The Asylum is Sick: The Mental Institution from Medical Prison to Laboratory for Change

This is part of a series of presentations on the history of radical mental health projects called Mental Health in Crisis. Find recordings at unsoundmind.org/blog and the landing page for the series with notes, slideshows, and info for how to follow the series at https://www.unsoundmind.org/post/mhic-presentation-series.

Mental institutions loom large in the history of psychiatry and disability. As a theme, they conjure up more associations and images of what it means to be insane than anything else. As physical structures, they dominated (and dominate) the landscape and were effectively the center of many towns’ economic life and collective fantasy. It would be impossible to give even a basic outline of what the mental institution means in the history of radical psychiatry in one talk. Therefore, I plan to split up the topic into multiple separate presentations. Today, I’ll be focusing on the internal social world, the physical arrangement of space, and individuals who tried to modify these to create a different way of being with one another from within; in the next session, I will talk about those who saw the institution itself as a bulwark to new social forms and sought to negate it (mainly in Italy and Brazil); and in one month, I will try my best to give a coherent account of the extremely complex topics of “deinstitutionalization” and “psychiatry in the community,” focusing on the US and England.

The social world of the asylum

The projects we will be looking at today all place a great emphasis on this thing called the “social.” Some of them even oppose a “social” conception of distress to somatic, neurological, psychological, or developmental conceptions. But what is this thing we call the “social?”

There has been much talk from an increasingly large reformist corner of the contemporary psychiatric world around reintroducing and valorizing the social in our understanding of mental illness. This means different things to different people: some have been pushing for a “bio-psycho-social” approach that often just tacks on this thing called “social” onto standard psychiatric diagnostic entities and the structurally subordinate accompanying psychological theories. This approach often takes the form of a discussion of “factors:” a person’s wellness and ill-health are the result of biological factors (your brain chemistry, genetics, etc), social factors (job or food security, familial relationships), and psychological factors (beliefs, coping mechanisms, or, even worse, IQ scores). The “social factors” are often just one’s immediate material reality, the facts of one’s life, and psychiatry deserves no praise for adding their patients’ housing stability or job precarity as “factors” of its ultimately biological mystifications. A few push this further and say that mental distress is wholly tied to the social, or, they might say, the political and economic spheres. In this moment in time when we are still so thoroughly inundated with rigid neuro- and chemical ideologies, it is tempting to believe that the dehumanization of the patient could be avoided if psychiatric professionals and service providers searched for the roots of our issues in our social relations. We cannot forget, though, that the dominant ideology of the psychiatrists who fought for and oversaw the first major period of asylum construction in the United States in the early to mid 1800s was a social one that held civilization responsible for psychic illness and sought the cure in removal from the intensity of city life. It was a social understanding of madness that animated the production of this massive network of medical prisons and not the organic framing that would be used later to justify their maintenance.

Is the social just everything that happens “in society?” This tautology represents a common but very impoverished concept of sociality. One idea we discard is the notion that you and I exist as pre-defined individuals–contained biologically, mentally, and emotionally– who go out into the world and meet in a neutral “social” space. For Fanon, whom I talked about last session, and for those whom I will discuss today, the social world is not the name for the encounter between self-contained individuals. In the broadest sense, each of them, to varying degrees, conceive of sociality as a fundamental condition for understanding and identification. In Fanon’s work, for instance, the social world is described in terms of reciprocity, especially those moments in a racist and colonized society when it is broken or does not take place. If the social is found in reciprocity, and my own notion of who I am and what it means to live in this world is tied to the event of mutual recognition, that also means that the individual (and therefore the psyche, the emotions, and the rest) who goes out into the world to meet others is constituted and defined in relation to others. The experience of encountering the other is coeval with the construction of self. Even our bodies, which seem to belong to us as an exclusive property, can be said to exist in this way: they are permeable, open, they leak, bleed, consume, excrete; our bodies flow out into a common world, and are open to outside influence, as the COVID-19 pandemic has made so excruciatingly clear. This question of what the social is or where social activity takes place, which I want to leave open for now, is the implicit question underlying this presentation today.

As I mentioned, the founders of the asylum system believed that the social world of contemporary civilization, that is, city life, was the primary cause of insanity. The road to health then obviously required quick and decisive removal, a policy which justified lax civil commitment laws and the construction of self-contained asylums. Over time, in periods when pessimism around this thesis set in, the justification changed: the patient had to be removed because they were too disruptive or dangerous, though even here it is “society” the mental patient threatens. In any case, the result was the same and the patient found themself locked up and subject to institutional administration. The Canadian sociologist Erving Goffman offers some useful tools for thinking about sociality in the context of the asylum based on his ethnographic studies at St. Elizabeth’s, one of the only United States’ federal asylums. Significantly, Goffman was not exclusively studying the asylum, but rather the “total institution,” a space set out apart from the outside world where inmates or lodgers are immersed into a social field with its own separate codes, laws, norms, and expectations. Michel Foucault leveled a friendly critique at Goffman’s characterization in his lecture series Psychiatric Power: he said that Goffman tended to isolate the psychiatric hospital more than was actually possible. There may have been attempts to close it off to the outside world, but with staff, visitors, and new patients, outside influences were flowing in constantly. The institution is not so much an alien planet as an island. In the essay “On the Characteristics of Total Institutions,” Goffman explains that the asylum sets out to “untrain” the incoming patient, in a bid to institute a break in their life to put them on the path to a cure, or simply to break them and ameliorate their more excessive behaviors for the benefit of the staff and society at large. Keeping Foucault’s critique in mind, I think we can say that the hospital tries to sever the patient from their social world, but that social forms nevertheless arise within this new environment.

Upon arrival, personal belongings are taken and stored, clothes are removed, their hair may be cut, and their personal boundaries are immediately unsettled when they find out that the staff has access to the most intimate regions of their body and can, at their own discretion, exert force and violence when deemed necessary. In this way, the patient is “shaped and coded into an object that can be fed into the administrative machinery of the establishment, to be worked on smoothly by routine operations” (Goffman, 16). But, for all that, are the inmates transformed into mere robots mechanically acting out the performances expected of them? Not at all. Desire does not disappear; it is displaced and dispersed across a new social field. If cigarettes, alcohol or treats are offered as rewards or in the black market, new activities arise oriented around these small pleasures (gambling, for example). Sexual relations are pursued in secret. Slangs and linguistic shorthands are coined to facilitate underground economic or social exchanges. While the staff may be invested in trying to break the patient, to discipline them, or to inscribe them in a treatment program, a whole range of counter-measures are available: they can pretend to participate in therapy or activities to have more social interactions or pursue a romantic interest, they can pretend to take medicines and parrot the language of the psychiatrist, and they can even sabotage infrastructure or organize a small protest against bad conditions or simply run away. The psychiatric inmate is not fated to become the model patient and adopt the language of their doctors; they can just as well withdraw into isolation in a corner, lash out in violence to maintain personal integrity, or carve out a niche existence with enough pleasures. In other words, the mad doctors could never remove people from the social world; all they could do was transplant them from one milieu into another –one that was much more impoverished, and entirely lacking in self-awareness.

War psychiatry/camp psychiatry

We can treat Goffman’s account here as a description of the typical social life of an asylum based on segregation and concentration. To anticipate what’s about to come by using a term popular with the French group I want to discuss, one could describe this mode of life using Jean-Paul Sartre’s concept of “seriality:” a life lived according to a formal, rigid schema, “a ritualization of the quotidian, a regular and terminal hierarchization of responsibility” (Chaosophy, 181). As terrible as they were, a group of dissident psychiatrists and communists in central Europe, shaken by wartime experiences, nevertheless believed they could transform mental institutions into true places of refuge worthy of the name “asylum."

The first of these radicals in Europe was François Tosquelles. Tosquelles was born into an anarcho-syndicalist family in Catalonia, Spain in 1912. During the Spanish Civil War, he was part of a group that founded POUM, an anti-Stalinist Marxist party. During the war, he served as a psychiatrist, treating partisans’ traumatic reactions to battle within just a few kilometers of the frontline. Likely by virtue of necessity, he worked with non-professions –he names lawyers, soldiers, and sex workers– and found that the lack of professionalism actually inculcated a spirit of collectivism and mutual reliance. After the war, Francisco Franco’s regime put out a death sentence on Tosquelles’ who was forced to flee to France along with many other Spanish republican, anarchist, and communist comrades. Like many others, Tosquelles ended up in the Septfonds concentration camp, where Tosquelles again practiced psychiatry under extraordinary conditions. From then on, Tosquelles intimately understood the deleterious effects of living in confined spaces defined and organized by inhuman, bureaucratic categories. In this way, he became one of the first of a long line of psychiatrists and critics to draw a direct line between the organizational principles and physical space of the mental institution and the prison to the concentrationist and segregationist model of the concentration camp. Particularly after the horrors of the Shoah would become more widely known, this mode of comparison would be frequently and successfully mobilized in campaigns for deinstitutionalization. Even Goffman’s study of total institutions was on prisons, mental institutions, and concentration camps.

In 1940, French Resistance soldiers facilitated the successful escape of the detainees at Septfonds. Free, but unable to return home, Tosquelles accepted the invite of Paul Balvet, then director of the remote Saint-Alban psychiatric hospital to come work with him. Soon after, and especially after Balvet left and was replaced by the communist Lucien Bonnafé, Tosquelles and company welcomed Jewish refugees and resistance fighters like Georges Canguilhem and Paul Eluard, oftentimes signing false admission forms, if necessary. This convergence of communists, poets, and refugees was the dynamic environment that gave birth to the movement later named “Institutional Psychotherapy:” Tosquelles wrote about it that “A good citizen is incapable of doing psychiatry. Psychiatry includes an anti-culture, a culture with a different point of view” (in Melitopoulos, 125). The position of this new rebellious milieu, whose members had survived war and camp life, was that it was not the psychiatric patient who ought to be the object of therapeutic intervention, but the hospital and all the factors that converged to make it into a medical prison.

The hospital was sick, they said. It had a social life but it was impoverished and dehumanizing. It claimed to offer shelter and refuge from the outside world, but took the form of a prison, or even a camp. If the asylum was to become a real refuge, then its role must be to “disoccupy” and “disalienate” the person, not adjust them to alienation. In their strivings to heal this space, they mobilized disparate discourses and histories: Marxist political and social theory, Freudian insights into mental alienation, theories of psychiatric architecture, semiotics, and a variety of local, rural knowledges about communal life, agriculture, and more. In preparing this talk about this group, I was not just confronting one Pandora’s box, but seemed to find myself in a shop full of such boxes, left only the choice as to which one I would open. They were not the first to combine Freudian insights into mind with a Marxist orientation –the rogue German psychoanalyst Wilhelm Reich had already written The Mass Psychology of Fascism that connected the economic unit of the patriarchal family in capitalism to mass neuroses and the desire for fascism– but they seized, in this small, neglected hospital in France, the chance to apply the idea that the goal of psychiatry was to confront social and mental alienation through the organization of space and social life arguably more thoroughly and more effectively than anyone before. Jean Oury, who worked at Saint-Alban in the 40s, opened a second, private clinic under the same premises along with Felix Guattari in 1953 called La Borde. Guattari later became the most famous member of the Institutional Psychotherapy group after publishing the book Anti-Oedipus with Gilles Deleuze, which, for many, captured the excitement and imagination of the movements of ‘68. He, like many others, had a background in militant political activities before pursuing training as a psychotherapist. Though he belongs to the second generation of practitioners, I will make frequent reference to his work, because he developed a number of useful concepts for describing the theory of Institutional Psychotherapy and its practical import.

To modify the space is to modify the milieu

The first necessary task was to change the way one organizes space and the opportunities for social life, for this, in turn, meant changing the way space organizes people. Psychiatry had to become a “geo-psychiatry” in which space was conceived as a therapeutic agent. Jean Oury described the effect of interning madness within walls when he said that

an illness exists because there is a certain wall surrounding it. In the end, nosologies are only frameworks for imprisoning madmen. They are put in books, like a butterfly collection. A psychiatry book is the same thing: what the butterflies are like, in what room; to preserve them you drop them in formaldehyde, to observe them you put them in rooms with portholes. It doesn't stop there: now they have to be occupied, you have to put them on machines, give them tools, but it is aIl the same thing (Psychoanalysis and Transversality, 27).

Patients were enlisted to literally tear down walls created to hem them in, and doors were unlocked. Townspeople were invited into the hospital, and the patients left their confinement on the hill to go into town. What mattered were not the specific spaces themselves, but, as Tosquelles said, “to be able to go from one part to another, from one’s quarters to the kitchen, from the kitchen to the cemetery even” (in Melitopoulos, 141). Common space, or space in general, was defined by constantly shifting patterns of movement–routes and pathways–rather than defined physical boundaries. Some of the staff and doctors began living at the hospital with the patients with their families, eating the same meals, and participating in the same activities; this created a situation in which everyone was materially invested in improving the living conditions of the space, where a superintendent could no longer say “I’ll have the dining room cleaned later” because it didn’t really matter to him. Increasingly, patients and staff worked side-by-side. This role refusal and breakdown of boundaries was not an addition to a biological treatment, but was the therapy itself. Beyond that, the collective spirit of work was a saving grace in a time when the Vichy government allowed over 40,000 patients to die of malnutrition or cold; since Saint-Alban’s productive output was much higher, and the doctors had no qualms about flubbing records to receive extra rations or trading with villagers, no patients died in this way. The space of the hospital became permeable and open, its boundaries were fluid. It was no longer the isolated island described by Goffman, with its paranoid directive to keep all contagions, that is, human beings, contained and segregated.

What had to be avoided was the comfort and passivity of distinct roles and positions. Everything had to be put into motion; the world had to invent itself anew everyday. For Tosquelles,“[w]hat counts is not the head, but the feet. Knowing where you put your feet. It is the feet that are the great readers of the world, of geography” (in Melitopoulos, 109). His experience of being a migrant and a refugee is doubtless tied to this attitude: he said that “[t]he human is a creature that goes from one space to another, she cannot stay all the time in the same space [...] That’s to say that the human is always a pilgrim, a creature who goes elsewhere” (in Ibid, 51). There was a joke at La Borde that it was actually the doctors who were the most chronic cases: they never left, while the patients were just passing through (Psychoanalysis and Transversality, 31). The patient club, in which political power was invested, was one of the major innovations. Patients were asked to make significant decisions for the hospital and could contest decisions made from the staff. A patient bar was opened, dances were organized regularly, along with films and dinners. Isolation, cliques, and “egocentrism” were to be combated with festivals, parties, and the reorganization of roles to shake things up and create new connections or associations. In this way, a principle of freedom and experimentation, the ability to remake yourself everyday was part of the therapy. At La Borde, they instituted a complex grid for redistributing roles and the division of labor on a regular basis to produce new social arrangements and “frame the deregulation” (in Cálo, “The Grid”). This ensured that nurses would wash dishes, doctors would farm, staff members would perform routine medical tasks, and residents would lead art classes. Guattari emphasized in his work that, thanks to this arrangement, the same person could be a patient at one time, a nurse at another, and the analyst at another. This constant changing and shifting was meant to break people free of the seriality imposed by other institutions, so that they could, in Guattari’s words “reappropriate the meaning of their existence in an ethical and no longer technocratic way” (Chaosophy, 180). To understand Institutional Psychotherapy, you might be better off studying ecology rather than psychopathology.

Lines of communication, paths of desire

In the typical mental hospital, desire officially flows in one direction: the only desire with any acknowledged reality is that of the superintendent, the guard, or the nurse. Desire only exists, or is represented, as the expression of force. “Fatally,” said Tosquelles, “the guards, leaders, bosses, the doctors, or psychiatrists only make everyone a prisoner of their own particular psychopathology, their character” (in Melitopoulos, 142). Unlike the traditional asylum, desire was acknowledged and taken seriously as a common factor at La Borde and Saint Alban. Goffman describes how, at a locked psychiatric hospital, desire from below had to seek out hidden routes in illicit romances and black market exchanges. Pleasure seeking, when it was acknowledged, was exploited by the staff who could, for instance, trade cigarettes or liquor for obedience. The urge to move, to develop relations with the world, new associations, to try out new tasks or set out exploring a novel sexual, romantic, or friendly relationship do not disappear in the mental institution; but by being denied, by forcing the patient to quash their wants and enthusiasms while providing no means of exploration, they are transformed into niche hidden corners if not frustrations, anger, aggression, and despair. As Wilhelm Reich argued time and again, desire and sexuality flow through the social world, not as a separate moment, but all the time. In the Institutional Psychotherapy paradigm, such desire is treated as a common factor of social life; in fact, it is celebrated as a motor of collective transformation and growth. This is a bigger break that it seems: I for one cannot imagine a hospital ward, group home, or security hospital today that would encourage let alone permit romantic or sexual encounters between residents or residents and outsiders, not to mention, any friendship worthy of the name is impossible with someone who holds the keys to your free movement.

The expression of desire facilitates, in turn, the development of new minor languages, lingos, and slangs. One of the organs of communication at Saint Alban was Traite d’Union, a newsletter run by and for residents. This publication differed from a typical asylum newsletter, since the latter were often edited as therefore limited by staff who oftentimes recruited only those patients who were already sympathetic to the institution’s operations. In my own study of patient publications at Minnesota’s institutions, I commonly came across articles in which the author expressed the hope that, by writing, the staff would consider them more competent and therefore potentially worthy of an earlier release. But because the psyche is, according to Guattari, “the resultant of multiple and heterogenous components,” it was necessary to go beyond Lacan, who suggested that the unconscious is structured like a language, and also take seriously “nonverbal means of communication, relations of architectural space, ethological behaviors, economic status, social relations at all levels, and, still more fundamentally, ethical and aesthetic aspirations” (Chaosophy, 191). While still in Spain, Tosquelles had studied muscular tonus; he compared the psychiatric encounter to a game of football: what is important is to pay attention to the positions of the players, their postures, their attitudes and conflicts, and their muscular tones and reactions. What we are dealing with here are mediums of communication not involving the privileged verbal form involving the enunciation of words. In the normal psychoanalytic dualism, the therapeutic encounter takes place between two people, in verbal language, often in a private, closed room. One can describe the concept of Institutional Psychotherapy as the style of treatment that opposes this format point-by-point: the therapeutic encounter takes place within groups in common, fluid space and in irregular, incommensurable mediums of communication, that is, in body language, through visual cues, touch, activity, or something else.

Any “analysis” taking place in this paradigm, any treatment being pursued, does not flow downwards from the analyst to the patient in a vertical way, but neither does it pass from one patient to another in a horizontal way. It cuts across many lines at once, in an irregular fashion. Guattari coins the concept of “transversality” to describe therapeutic encounters, which he opposes to the psychoanalytic notion of “transference” wherein a patient's feelings from outside the binary therapeutic relationship are “transferred” into the present–onto the analyst, for example. With transversality, Guattari (and I think he is representative of the general thrust of Institutional Psychotherapy here) offered an alternative to traditional psychiatric hierarchies, but also to isolated forms of self-management, anticipating exclusively patient led projects in the decades that followed. Transversality can be said to describe the ways in which diagonal lines of communication or social encounters cut across and through vertically and horizontally arranged ones, “when there is maximum communication among different levels and, above aIl, in different meanings” (Transversality and Psychoanalysis, 113).

Nise da Silveira and the "unity of things"

Given its importance to 20th century projects, both reformist and radical, I want to explore whether visual art can be thought of as a nonverbal medium of communication with the capacity to cut across such lines. There were multiple movements and individuals that recognized psychiatric patient artwork in the 20th century: Jean Dubuffet, through his encounters with it at Saint Alban, coined the term “art brut,” or “raw art” and saw psychiatric patient art as an expression of an untamed, primitive creative force; Hans Prinzhorn wrote a systematic study of “psychotic art” in 1922 and collected over 5,000 pieces that are in the Prinzhorn museum in Heidelberg today, which continues to grow and display pieces by psychiatric patients. But I want to leave these masculine circles in Europe and go to Brazil to examine another hospital where ideas similar to those of Institutional Psychotherapy were being put into practice through artistic activity by the inimitable psychiatrist Nise da Silveira. According to the Brazilian author Graciliano Ramos, it was, for her, “not enough to be woman and Northeastern, doctor and psychiatrist; but [she also had to be an] early antipsychiatrist and communist in the fascist State.” She was not the first to introduce art therapy into Brazil –it has enjoyed a great deal of popularity since Osório César began collecting work in the 1920s–but she elevated it as a technique at greater personal and professional risk and with a greater degree of experimentation.

In the 1930s, Silveira began working at the Centro Psiquiátrico Nacional Pedro II in the neighborhood of Engenho de Dentro in Rio –Brazil’s first asylum– in the period of the fascist Vargas government. Marlon Miguel characterizes early Brazilian psychiatry as being split between a progressive vanguard and a “heavy, exclusionary, violent, and carceral” (251) mode. Like the United States, the former slave state of Brazil governed its subjects through race, resulting in uneven and differentiated lines of force and distribution of resources. This sometimes happened through more covert channels than in the United States, because of a popular notion of “racial democracy” touted there, but, like in the US and Canada, it was clear in the popular theory of eugenics. The supposed “mental disturbances of blacks” was a common theme in this discourse up until the dictatorship period, when eugenics became linked to the state’s project of purging the ever-feared communists, who were linked to this notion of inherent degeneracy, and whitening the population through external immigration controls and internal population management. The language of inheritable degeneration and disease and the strong link between localizable biological factors and pathology contributed to the widespread popularity of aggressive physical treatments like the leukotomy technique of the Portoguese psychiatrist Egas Moritz, along with electroshock and insulin shock later on. Already, in this early period, she defied the logic of this violent regime by forming simple human relationships with her patients. She describes at one point how, despite her colleagues telling her that schizophrenic patients have no affect or internal life, she formed a friendly relationship with a patient with this diagnosis even though the latter did not verbally communicate. In 1936, a nurse found Marxist literature among Silveira’s things and turned her into the state. While she was gone serving her year and a half sentence, the patient found out who had given her up and beat the nurse up very badly. Silveira said “The schizophrenic is not indifferent” (in Cabañas, 81).

After 8 years in exile, she returned to the hospital Pedro II in 1944 and set out to form an entirely new psychiatric practice within this urban prison. She arrived at a moment when electroconvulsive therapy was being introduced onto the wards and describes seeing it applied for the first time: “We stood over the bed of a patient who was there to have electric shocks,” she said, “[t]he psychiatrist pressed the button and the man started to seize. When the other patient was ready to receive a shock, the doctor said to me, ‘Press the button.’ I said, ‘I won’t!’ And that’s where the rebel began” (in Megaldi, 6). Beyond simply being revolted by the raw brutality of these acts, Silveira also questioned their philosophical underpinnings: what concept of the body was being operated on here? To her, reliance on such practices betrayed a faith in the mechanistic model of the human body with roots in Descartes’ assertion that the body was a mere automaton mirrored in her time by various branches of phrenology which sought the final cause of human behaviors in localizable regions of the brain. She turned sharply away from this school that framed the mental patient as a “sick machine” and towards concepts that opened doors to communication and simple human relationships. In her 8 years of exile, she studied the 17th century philosopher Baruch de Spinoza who revealed “the unity of things” to her through his monist conception of the universe in which everything is interrelated and has the capacity to affect everything else. She became especially fond of Carl Gustav Jung’s exploration of the collective unconscious, which, for her, allowed her to comprehend small gestures and visual productions as expressions of a primordial, but more importantly, communicative acts. A third influence was the work of the French madman and playwright Antonin Artaud, who, perhaps more forcefully than most, declared the fundamental right of the insane to be and to remain insane.

What do these influences have in common? For one, all three assumed that communication was not limited to verbal language. It is telling that Silveira chose Jung over Freud here: to speak quite broadly, much of Freud’s method of approaching clinical cases involved interpreting seemingly incoherent enunciations, dreams, visual materials, or acted behaviors back into symbolic language. Psychoanalysis, according to Silveira, had mainly acted as a detective aiming “to discover materials repressed in disguise in painted images.” The image, she said, is treated “merely as a starting point for verbal associations until the repressed unconscious is reached [...] The images, then, have to be translated into words” (in Megaldi, 8). By mobilizing Spinoza, Jung, and Artaud, Silveira began to consider how the image alone had concrete effects on those who perceived it and that this alone, without translation, was a sufficient medium of communicating and relating:

There are schools that study the images, but understand that the painted images serve only as means to develop verbal expression, that is considered to be by them the only valid language. [...] For us, the image is valid in its own value, it speaks by itself, and eloquently (in Pordeus, 5-6).

To get closer to what this might mean, we might contrast Spinoza’s thinking about falsity to the standard psychiatric one, since this is a prototypical problem of the understanding. Traditionally, delusion is considered negatively as simple non-reason; it is that which is incommensurable with reality. False ideas are non-true ideas. Spinoza explains that a false idea, or, in our case, a delusion, is not untruth, but inadequate truth. Inadequate according to what? Since ”[t]he order and connections of ideas is the same of the order and connections of things,” it can’t be according to some transcendental standard of truth, but rather an imminent, relational one. A falsity is actually positive, insofar as it is an expression of a concrete relationship to the world; no idea, he reminds us again and again, is formed separately from the body and mind being affected by something else in the world, thus the products of the imagination are always true in themselves. For Spinoza, the imagination, falsity, or so-called delusion should not be judged according to a simple criteria of reality-unreality, but rather must be thought in relation to the ways in which we form ideas through being affected by things. All ideas, insofar as they express a manner of being bodily or mentally affected, express a kind of truth. This allows us to say: you are not wrong, not misguided nor lost; what you are expressing and doing is an idea born of this world with an effect on the people and things around you and is, in that sense, real and true, but your expression could be made more adequate, that is, shared more fully, by pursuing development within a common social world. And, in fact, Silveira’s notion of visual communication was far from static; rather, she held that by continuously flexing this creative and communicative muscle in a common space, clients would become increasingly adept at expressing themselves and understanding others through the visual field.

To sum up these points: the image is itself communicative, and not necessary linguistically; and second, expression and perception through artistic practice in a common space (in this case in the visual field) constitutes a sufficient and complete social world. This social form is not impoverished; it is not “lacking language,” at least not any more than primarily verbal communicators are lacking in touch, smell, and visual relations with the world. Despite its immense importance for Nise da Silveira’s practice, I would surmise that the image is not essential: if she had opened up a floral arrangement clinic, however odd that would be, the same arguments could be made for olfactory productions. Her aim was to “[coordinate] intimately hand and eye, sentiment and thinking, body and psyche” (in de Castro and de Araújo Lima, 10). With this aim in sight, Silveira was even able to conceive of the cats and dogs she gave to the patients to take care of as “co-therapists.” This was no humorous simile: insofar as the animals had imminent therapeutic effects in the orientation of self to group and group to world, they were in fact therapists. We should also understand that in no sense is the body here (or in Institutional Psychotherapy) being denied. Instead, it is being invested with intensive capabilities denied it under the hospital regime.

Silveira struggled to maintain her artistic circle within the hospital for years before achieving wider recognition in the Brazilian art scene, which likely saved her practice. In 1952, she opened the Museum of Images of the Unconscious in Rio de Janeiro, which is still open and is the largest museum of its kind, containing over 350,000 works. The long relationship between psychiatry and the art world is highly ambivalent and I want to be clear that I am not necessarily singing the praises of art therapy, and certainly not artistic production alone. Those of us who look for rebellions and revolts have an unfortunate tendency to universalize a practice or group form, but it really depends on the context and the social form our practices take. The Nazis were also very interested in the artwork of the insane and displayed it to interested audiences alongside art by Jewish and avant-garde artists under the banner of “degenerate art” in cities around Germany. More often, mad artworks are excitedly and proudly displayed by a staff that “can’t believe” what the mentally ill and disabled are capable of. And there is hardly an institution or ward today that wouldn’t espouse the value of art therapy as a mechanism for calming patients. Distracting someone with painting is better than lashing out, they might say.

To give a concrete example of how art is co-opted today, I once visited the Glore Psychiatric Museum in St. Joseph, Missouri, which has a relatively large collection of patient art works. This section of the museum was called “Faces, Places, and Traces of Sanity;” as a spectator, I was supposed to be on the lookout for fragments of reason–the thing the artist mostly lacked–and even given parameters of visual and symbolic features I should be on the lookout for. On one wall, a tapestry covered in colorful stitched words is prominently and proudly displayed alongside the words “Silent Voice.” The blurb explains that it was created by a non-verbal black woman patient. Twice, it tells you, “research has shown” that, despite the psychotic nature of her words, there may actually be fragments of an “interesting” relationship to her environment. Look, most of this is nonsense, and it’s all pretty ugly, but you might be able to find a face or room you recognize! There is nothing social about this rote performance of connecting single words to recognizable objects in a room. The words on the tapestry reflect a full, neither impoverished nor lacking, experience of the world. They do not need to be interpreted, and no research could tell us anything noteworthy about them. I would go so far as to say that its chaotic flourishes express a deeper and more immediate relationship to the world than either the sociologist’s study of the quantitative recurrence of specific words or the art critic who seeks only to connect specific words to single objects. A machine could perform either of these tasks perfectly well.

What matters is the sociality and communication opened up by a practice, not this or that treatment, no matter how calming or pleasurable, and these in turn, as the school of Institutional Psychotherapy teach us, cannot be conceived separately from institutional organization. Everyone knows that a prisoner would rather do theater or paint than sit in isolation all day, but, if they are locked inside, this doesn’t say anything profound. Nise da Silveira expressed this better when she said that "hardly ever will a treatment be efficient if the patient does not have someone by his side representing a point of support in which he makes an affective investment” (in de Castro and de Araújo Lima, 9). Art can be valorized anywhere, as an aesthetic object or pleasurable activity, but to follow through to the end the notion that greater social cohesion and robust lines of communication can emerge through artistic practice would mean placing institutional constraints and treatments in question, something the vast majority of psychiatric hospitals, prisons, and group homes are unwilling to do. Like the Institutional Psychotherapy group, Silveira began to see the psychiatric hospital’s organization as a sick place that made the people who stayed there sicker: “[t]he hospital is reinforcing the pathology, because it does not help at all in re-establishing connections between the patient and their milieu, from which they are being separated because of the pathology [...] The Hospital becomes an extremely efficient apparatus for the chronification of disease” (in Miguel, 255). This is likely why, in 1956, she opened the Casa das Palmeiras, or Palms House, a pioneering outpatient facility where visitors could pursue an artistic practice outside of the confined spaces of both the home and the hospital.

What and where is the institution today?

There is a common myth that goes around that the age of mental institutions is past, that deinstitutionalization happened, and now all the remains are the ominous haunted relics of a bygone era. This is unfortunately far from true. Besides the numerous hospital wards, many long-term residential psychiatric facilities are in operation, some of which are in the very same old psychiatric hospitals many assume were closed. Many changed their name to “residential treatment center” or “security hospital.” The network of nursing homes and group homes also serve many of the same functions as the psychiatric hospital, while psychiatric wards have been opened in maximum security prisons. We have certainly witnessed a shake-up, but one which is perhaps better characterized as a reshuffling of the deck than a total transformation of paradigm. So, is there any possibility for institutional revolt today? Were the French thinkers correct in thinking that we need institutions to experiment with broad social and group transformations? They felt that the movements that would soon arise in Italy, the United States, and later in Brazil and elsewhere that called for the negation or destruction of the institution were misguided, because they were losing in this way a space that could be appropriated and transformed to offer true refuge and transform our relations with one-another. Guattari wrote that “the mental institution could become, if permanently rearranged [...] a very elaborate instrument for the enrichment of individual and collective subjectivity and for the reconfiguration of existential territories concerning –all at once– the body, the self, living space, relations with others…” (Chaosophy, 194) They were treated as spaces in which to build a new life in common. Let’s review some of the salient features the rearrangements required with some help from psychiatrist Jean Claude Polack: the elevation of patients to client status with rights and an autonomous social life; the constant reshuffling and questioning of professional roles to “prevent the identification of carers with their status” (59); the generalization of the analytic and therapeutic capacity of everyone involved; the valorization of non-standard mediums of communication; and the permanent decentering of a sane, normal subject as a model to adjust to. It’s hard to imagine anything comparable happening in today’s institutions, at least where I stand in the United States.

Already by the 1970s, the founders of the institutional movements also began to doubt how transferable their modes of operation were. Guattari considered the reformed psychiatry of that time to be so overbearingly technocratic and functionalist that it strangled every innovation while it was still in its infancy. Tosquelles said simply in an interview that Institutional Psychotherapy “died with pills” (in Melitopoulos, 146). Polack remarked that Saint-Alban went in decline following the death of Tosquelles while La Borde began to change once Guattari passed, and further wondered whether institutional experiments were essentially tied to a confluence of events: the war and camp experiences above all. For all the talk of intensities, milieus, and escaping egocentrism, this reflection forces us to ask whether movements such as these are only possible within an institution when rooted to a charismatic individual, usually a well-spoken and well-known man. On the other hand, the effects of the transformations, however much they softened with time, did not die along with the founders, and I would like to think they still reverberate as possibilities waiting for activation or a confluence of events and energy. But just what are these effects? Is something like the “Secteur” policy of France an outgrowth of these movements or a co-optation? What about the “service-client” model? The same could be asked with the prevalence of “art therapy.” What does the institutional field look like today? Which institutions can be adapted or transformed today and what shape would this take?

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