in any event, carriedout only partially in medical terms. Diagnosis comes to operate also in terms of avariety of other forms of expertise about such matters as employment history,family life, coping skills, capacity to cook, shop and manage money, as well asinformation on past conduct and dangerous behaviour. Whilst the psychiatristmay formally remain in charge of the case - although even this is in doubt withthe nomination of key workers from other disciplines - the terms of psychiatricjudgement are no longer clinical (or even epidemiological, as Castel suggests) butwhat 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 butrestricted. Drug-induced psychosis, schizophrenia and other diagnostic cat-egories were assigned by various medics at different points. However, the keyquestion asked of the psychiatrist again and again was a different one: whatshould be done with this person, should he be sent to this institution or to that, tothis hostel or that sheltered housing scheme, back into the community or backinto prison? The logic of prediction comes to replace the logic of diagnosis - andthis is a logic at which the psychiatrist can claim no special competence. What is atstake is the classification of the subjects of psychiatry in terms of likely futureconduct, their riskiness to the community and themselves and the identificationof the steps necessary to manage that conduct. And within this rationale, themedical institution is redefined - no longer a place of cure, it becomes little morethan a container for the most risky until their riskiness can be fully assessed andcontrolled. Hence the ’multidisciplinary team’, so beloved of the programmers asthe solution to so many problems, emerges less out of the recognition of thediagnostic and curative significance of different sorts of clinical and socialexpertise, than out of the attempt to answer the administrative question: what isto be done and how can we decide.



17

On the new territory of psychiatry, it thus appears that one is seeing asubordination of the medical to the administrative function of expertise. RichardEricson has recently argued that police have become primarily ’knowledgeworkers’ and that their trade is now increasingly constituted by a knowledge ofrisk and risk management, through a meticulous collection and correlation ofinformation - police as advisers to other agencies on the nature of risk, theriskiness of communities, areas and activities, and the means of avoiding andmanaging risk.34 Perhaps one might say that the functions of social protectionpreviously accorded to psychiatry have now been reconfigured in somewhatsimilar terms: psy-professions are allotted the role of ensuring communityprotection 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 ofthe 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 thathas been proposed in the UK, on which all patients who have entered psychiatrichospital under a section of the Mental Health Act would be recorded, reactivatesa pattern that has already been applied to child abuse for some two decadeswithout notable success. We are certainly a long way from the position describedby Castel, in which a general system for risk prediction of child abnormalities isproposed, upon which would be recorded a whole array of factors whoseconnection with these abnormalities is abstract and statistical - age of mother,nationality, previous history of illness and so forth - and where a certaincombination 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 thatthe new technologies of information-recording and coordination embody thepossibilities of new modes of surveillance. Unlike the forms of individualizationwhich were born in the 19th-century asylum - and the prison, school andhospital - these are not dependent upon the visibility conferred by theinstitution. Rather, material gleaned from a whole variety of sources, designatedby diverse experts as risk factors, may be brought together to individualize asubject in terms of the likelihood of future offending, mental breakdown, childabuse, or whatever. But I am not convinced that the future lies in the totalizationof these modes of surveillance, with the prospect of the prophylactic assignationand 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 managementwill be enjoined upon individual professionals, governing them ’at a distance’from the formal political apparatus, with the prospect held out of legal or othersanctions 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 illnessmay be unpredictable and operate according to an organic or esoteric logic for



18

which neither the doctor nor the patient can be held accountable. But com-munity protection may nonetheless be ensured by administrative rather thanclinical means: by adding the administrative obligations of coordination, infor-mation, planning and so forth to the obligations of each professional involved.Of course, as the case of Christopher Clunis illustrates, techniques of adminis-

tration that rely upon the coordination and evaluation of information and theinitiation of timely preventative intervention are always failing. But failure doesnot lead to the abandonment of the dream of secure administration of trouble-some sectors of the population according to a logic of normalization, risk reduc-tion and neutralization, though this is certainly the lesson drawn by some. Nordoes 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 demandsfor more information to be noted in better files, for more coordination betweendifferent professionals, for tighter standards, codes of conduct and so forth.Thus, speaking in August 1994 in the light of a report into homicides committedby 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 dischargedpsychiatric patient in the community.’35 But the response of his government wasto seek not to reinvent the coordinated machinery of welfare psychiatry, but todevelop procedures, targets, standards, audits, evaluations and the like. Thesewould aim to establish mechanisms for control of professionals which would notbind them into a centrally directed bureaucracy, but would nonetheless shapeand regulate their actions and decisions and hold them accountable for their con-sequences. 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 thestrategy of reducing risk and minimizing harm under threat of sanction andwithin 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 chosenmy focus 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 tinyproportion of that vast cost in social inefficiency and personal unhappiness at-tributed to the psycho-neuroses. To redress this emphasis would require anotherpaper. For the present, I would just say that, first, it is on the issue of communityprotection rather than the maximization of health through prophylactic meansthat our present problematizations of madness have come to turn. And second,that the rationalities of risk assessment, risk management and risk minimizationhave become features of our current ’experience of madness’ that are not con-fined to a small sector of the psychiatrized population.A few words in conclusion. The asylum conferred a certain unity upon the



19

subjects of psychiatry and upon the project to underpin that institutional andmoral unity with a unified system of knowledge. Whole libraries of psychiatrictaxonomies are the legacy of that quest. The unity conferred by the territory ofthe community and the rationales of risk is less accessible to such utopian dreamsof a totalized theory or taxonomy of madness, and to the claims for a singlesource of authority which go along with them. Perhaps, then, the currentproliferation of claims to expertise in ’care in the community’ is not only aninevitable consequence of professional ambitions but arises from the diverseforms of visibility and manageability which appear in this new territory. For onthe community many others, and not merely professionals, appear able to make aclaim to knowledge and status - as, for example, in the assaults on psychiatrymounted by voluntary organizations made up of lay persons, frequently parentsor relatives of users. And, more particularly, it is within this configuration that anew power may be accorded to those who are users, consumers, or survivors of

psychiatry, as manifested in the growth of organizations of recipients ofpsychiatric ministrations in so many different countries. Thus the veryuncertainty and contestability of knowledge which ’community psychiatry’embodies and intensifies is not wholly without progressive possibilities. For if allothers can claim their portion of expertise, so, perhaps, can those who have for solong been denied a voice in the system which governs them: the subjects ofpsychiatry themselves.

Further, the disenchantment of transgression associated with the birth of theasylum transformed the subject of psychiatry into a case, a pathological entitysuffering from an internal moral, psychological, or biological fault. This waslinked to the elaboration of a series of technologies of cure that sought to accessand transform that internal space by moral, chemical, psychological, or physicalmeans. Perhaps the very ’superficiality’ of many of the new technologies ofbehavioural management, the demands that they place upon themselves for theactive involvement of the users of psychiatry in the games of power that wouldmanage them, opens up new possibilities for the contestation of psychiatricexpertise. Like the logics of choice which inform so many advanced liberalstrategies of management, they open new two-way relations between authoritiesand the subjectivities of those they would govern, relations that open new spacesfor contestation and amplify the possibilities for legitimate disputation ofprofessional 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 wouldbe less judgemental and more caring than those to which we have becomeaccustomed in the forms of madness that now pass for normality. Themanagement of populations in terms of communities of risk blurs the divisionsymbolized by the walls of the asylum.36 We can all be allocated to risk



20

categories, may indulge in behaviour like drunk driving which poses risks toothers as well as to ourselves, require guidance from experts as to how we shouldmanage our lifestyle in order to reduce its riskiness. Practices of recording,accounting, monitoring, collecting and acting upon information in relation torisk have consequences for the values of liberty, democracy and civil rights whichhave been much discussed. But as Jonathan Simon has recently pointed out,perhaps more significant are the costs of the transformation of security into avalue in its own right. In reconceptualizing accidents and misfortunes as

calculable risks, and in holding professionals and politicians to account whenthese events occur, we allow all cultural practices to be ’vivisected at themicro-level’ and give our experts the duty of defining and managing them inorder to eliminate or minimize any possible features that might provedangerous.&dquo; It is not that these strategies and devices for total security will eversucceed in their ambitions. But rather, what one should be concerned about arethe forms of life and the logics of culpability to which those obligations andambitions are attached.

Goldsmiths College, University of London, UK

NOTES

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 ofScience and Technology, University of Toronto, April 1994. This version was preparedfor a Society for the Social History of Medicine conference, ’From Mental Illness toMental Health’, held at Sheffield, September 1994 and a conference on the ’History of theHuman Sciences’, at Melbourne, September 1994. Thanks to all for their comments and toNigel Parton for letting me read his forthcoming work on risk in social work prior topublication. 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 theWorld Health Organisation under the chairmanship of John Bowlby. Also significanthere was the role of major foundations such as Rockefeller.

7 On the work of Franco and Franca Basaglia and their colleagues, see Lovell andScheper Hughes (1987).

8 See the reports of the Ministry of Health and the Chief Medical Officer during the1950s.

9 Castel (1988).



21

10 A number of the points that follow are derived from Rose (1992).11 Esquirol (1838); Bucknill and Tuke (1869).12 Foucault (1961: especially Ch. 4).13 Gordon (1992).14 Cf. Markus (1993).15 Quoted in Rose (1992:146).16 Cf. Castel (1988); Scull (1993).17 Judith Walkowitz provides a detailed discussion of one example (1992). For a

discussion of the history of hysteria, see Veith (1970).18 Cf. Smith (1981).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 Beck’s proposition that we live in a ’risksociety’ (Beck, 1991). While this paper was in proof, I read some recent work by NigelParton which makes similar arguments in relation to the current obsessions with risksin social work and their role in the ’blaming system’ (Parton, 1996).

27 Castel (1991).28 O’Malley (1992). While the new prudentialism shares many features with the forms of

prudentialism advocated in the 19th century, the differences lie in at least threefeatures: the novel forms of autonomization of the subjects of risk; the role ofmarket-based insurantial expertise; the new objectives of prudentialism in terms oflifestyle maximization.

29 Hacking (1992).30 For an example of this logic applied to the health service itself, see NHS Management

Executive (1993). See also Parton (1996) for a discussion of the Risk Initiativeundertaken by the Social Services Inspectorate.

31 ibid.: ii.32 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 fixedand categoric taxonomy. Diagnosis itself becomes statistical: a matter of describing aconcatenation of indicators, co-occurring in certain regular patterns. No doubt thestatisticalization of diagnosis goes back at least to the emergence of the social

psychiatries in the middle decades of this century, and the psycho-epidemiologies ofthe 1960s and 1970s. Nonetheless, the conduct of diagnosis in probabilistic terms isentirely amenable to its new role - to make predictions as to the future course of eventswith a view to developing expert strategies for administering the subjects in a way thatminimizes their riskiness.

33 Castel (1991: 282).34 R. Ericson’s paper delivered to a workshop on ’Radically Rethinking Regulation’,

University of Toronto, Centre for Criminology, April 1994.



22

35 John Bowis, Junior Health Minister, radio interview, BBC Today programme, Radio4, 17 August 1994.

36 Cf. Cohen (1985).37 Simon (1994:38).

BIBLIOGRAPHY

Armstrong, D. (1983) The Political Anatomy of the Body. London: CambridgeUniversity Press.

Beck, U. (1991) A Risk Society. Cambridge: Polity.Bucknill, J. and Tuke, W. (1869) Manual of Psychological Medicine. London: Churchill.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. W. D. Halls. Cambridge: Polity.

Castel, R. (1991) ’From Dangerousness to Risk’, in G. Burchell, C. Gordon and P. Miller(eds) The Foucault Effect: Studies in Governmentality. Hemel Hempstead, Herts:Harvester Wheatsheaf.

Cohen, S. (1985) Visions of Social Control: 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 l’âge 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.NHS Management Executive (1993) Risk Management in the NHS. London: HMSO.O’Malley, P. (1992) ’Risk, Power and Crime Prevention’, Economy and Society

21(3):252-75.Parton, N. (1996) ’Social Work, Risk and "The Blaming System"’, in N. Parton (ed.)

Social Theory, Social Change and Social Work. London: Routledge.Pasquino, P. (1991) ’Criminology: The Invention of a Savoir’, in G. Burchell, C. Gordon

and P. Miller (eds) The Foucault Effect: Studies in Governmentality. HemelHempstead, Herts: Harvester Wheatsheaf.

Pick, D. (1989) Faces of Degeneration: a European Disorder, c. 1848-1918. Cambridge:Cambridge University Press.

Richie, J. H., Dick, D. and Lingham, R. (1994) The Report into the Care and Treatment ofChristopher Clunis. London: HMSO.

Rose, N. (1985) The Psychological Complex: Psychology, Politics and Society in England,1869-1939. London: Routledge & Kegan Paul.

Rose, N. (1986) ’Psychiatry: the Discipline of Mental Health’, in P. Miller and N. Rose(eds) The Power of Psychiatry. Cambridge: Polity.



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Rose, N. (1992) ’Of Madness Itself: Histoire de la folie and the Object of PsychiatricHistory’, 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 ofGovernment’, British Journal of Sociology 43(2):172-205.

Scull, A. (1993) The Most Solitary of Afflictions: Madness and Society in Britain1700-1900. New Haven, CT: Yale University Press.

Simon, J. (1994) ’In the Place of the Parent: Risk Management and the Government ofCampus Life’, Social and Legal Studies 3: 15-45.

Smith, R. (1981) Trial by Medicine: Insanity and Responsibility in Viaorian Trials.Edinburgh: Edinburgh University Press.

Veith, I. (1970) Hysteria: the History of a Disease. Chicago, IL: University of ChicagoPress.

Walkowitz, J. (1992) Cities of Dreadful Delight. Chicago, IL: University of ChicagoPress.



Documents

Nikolas Rose - Psychiatry as a Political Science - Advanced Liberalism and the Administration of Risk