‘Disalienation of the Total Fact of Madness’An IntroductionMarlon Miguel and Elena Vogman

Situating Institutional Psychotherapy

This book brings together two texts, both originally conceived as talks, belonging to the French psychiatric reform movement of ‘institutional psychotherapy’. The first, ‘Psychopathology and Dialectical Materialism’,11This title was chosen by the French editor, Sophie Lesage. Tosquelles’s original title was ‘Psychopathology in Light of Dialectical Materialism’, see also François Tosquelles, ‘Psychopathology and Dialectical Materialism’, in this volume, p. 47, note *. was presented in 1947 by Catalan psychiatrist François Tosquelles, director of Saint-Alban-sur-Limagnole psychiatric hospital in Central-Southern France, in the context of a lecture series on neurology and psychiatry at École normale supérieure in Paris. The second, ‘Institutional Psychotherapy: From Saint-Alban to La Borde’, was given by French psychiatrist Jean Oury — founder and director of La Borde clinic in Cour-Cheverny — in 1970 in Poitiers. These somewhat heterogeneous texts, formulated in distinct historical situations, are clear attempts at taking a stand in a conflictual epistemic and political sphere of psychiatric knowledge and practice. Both presentations testify to their authors’ engagements not only in textual but also in oral transmission of their critical clinical experiences.22Oury, for example, taught weekly seminars until just before he died. These were held at both La Borde (from 1971 onwards) and at Saint-Anne hospital in Paris (from 1981 onwards). Such experiences aimed to transform psychiatric institutions and bring a new understanding of care practice involving social, environmental, and aesthetic realms. Against the dominant dehumanizing and devalorizing psychiatric practice of his time, Tosquelles claimed ‘madness’ to be crucially ‘a human phenomenon’, endowed with ‘freedom, responsibility, and meaning’.33François Tosquelles, Le Vécu de la fin du monde dans la folie. Le Témoignage de Gérard de Nerval (Grenoble: Jérôme Millon, 2012), p. 98. Unless otherwise indicated, all translations in this introduction are the editors’ own.

Institutional psychotherapy — a term coined in 1952 by psychiatrists Georges Daumézon and Philippe Koechlin44Georges Daumézon and Philippe Koechlin, ‘La Psychothérapie institutionnelle française contemporaine’, Anais portugueses de psiquiatria, 4.4 (1952), pp. 271–312. Georges Daumézon (1912–1979) was a French psychiatrist. He was medical director at Fleury-les-Aubrais psychiatric hospital from 1938 to 1951, where he initiated significant reforms in psychiatric care. Daumézon first met François Tosquelles in 1942 at a conference in Montpellier, marking the beginning of their collaborative work and his frequent visits to Saint-Alban (see Histoire de la psychiatrie de secteur ou le secteur impossible?, ed. by Lion Murard and François Fourquet, special issue of Recherches, 17 (1975), p. 109). In 1952, Daumézon and Philippe Koechlin (1938–2010), who was completing his specialist training in psychiatry with Daumézon, would coin the term ‘institutional psychiatry’ in one of the first articles offering an overview of the theoretical and historical backdrop, as well as the concrete changes the movement had introduced in psychiatric institutions in the post-war years. This seminal article, titled ‘La Psychothérapie institutionnelle française contemporaine’, was published in the Anais Portugueses de Psiquiatria, a journal edited by Hospital Júlio de Matos in Lisbon. In 1951, the journal started an exchange service with foreign publications, fostering an international dialogue in psychiatry, publishing titles in languages as diverse as German, Czech, Croatian, Spanish, Finnish, French, English, Italian, Japanese, Polish, Russian, and Portuguese (see ‘História da Biblioteca’, Centro Hospitalar Psiquiátrico de Lisboa, n. d., <https://www.chpl.min-saude.pt/servicos-de-apoio-geral/biblioteca/historia/> [accessed 23 June 2024]). According to Carlos De Brito, Daumézon and Koechlin’s article did not find a publisher in France and was therefore published in the Anais Portugueses de Psiquiatria thanks to one of its editors, Barahona Fernandes (see Carlos De Brito, ‘Jacques Postel, de loin et de près, in memoriam’, L’Information psychiatrique, 99.2 (2023), p. 126). This fact reveals the difficulties of speaking critically about psychiatric conditions in post-war France. — was a psychiatric reform and resistance movement. It proposed a radical restructuring of clinical institutions by actively involving patients in these processes. While undertaking a Marxist rethinking of psychoanalysis, institutional psychotherapy also implemented Gestalt psychology and existential philosophy into clinical theory and practice. One of its main goals, as Oury points out, was to fight against forms of confinement that were ‘concentrationary’55See Jean Oury, ‘Institutional Psychotherapy: From Saint-Alban to La Borde’, in this volume, p. 91. In Daumézon’s and Koechlin’s formulation articulated in the aftermath of World War II, ‘the comparison between the asylum world and the concentrationary universe inevitably imposes itself’ (Daumézon and Koechlin, ‘La Psychothérapie institutionnelle française contemporaine’, pp. 282–83). — a recurrent term used in the aftermath of World War II following the revelation of the crimes of

eugenics and concentration camps that describes psychiatry as a biopolitical and social regime of modern states and their dealings with confinement. Félix Guattari, who worked his entire life at La Borde, historically situated institutional psychotherapy as follows:

After the prison camps and concentration camps, a few nurses and psychiatrists started to look at the problems of psychiatric hospitals from an entirely new angle. Incapable of supporting concentrationary institutions [institutions concentrationnaires], they undertook to transform services from top to bottom, knocking down fences and organizing the fight against famine. […] Surrealist intellectuals, doctors strongly influenced by Freudianism, and Marxist militants all mingled.66Félix Guattari, Psychoanalysis and Transversality: Texts and Interviews 1955–1971, trans. by Ames Hodges (Los Angeles: Semiotext(e), 2015), p. 60, the editors have slightly amended the translation; Psychanalyse et transversalité. Essais d’analyse institutionnelle (Paris: La Découverte, 2003), p. 39.

The insight into the politics of confinement as entangled with social, mental, bodily, and spatial conditions led institutional psychotherapy to shift the focus in a crucial way: rather than an individual body needing treatment, it is the hospital as a form of warehousing bodies and institutional politics that requires attention. Institutional psychotherapy proposed that in order to adequately support individuals with psychic suffering, the primary step was to treat, heal, and care for the institution itself — soigner l’institution in French.77François Tosquelles, Le Travail thérapeutique à l’hôpital psychiatrique (Paris: Éditions du Scarabée, 1967), p. 41; republished as Le Travail thérapeutique en psychiatrie (Toulouse: Érès, 2015).

The movement emerged at the Saint-Alban hospital in the Lozère department as a practice of resistance during the German occupation and the fascist Vichy government. Today it is known that during this period between 40,000 and 80,000 patients of psychiatric institutions fell prey to the so-called ‘soft extermination’ policy.88Max Lafont, L’Extermination douce. La Cause des fous, 40 000 malades mentaux morts de faim dans les hôpitaux sous Vichy (Lormont: Le Bord de l’Eau, 2000); Isabelle von Bueltzingsloewen, L’Hécatombe des fous. La Famine dans les hôpitaux psychiatriques français sous l’Occupation (Paris: Flammarion, 2009); Armand Ajzenberg, L’Abandon à la mort… de 76000 fous par le régime de Vichy and André Castelli, Un hôpital psychiatrique sous Vichy (1940–1945) (Paris: L’Harmattan, 2012). As a way of resisting those measures of annihilation, which included a deficient diet and shortages of medication and clinical care, Saint-Alban became a collectively organized site of resistance and clandestine activities. To navigate the emergency years of the occupation, the patients were involved in different activities to provide alternative infrastructures of alimentation: these included gardening as well as foraging for pine cones and mushrooms in the forest, guided by the hospital’s mushroom displays.

The patients were also engaged in undertakings on nearby farms, contributing to the harvesting process. Hospital-based work included activities like sewing and knitting for local farmers. An informal bartering system emerged, offering creative communal solutions that overcame the severe shortages.99Dominique and Renée Mabin, ‘Art, folie et surréalisme à l’hôpital psychiatrique de Saint-Alban-sur-Limagnole pendant la guerre’, Mélusine, 13 March 2015 <https://melusine-surrealisme.fr/wp/art-folie-et-surrealisme-a-lhopital-psychiatrique/> [accessed 30 March 2024]. As a result, according to Dominique and Renée Mabin, Saint-Alban had the lowest mortality rate from starvation among French psychiatric hospitals: ‘There was no “extermination douce”’.1010Ibid. Initiated by psychiatrists François Tosquelles, Lucien Bonnafé, André Chaurand, and André Clément, the movement was carried out by a heterogeneous group comprised of surrealist artists, nuns from the Saint-Régis community, Jewish refugees, philosophers, and resistance fighters including Georges Canguilhem, Tristan Tzara, Jacques Matarasso, Paul Éluard and Nusch Éluard. This entangled pursuit of political resistance and mental ‘disalienation’ became key to institutional psychotherapy, which was later developed and transformed by authors such as Frantz Fanon, Félix Guattari, and Oury — all of whom spent a significant amount of time at Saint-Alban — as well as Anne Querrien, Ginette Michaud, Danielle Sivadon, Fernand Deligny, and others.

In the post-war period, institutional psychotherapy was further developed as a set of theoretical and practical interventions into the structure of the institution, operating at the intersection of environmental, medical, aesthetic, and social dimensions (Figures 1–5). It instituted a radically horizontal collective of patients, workers, and doctors, and developed media-therapeutic practices that aimed to transform the inner and outer milieus of psychic suffering. These milieu-oriented experiments were realized through an intense, multifaceted use of media such as the patient-run production of an intra-hospital newspaper titled Trait-d’Union (Figures 6–9), writing and theatre workshops, and filming, as well as the organization of ciné-clubs, carnivals (Figures 10–12), and other festivities welcoming the inhabitants of Lozère (Figure 13).

Despite taking a critical position with its social and political stance, institutional psychotherapy nonetheless embraced contemporary treatments of psychosis such as electroshock or insulin cure in its medical practice. Those ‘inopportune and hybrid therapies’1111Antonin Artaud, ‘Alienation and Black Magic’, in Artaud the Mômo, ed. by Stephen Barber and trans. by Clayton Eshleman (Zurich/Berlin: Diaphanes, 2020), pp. 88–111 (p. 91). — as critically referred to by Antonin Artaud, artist and psychiatric patient of Rodez, who was also partly in Tosquelles’s treatment — were a common intervention, which was accompanied by rehabilitation via social therapy. Tosquelles, Fanon, and later Oury and Guattari had positively theorized electroshock as a therapy of ‘annihilation’ induced by electricity, known also as ‘Bini method’, named after its Italian inventor, Professor Lucio Bini.1212In an article co-authored by Tosquelles and Fanon, the question is to ‘situate’ the ‘annihilation therapy through repeated shocks within an institutional therapeutic performance’. Frantz Fanon and François Tosquelles, ‘On Some Cases Treated with the Bini Method’, in Frantz Fanon, Alienation and Freedom, ed. by Jean Khalfa and Robert J. C. Young, and trans. by Steven Corcoran (London: Bloomsbury, 2018), pp. 285–90 (p. 285).

Tosquelles’s emphasis on ‘activity’ and activation of the patients was at the core of his clinical practice. These notions were inspired by Marxist theory — in particular the early Marx of Theses on Feuerbach, but also the Economic and Philosophic Manuscripts of 1844, extensively quoted in Tosquelles’s text — and the insistence that knowledge is ‘sensibly human activity, practice’.1313Tosquelles quoting Marx in ‘Psychopathology and Dialectical Materialism’, p. 56. The notion of ‘activity’ was also derived from the work of German psychiatrist Hermann Simon. Tosquelles’s ‘social therapy’ — a term he used throughout the 1950s — was based on patients’ activation, their participation in daily life at the hospital, and responsibility. It relied on Simon’s Aktivere Krankenbehandlung in der Irrenanstalt (More Active Patient Treatment in the Mental Asylum), published in 1929. Tosquelles recalls having brought a copy of this book from Catalonia. At Saint-Alban, it was collectively translated into French, likely with reference to the Spanish translation of the book, and thanks in particular to the efforts of Eugénie Balvet. It was then printed and circulated there in the 1940s. Whilst being the founder of modern work therapy, Simon embraced and supported ideas later propagated by the Nazi state, in particular those relating to social Darwinism: it was Tosquelles who transformed this theoretical impulse into a therapy of resistance and empowerment of the patients.1414 ‘Simon placed his concept [of more active patient treatment] within broader “biological” and psychological contexts, which were rooted in a biologistic-social Darwinist worldview. This worldview was also open to eugenic-racial hygiene ideas and a fundamental critique of welfare state provisions.’ Bernd Walter, ‘Hermann Simon — Psychiatriereformer, Sozialdarwinist, Nationalsozialist?’, Der Nervenarzt, 73 (2002), pp. 1047–1054 (p. 1047). It is unknown whether Tosquelles knew about Simon’s eugenic stance towards chronic psychiatric patients deemed unfit for work. Nonetheless, Tosquelles’s socially and politically engaged psychiatric approach during World War II and in its aftermath was certainly the opposite of Simon’s postulate of labour as ‘education’ of the patient. Within this framework, Simon fully aligned with the dramatic shift in health policies following the National Socialists’ rise to power in 1933 and was even supportive of euthanasia practices: ‘There was no significant distance between his conservative stance, his understanding of the state, his biologistic thinking, and his clear support for Hitler and Nazi racial policies.’ (Ibid.) Simon’s practices of labour as therapy were theorized and advanced by Carl Schneider, professor of psychiatry at the University of Heidelberg after the Nazis removed his predecessor from office. Schneider is known to have actively participated in Aktion T4, the Nazi regime’s mass murder campaign targeting individuals deemed unfit or undesirable. In any case, in 1967, Tosquelles addressed a clear critique vis-à-vis Simon and Schneider’s ideas, revealing their ‘“biology” of work’ as ‘leading directly or indirectly to murder’, which was ‘the case for the patients in Germany’ (Tosquelles, Le Travail thérapeutique à l’hôpital psychiatrique, p. 38).

Another reference, even prior to that of Simon, is Emilio Mira y López, who Tosquelles credits with completing the conceptualization of activity through his emphasis on the intimate relationship between bodily and muscular activity and social and mental activation.

Mira y López was Professor of Psychiatry at the University of Barcelona, and a friend and close collaborator of Tosquelles at the psychiatric hospital Institut Pere Mata in Reus, Spain. Their joint experiments developed into an ‘extensive psychiatry’: an expanded perspective of psychiatric care through the implementation of Gestalt psychology, psychotechnics, and psychoanalysis, which highlighted the agency of the body in the frame of ‘occupational therapy’. Occupational therapy — or ‘ergotherapy’, the term Tosquelles generally uses and which refers to a different tradition — was practised at Pere Mata and relied on the conviction that ‘the performance of new [bodily] movements would destroy the distorted patterns of muscular reaction that have become fixed and rigid in the individual, thus creating the possibility of the corresponding change in his frame of mind’.1515Emilio Mira y López, Psychiatry in War (New York: W. W. Norton & Company, 1943), also available online at <https://www.miraylopez.com/PsW_tot.html> [accessed 3 April 2024].

At Saint-Alban, the activation of patients through ergotherapy went hand in hand with the implementation of aesthetic practices and media that would enhance the social ties between patients, doctors, and nurses. In this way, the film ‘Société lozérienne d’hygiène mentale’ (Lozerien Society of Mental Hygiene) produced by François and Hélène Álvarez Tosquelles together with their patients between 1954 and 1957, presents the hospital as a ‘society’, a formation of resistance against the state-imposed conditions of confinement. Another more structural example of the hospital’s activity was the ‘Club’, which was a central organ of the institution, independent from its administration, that was maintained by the patients. The Club was responsible for the hospital’s social activities — such as ergotherapy sessions, the production of newspapers, or the organization of ciné-club sessions and festivities. As an ‘institutional object’,1616François Tosquelles, Théorie et pratique de la psychothérapie institutionnelle, in particular, Chap. 3: ‘“Objets institutionnels” ou “organismes institutionnels” utiles et indispensables dans le champ de la psychothérapie institutionnelle’ (‘Institutional objects’ or ‘institutional organisms’ useful and indispensable in the field of institutional psychotherapy), 1982, in Tosquelles Archives, organized by Jacques Tosquellas. By ‘institutional object’ or ‘organism’ Tosquelles means apparatuses invented and practised that have an ‘instrumental function’ in the psychiatric setting, helping to set up patients’ activities and circulation. Tosquelles also mentions an idea of ‘intermediary objects’ to create these specific psychotherapeutic spaces. The idea is inspired by Winnicott’s ‘transitional objects’. The editors would like to thank Jacques Tosquellas for sharing with them this yet unpublished document. the Club became a constant in later clinical experiments in different settings of institutional psychotherapy, such as La Borde. It can be seen as an instrument of conviviality, enabling exchange among patients themselves, but also between patients, nurses, and the hospital’s outside; it allowed for patients’ autonomous decision-making and for a crucial de-hierarchization and multiplication of the relations between inmates and staff, ‘doctor’ and ‘patient’.

Institutional Psychotherapy’s Legacies

Institutional psychotherapy considered sociability, generated through activity, as the catalyst of its ecology of care. Again, when following a Marxist vision, social relations cannot be predetermined, but instead are situated and emerge in a complex environment co-constitutive of the singular individuals inhabiting it. In this sense, the very principle of institutional psychotherapy is its constant reinvention: reinvention of activities, structures, and forms of organization. If we can definitively identify a legacy of the Saint-Alban experiment, this would not be the simple reproduction of solidified principles, but their reinvention in situ, in a new context.

Two key examples can be cited that contributed to such a reinvention of institutional psychotherapy in a new context: the clinic of La Borde, co-founded in 1953 by Oury in France, and Blida-Joinville hospital, directed by Frantz Fanon between 1953 and 1956 in the radically different climate of the anti-colonial war in Algeria. In both cases, an encounter with Tosquelles and an experience at Saint-Alban preceded these new constellations. For Oury, Tosquelles’s lecture at École normale supérieure in 1947 — translated in this volume — gave him the impulse to join Saint-Alban that same year for an internship with psychiatrist Maurice Despinoy, who studied in Lyon. Only a few years later, after finishing his studies in medicine, also in Lyon, Fanon joined the same internship position alongside Despinoy at Saint-Alban, where he worked for fifteen months in close collaboration with Tosquelles between 1952 and 1953. There, he was responsible for the nurses’ training in social therapy.

Upon his arrival at Blida-Joinville, Fanon implemented several changes modelled upon institutional psychotherapy: he set up a Club, built a soccer stadium and a theatre within the clinic, organized an intra-hospital newspaper, Notre Journal, and established an open clinic in collaboration with psychiatrist Raymond Lacaton. Fanon, with the help of his assistant Jacques Azoulay and a nursing team, developed a cooperative framework described as an ‘experimental milieu’ involving ‘bi-weekly ward meetings, as well as staff meetings, newspaper meetings, and bi-monthly celebrations’.1717Frantz Fanon and Jacques Azoulay, ‘Social Therapy in a Ward of Muslim Men: Methodological Difficulties’, in Fanon, Alienation and Freedom, pp. 353–71 (p. 354). A key component of these therapeutic endeavours was the ‘Film Committee’, which adopted a unique approach to film image which was also then discussed in Notre Journal.

In 1953, Fanon was facing extreme difficulties at Blida-Joinville, which were caused by the racist ethnopsychiatry of the Algiers School on the one hand, and the bloodshed of the anti-colonial war on the other. In that very same year, Oury initiated a series of institutional experiments attempting a disalienation and decolonization of the psychiatric care practice in the frame of La Borde clinic in Cour-Cheverny, France. From the very beginning, he was accompanied in this new experiment by Félix Guattari in particular:

By 1953, Félix was already very active in the collective invention of La Borde, and came there from time to time. It was in August 1955 that Oury asked him to join and truly settle and work there. It was the time of organizing all the functional infrastructure of the place.1818Clara Novaes and Ana Carolina Patto, ‘Félix et Jean. Des terrains vagues de la Garenne-Colombes à l’expérience de La Borde’, Chimères, 102 (2023), pp. 129–42 (p. 136).

At La Borde, Guattari was responsible for the implementation of extra-medical activities, including in particular the organizational structure of the ‘grid’, which implied a rotational work schedule of tasks and activities. Those shifting positions were meant to prevent the calcification of roles that led to institution’s mental and social alienation. This ‘internal mini-revolution’ required ‘all service personnel work to be integrated with medical work, and that, reciprocally, medical staff be drafted for material tasks such as cleaning, cooking, dishwashing, maintenance’.1919Félix Guattari, ‘La Borde: A Clinic Unlike Any Other’, in Chaosophy: Texts and Interviews 1972–1977, ed. by Sylvère Lotringer, and trans. by David L. Sweet, Jarred Becker, and Taylor Adkins (Los Angeles: Semiotext(e), 2009), pp. 176–94 (p. 178). See also, for instance, the prolific work on this topic by Susana Caló, including ‘The Grid’, in Anthropocene Curriculum, 23 April 2016 <https://www.anthropocene-curriculum.org/contribution/the-grid> [accessed 7 April 2024]. ‘I came to La Borde as an activist’, Guattari states in a conversation with psychiatrist and psychoanalyst Danielle Sivadon. ‘I started organizing workshops, meetings, schedules, much like how I had organized the political cells I was involved in.’2020Félix Guattari and Danielle Sivadon, ‘Le Préjugé démocratique. Juin 1987’, Chimères, 94 (2019), pp. 144–48 (p. 146). This conversation was filmed by François Pain in May 1986, ‘Le Divan de Félix’, chaosmosemedia, 2021 <https://chaosmosemedia.net/2021/05/25/le-divan-de-felix/> [accessed 7 April 2024].

Guattari’s relation to Saint-Alban was not only mediated by Oury. Indeed, he spent a month as a patient at the Lozerien hospital in 1956. According to him, thanks to this time there, he became aware of the importance of leaving more space for the patients, ‘letting them alone for a bit’. The Saint-Alban experience had a crucial impact on Guattari’s institutional practice, described as a ‘mutation’ and ‘decentring of the subjectivity’ in an institutional context.2121In Guattari’s own words: ‘Tosquelles’s great strength was his consistent stance as a political activist. Let’s be clear, this doesn’t mean he was conveying political ideas, but rather that his manner of being, in any situation, was political. This is something hard to articulate, and perhaps I’m particularly attuned to it through some form of unspoken complicity with him. At Saint-Alban, Tosquelles immediately adopted this approach, whether interacting with the nuns, staff members, or the supervisory administrative entities. He operated with a militant logic that was more an existential logic than merely a matter of ideological content’ (Guattari and Sivadon, ‘Le Préjugé démocratique’, p. 147).

The text by Oury presented in this volume engages with the role he played in the legacy of institutional psychotherapy, and in particular with the foundation of La Borde. However, it is important to note that, except for Tosquelles, Oury does not mention other people in this text, and there is an omission of the names of female psychiatrists, caregivers, and psychoanalysts. In this sense, we feel it is crucial to acknowledge how the La Borde experiment was in fact a radically collective endeavour. Its constant reinvention throughout the years was only possible thanks to the participation and intervention of figures such as Micheline Kao, Gisela Pankow, Anne Querrien, Danielle Sivadon, Ginette Michaud, Jean-Claude Polack, François Pain, and Fernand Deligny. Indeed, this collective activity is reflected in the journal Recherches, edited by Centre d’études, de recherche et de formation institutionnelles (CERFI), and groups closely associated with it.2222Centre for Institutional Study, Research, and Development (CERFI) was a transdisciplinary research cooperative formed of psychiatrists, sociologists, video artists, educators, urbanists, architects, and economists. See Susana Caló’s and Godofredo Pereira’s project on this topic: ‘CERFI: Militant Analysis, Collective Equipment and Institutional Programming’, Royal Collect of Art <https://www.rca.ac.uk/research-innovation/projects/cerfi-militant-analysis-collective-equipment-and-institutional-programming/> [accessed 7 April 2024].

Even though each new site modelled upon institutional psychotherapy developed its own specific strategies — as for instance the patient-run ‘Hospital Committee’, mentioned in Oury’s text, or the Club, which functioned differently, according to the singular conditions of each institution — the experience of Saint-Alban was foundational for those transformations and deterritorializations. It laid the ground for sector psychiatry, schizoanalysis, and for other disalienist approaches situated closer to anti-psychiatry and its programme of deinstitutionalization.

Towards a Materialist and Relational Psychiatry

Both texts included in this volume deal with a certain conception of psychiatry. On the one hand, they criticize a purely mechano- and organo-oriented practice of care — one that would correlate mental disorders only with a disturbance localized in the patient’s body. On the other hand, they propose an understanding of mental disorders according to a more complex vision, that is, implying that they necessarily maintain a relation to several elements such as the subject’s social and perceptual milieu and its alteration, their particular history, and their conflicts. According to this vision, psychic suffering is marked by a problem in the world of a subject’s relations and the only way to treat it is to reconstruct (or to construct new) relations.

Oury’s ‘Institutional Psychotherapy: From Saint-Alban to La Borde’, was written only two years after the events of May 1968, a period marked by both a new critical energy and a severe conservative counter-reaction, which aimed at the ‘recuperation’ of the meaning of such events and at the subversion of their possible revolutionary consequences.2323See Serge Audier, La Pensée anti-68. Essai sur les origines d’une restauration intellectuelle (Paris: La Découverte, 2008). As Oury remarks, during the war years, psychiatry, ethics, and politics had become intrinsically connected. He has here in mind, of course, the Saint-Alban experience and the connection between psychiatry and resistance. However, writing almost three decades later, these years had started to recede from people’s memories. Oury’s text is marked by a certain urgency to recall this history, insisting that the eagerness for reinvention that marked those years continually needs to be reactualized. Furthermore, his lecture is historically situated in the wake of a new era for psychiatry following the introduction of antipsychotics in early 1970s — their popularization would happen over the span of the 1980s — and the harsh critique of psychoanalysis. For these reasons, Oury deemed it necessary to recall the history of institutional psychotherapy, retracing its trajectory from Lozère to Cour-Cheverny.

Oury highlights many of the practical principles developed by institutional psychotherapy: the fight against segregation and ‘concentrationary’ forms that psychiatry usually tends to develop; the importance of ‘break[ing] down hierarchical barriers’; the creation of spaces inside the hospital that follow an ‘axiom’ of the ‘freedom of circulation’, that is, that patients should be able to freely move around inside its spaces — a hospital should not be conceived as a prison — ; the instituting of a self-governed society inside the hospital (‘a society which will manage itself’); the transversality of psychic care and its connection to other social and pedagogical movements.

Oury notes that many of the principles practised at La Borde go back to strategic inventions by Tosquelles that could help disarticulate institutional rigidity imposed by the traditional top-down organization of establishments. He mentions in particular the creation of a sub-structure inside the institution: the hospital committee or the Croix-Marine society.[Oury, Jean] This peculiar status given to such instances was used as a strategy so that different patients’ organizations (such as the Club, for example) could exist autonomously and beyond the control of the hospital administration. In this way, what would eventually be produced by patients inside the hospital — in ergotherapy sessions or in the cafés, for example — and subsequently sold by them could also be reverted to these intra-institutional organizations and managed by them accordingly. Furthermore, this status could help prevent the administration from exploiting the patient workforce for the hospital’s own interest — for example, to improve facilities or to generate money for the administration.

As such, the patients could have a budget of their own to realize their preferred activities (a diner, a party, a painting atelier, a game, etc.), or in other words, to facilitate a cultural and social life inside the psychiatric hospital that is adapted solely to the patients’ needs and interests. The Club and other intra-institutional entities allow for the patients to leave the stasis of the hospitalized life and to once again take an active part in organizing their own group and social life. It works as a sort of dispositif (apparatus) of conviviality, relationality, and of culture, producing an exchange between patients, but also between them and non-patients. Such a strategy is a perfect example of how the autonomy given to the Club, for example, was also a form of resistance to the reproduction of capitalist functioning and the exploitation of labour, which traditional hospitals replicated when putting patients to work, thus transforming them simply into workers of a company.2424It is precisely as Ginette Michaud remarks in the following passage: ‘We can see that the [traditional] hospital’s economic structure is a replica of a capitalist company in our society, an alienating society to which we owe the numerous cases of “social maladjustment”, those very people who are locked up in hospitals, whose jurisdiction clearly transcribes the relations of alienation.’ See Ginette Michaud, Laborde… un pari nécessaire. De la notion d’institution à la psychothérapie institutionnelle (Paris: Gauthier-Villars/Bordas, 1977), p. 58.

Tosquelles’s ‘Psychotherapy and Dialectical Materialism’, constitutes the core of this volume. It is a dense theoretical text, in which the author develops a reflection on the scientific and philosophical status of the psychiatric discipline. It was written and presented in the aftermath of World War II, at a time when the transitional government had been established after the Liberation (1945–48), when Charles de Gaulle and the French Communist Party were still negotiating state repartitions, as well as new political and institutional programmes. Psychiatry was, at that moment, a discipline without any institutional and epistemological autonomy, since it was subordinated to neurology — this had been the case since the psychiatry law of 1838 and would only change after 1968 with a new decree.2525Henri Ey played an important role in these debates, defending an autonomy for psychiatry and criticizing the hospital-centrism of the old institutional mode of functioning. For further details on the discussion see Robert Castel, La Gestion des risques (Paris: Les Éditions de Minuit, 2011). The general prise de parole of 1968 certainly influenced this debate and was praised by Ey. A famous poster produced during the demonstrations of this period even claimed: ‘dénonçons la psychiatrie policière’ (‘Let us denounce police-related psychiatry’). Also for these reasons, psychiatry had a very unstable and debatable status — a discipline ‘in crisis’, as Sophie Lesage notes in her contextualizing and introductory ‘Note to the Reader’.

Tosquelles’s navigation of Marxism and psychiatry can be viewed as dialectical intervention — an articulation of a double critique. On the one side, he appeals to dialectical materialism in order to critically reveal the stasis of nosological categories; on the other — which is perhaps less obvious — one finds the repercussions of this dynamic understanding of psychiatry on his reading of dialectical materialism. ‘Society, the nervous system, and the organism in general are not irreducible, isolated compartments’, Tosquelles states.2626Tosquelles, ‘Psychopathology and Dialectical Materialism’, p. 65. As a result, the work of psychiatric disalienation needs to be considered as ‘a “disalienation of the total fact of madness”: the sick person, the asylum, and the psychiatrist at once’.2727Ibid., p. 72. Already in 1945, institutional psychotherapy regarded ‘madness’ as a ‘disorder in the relationship between the self and the world’.2828Lucien Bonnafé and others, ‘Valeur de la théorie de la forme en psychiatrie: la dialectique du moi et du monde et l’événement morbide’, Annales médico-psychologiques, 103.2 (1945), pp. 279–84 (p. 280). Combining Marxist analysis with Gestalt psychology, alienation was conceptualized as a double estrangement: both mental and social alienation of the self from its ‘participation in the environment’.2929Ibid. Such a holistic view undoes any progressivist ideology in favour of an ethical stance, an ‘activation’ extending even to the reader, as Sophie Lesage describes in her text.3030Sophie Lesage, ‘Note to the Reader on ‘Psychopathology and Dialectical Materialism’, in this volume, p. 46. Similarly, according to Tosquelles, the subject’s emotional manifestations reveal a dialectics of ‘action and reaction’ — emotion seen as agency and the potential for action and not merely as a reaction — in such a way that undoes the linear and teleological relation between cause and effect.

This Marxist perspective allows Tosquelles to question the classical division between history and nature, theory and practice, as he sees ‘every “action” or “situation”’ bearing witness to ‘the human being’s active presence in the world’. Thus, ‘history’ itself appears as ‘social physiology’: ‘There is no thought without a human brain, no human brain outside of the person [hors de l’homme], nor person outside of the world’.3131Tosquelles, ‘Psychopathology and Dialectical Materialism’, p. 59.

Many of the problems Tosquelles was confronted with at the end of the 1940s were related to a solely organo-oriented perspective of psychiatry. Against this reductionist view, Tosquelles advanced the phenomenological and existential dimension of the individual’s lived experience developed in his contemporaneous doctoral dissertation, defended in 1948 and later published under the title Le Vécu de la fin du monde dans la folie. Le Témoignage de Gérard de Nerval (The Lived Experience of the End of the World in Madness: The Testimony of Gérard de Nerval). In this work, the psychiatrist took up the challenge of thinking the experience of catastrophe in at least three dimensions: in its clinical manifestation, expressed through the form of schizophrenia; in its political and historical scope, in the inscription of the war; and in its atmospheric and poetic manifestation, through a concerted analysis of Gérard de Nerval’s novel Aurélia, written shortly before the poet’s suicide. Tosquelles introduced the German notion of Erlebnis (lived experience) from phenomenology and existential philosophy to conceptualize the relation between the singularity of an experience and the world it engenders. ‘What is at stake’, Tosquelles writes, ‘is the dynamic which produces the lived experience [experience vécu] of a person giving it its existential efficacy’.3232Tosquelles, Le Vécu de la fin du monde dans la folie, p. 51. Erlebnis etymologically inscribes ‘life’ (in German Leben) into experience, highlighting for Tosquelles the irreducible dimension of the lived temporality of ‘the end of the world’, and at the same time its complex, paradoxical continuity.

From this perspective, Tosquelles criticizes the scientific isolation of the brain from the rest of the organism and its situatedness in an environment, the ‘intra-organic correlations’ from the external processes.3333Tosquelles, ‘Psychopathology and Dialectical Materialism’, p. 55. In ‘Psychotherapy and Dialectical Materialism’ he claims that psychiatry, as every other scientific discipline, blindly subscribes to philosophical — or ideological — presuppositions that must be critically analysed, placing these in a concrete historical situation of a lived experience. Dialectical materialism and Marxism would be the method par excellence for undertaking such a critique, since it does not fall into the trap or the ‘error of taking processes in isolation’.3434Ibid., p. 54. Tosquelles follows here materialist psychologist Henri Wallon in particular for whom dialectical materialism constitutes a science different from others because it does not immobilize things, but instead tries to understand them in their permanent state of movement in relation to other things, and in their continual and processual becoming.

For Tosquelles, dialectical materialism appears even more urgent with regard to psychiatry than to other disciplines because of the specificity of its object: the human individual. Psychiatry’s object, to a greater extent in comparison to other disciplines, could not be taken abstractly, isolated and separated from its concrete situation, its milieu, its history, and its development; in sum, its object constitutes an extremely complex and mutable one. Tosquelles accepts the usual definition of psychiatry as a science dealing with an ‘anomaly of thought, belief, and action’.3535Ibid., p. 72. But, in order to deal with its problem, psychiatry would need to embrace situatedness, complexity, and relationality while considering the individual in its complex somatic, temporal, and psychic relations to the environment. Medicine emerges not as a nosological pursuit of abstractions, but a materialist and situated practice of concrete constellations, each time necessitating its own reinvention.

Indeed, Tosquelles goes back to a conception of psychiatry founded on relationality — patient-doctor relation crucially taken in a complex clinical environment — and on experimentation rather than on nosography and, as a result, a mythology of the ‘organism’ or, in his words, a ‘mythology of brain localizations’.3636Ibid., p. 69. According to him, psychiatry should be based on ‘trial and error’, on the ‘purest empiricism’ in which ‘techniques and therapeutics follow one another and, along the way, present us with new problems. It is in trying to solve these problems that new techniques are discovered. In this way, a dialectic of thought, experience, techniques, and object is established, in which each part conditions the whole, and the whole conditions each part’.3737Ibid., p. 71.

Dialectical materialism can be seen as a tool, which helps to complexify the psychiatric fact by posing that madness never exists as such, as an isolable and neutral category: it is always correlated to its actual society and its history, and even the psychiatrist is not an external observer, but also appears in the equation, since they do not stand ‘outside the world; they are integral to their epoch and subject to its technological and social influences’.3838Ibid., p. 66. Tosquelles thus surely subscribes to a Marxist conception of the human being according to which the human always appears in socially conditioned and concrete situations. That is why, in this sense, the psychiatric field needs to relate also to a sociological one; only then is it able to produce more effective diagnoses and treatments. For this precise reason, he thinks that positions more oriented towards positivism, such as that defended by Auguste Comte, had denied the very possibility of the existence of psychology as science, a problem that was now posed to psychiatry as well.

Relating psychiatry to its social field does not mean, however, that there should be the pure social before the individual. Tosquelles argues that this other extreme would also constitute a non-dialectical position. Indeed, he is interested in what could be called the ‘socio-genesis’ of the individual — an idea that he finds in Jacques Lacan’s doctoral dissertation,3939Jacques Lacan, De la psychose paranoïaque dans ses rapports avec la personnalité [1932] (Paris: Seuil, 1975). which resonates with Georges Politzer’s concrete psychology,4040Georges Politzer, ‘La Fin de la psychanalyse’ [1939], in Écrits 2. Les Fondements de la psychologie (Paris: Éditions sociales, 1973), available online at <https://wikilivres.org/wiki/La_fin_de_la_psychanalyse> [accessed 7 April 2024]. and will also find echoes in Fanon’s sociogenesis.4141Frantz Fanon, Black Skin, White Masks, trans. by Charles Lam Markmann (London: Pluto Press, 1986), p. 13.

Tosquelles — and later Oury — aligns with a current that he names ‘non-conformist psychiatrists’, including names such as Georges Daumézon, Pankow, Bonnafé, and others who opposed themselves to the school of Georges Heuyer. As professor to a whole generation from Lacan to Daumézon himself, Heuyer defended a very organo-oriented position and compared the fight against mental illness to the fight against tuberculosis: prevention, treatment, aftercare, and isolation. On the one hand, his position identified mental health and socius, but on the other, it naturalized such a relation and imposed the need for immediate isolation and treatment focused on the sick individual. Madness, following this line, was an illness to be treated as a pure clinical object.

Tosquelles certainly follows the principle of ‘biological unity of the organism and its milieu’.4242Tosquelles, ‘Psychopathology and Dialectical Materialism’, p. 55. A statement that will find echoes in those by ‘red’ psychiatrists Louis Le Guillant and Lucien Bonnafé: ‘Thus, the indissoluble unity of the individual and the milieu, which is of course a historical unity, a dialectical one, is the fundamental law, the law from which the normal or ill psyche, the patient in toto is unable to escape’ (Le Guillant, ‘Introduction à une psychopathologie sociale’, L’Évolution psychiatrique, 19.1 (1954), pp. 1–52 (p. 19)). But the fundamental notion of ‘milieu’ is here to be understood also as a complex one, implying the historical, social, cultural, and biological situation in which an individual evolves.4343Among other theoretical sources that were determinant to Tosquelles’s thinking on the milieu — and later to Oury and Fanon as well — were Kurt Goldstein and Georges Canguilhem. Both of them introduced a ‘normative’ and ‘adaptive’ milieu-based theory. In Der Aufbau des Organismus, the first posited that an organism maintains equilibrium with its surroundings through a sequence of ‘catastrophic reactions’ (Kurt Goldstein, The Organism: A Holistic Approach to Biology Derived from Pathological Data in Man (New York: Zone Books, 1995), p. 392). This perspective was further developed by Canguilhem, who emphasized the organism’s potential to set its own norms. See Georges Canguilhem, The Normal and the Pathological (New York: Zone Books, 1991). Building on such ideas, Tosquelles sees schizophrenia not as a mere loss of the world but as a creative effort: an attempt at reconstruction of the shattered world. Therefore, Tosquelles views madness not as a state of passivity but as a manifestation of prolific energy, marked by ‘freedom’ and a sense of ‘responsibility’. See Tosquelles, Le Vécu de la fin du monde dans la folie, p. 98. Wallon is indeed the key-figure in this debate. He had defined the object of psychology not as being the individual’s interiority, but ‘a situation’.4444Henri Wallon, De l’acte à la pensée (Paris: Flammarion, 1942), p. 50. Also, in opposition to Jean Piaget, he considered the individual, since their preverbal stages, as totally immersed in the milieu.

The non-conformist psychiatrists engaged in clinical practice in the opposite direction of that proposed by Heuyer and his students. Not isolation, but resocialization; not passive, one-directional, and localized treatment, but a holistic approach based on the activation of the patient through social practices. The institutional project here was indeed ‘the conversion of the asylum into a social milieu’.4545Tosquelles, ‘Psychopathology and Dialectical Materialism’, p. 73.

It is surely a question of non-conformism. It could also be called a disalienist tendency, which would get different more or less radical variations according to the positions developed over time by Tosquelles, Fanon, or Oury, to cite only these three. This non-conformist, disalienist, resistant tone seems to be absent in the discursive fields today dealing with care, clinical work, psychiatry. Against this backdrop, institutional psychotherapy’s ethically engaged and politicized practice — whose texts were barely translated into English until now — only gains its current topicality and urgency, in particular in times of super-abundance of diagnoses and increased psychic suffering rates.4646Very recently, three publications related to Tosquelles appeared in English: Francesc Tosquelles: Avant-Garde Psychiatry, Radical Politics, and Art, ed. by Carles Guerra, Joana Masó, Valérie Rousseau, and Edward Dioguardi (New York: American Folk Art Museum, 2024); Francesc Tosquelles, ‘A Politics of Madness’, trans. by Perwana Nasif, Parapraxis, 4 (August 2024); and Joana Masó, ‘The Collective’s Women’, trans. by Perwana Nazif and Jesse Newberg, Parapraxis, 4 (August 2024). The pharmacology-based ideology that dominates medical institutions and the unsuccessful attempts, first of genetics, and then of neuroscience, of giving a ‘definitive’ answer to the problem of madness, show that there is still a lot to learn from the clinical-political struggles of the twentieth century. This ‘problem’ cannot be dissociated from human agency and the world in which it takes place. In this sense, it will remain associated with ongoing struggles for transforming the social conditions of hospitalization and medicalization, as well as the institutional and societal issues of segregation.