Illness as a Work of Thought

A Foucauldian Perspective on Psychosomatics

Monica Greco

• Publisher: Routledge
• Year: 2002
• Print ISBN:
  9780415757409
• eBook ISBN:
  9781134684007
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Illness as a Work of Thought is a practical application of Foucault's archaeological and genealogical methods of the study of illness and modernity. From medicine and psychiatry to psychology and the social sciences, Monica Greco explores what the history of these different disciplines contributes to what we understand by the term 'psychosomatics' and analyses how the study of psychosomatic illness can transform the way we think of illness, subjectivity and the ethics and politics of health.

1
THE SYMPTOMS OF TRUTH

A historical search

Nothing in man – not even his body – is sufficiently stable to serve as the basis for self-recognition or for understanding other men.

(Foucault 1977: 153)

In what sense is the problematic of psychosomatics a specifically modern one? This question can be approached and answered at a variety of levels. First, we may consider ‘psychosomatics’ as a configuration of knowledge(s) that is specific to modernity in terms of what questions may be pertinently asked, and how. Second, we may regard this configuration of knowledge as addressing a problem, or the perception of a problem, that is itself historically specific. But what does ‘historically specific’ mean in this case? It could mean, in a realist vein, that the actual ways of falling ill changed historically, giving rise to different, new complaints and/or new pathologies. Or finally it could mean that a different way of thinking about illness – both on the part of laypersons and of experts – became pertinent to and for modern individuals, as a result of certain historically specific ways of envisaging the ‘mind’, the ‘self, the ‘body’, and the relations between these and other concepts. Or it could mean both – indeed, if we were to accept the psychosomatic hypotheses that thematize the role of thought (and therefore culture) in the pathogenetic process, this is what we would have to conclude.

In this chapter I explore the historical conditions of possibility of psychosomatics from the perspective of ‘subjective relations to the self. I will lay the ground to show that psychosomatic illness emerges, as a problem for knowledge, in the context of a historically constituted experience of the ‘self. In order to map this historical context, I propose that we distinguish analytically between the process whereby modern individuals have come to think of themselves as bearers of psychosomatic illness and the process whereby they actually fall ill. The historical account I provide of the changing organization of subjective experience will thus avoid any reference to the biological substratum of human beings or to notions of psychophysiological functioning. I shall not be asking whether modern individuals ‘function’ in such a way as to be subject to specific forms of pathology; I shall only ask how it is that they have come to envisage themselves that way. This is necessary in order to devise a critical vantage-point to later examine the production of modern psychosomatic questions. Without such a vantage-point we would inevitably reproduce, in our historical account, the forms of knowledge whose genealogy we are trying to chart.

The work of Norbert Elias and of Michel Foucault provides the backbone of this chapter. Their approaches respectively to the ‘genesis’ and ‘genealogy’ of modern subjectivity are complementary at a descriptive level, and yet contrast in fundamental ways. I will attempt to show that this contrast is productive when it comes to approaching the historical dimensions of psychosomatics. Elias offers a framework within which it is possible to move without breaks of continuity from the psychological dimension to the political one. The central problem addressed in his work is the relationship between changes in social structures and changes in personality structures. These changes he empirically investigated and described in The Civilizing Process (1978b), with reference to the transition from the warrior society of the Middle Ages to the court society of the Renaissance. The themes developed in that empirical investigation recur throughout Elias’ later work, including his sociology of knowledge, some aspects of which are relevant to this discussion.

Elias’ historical arguments provide a diagnosis of modern forms of selfperception, and hence a critique of dominant categories of explanation in the social sciences. In particular, Elias challenges the notion that various opposite concepts, such as ‘individual’ and ‘society’, ‘nature’ and ‘nurture’, ‘fantasy’ and ‘reality’, can be assumed to refer to an unchanging essence of things. Instead, he proposes, they should be regarded as historically specific ways of perceiving the world and the relationship of human beings to the world; to understand how they have historically emerged implies also understanding that they cannot be treated as universally applicable categories of explanation. At all times, Elias presents this critique as a ‘destruction of myths’ (Elias 1978a), in the sense of facilitating the advent of a more adequate, detached, and objective knowledge of reality (Elias 1994). It is thus possible to distinguish between two overlapping aspects of Elias’ work: one descriptive and diagnostic, the other indirectly prescriptive. Diagnosis and prescription overlap, for example, in the claim that:

at this stage [scientists] are not yet able to detach themselves sufficiently from themselves to make their own self-detachment, their own affectrestraint – in short, the conditions of their own role as the subject of the scientific understanding of nature – the object of knowledge and scientific inquiry.

(Elias 1978b: 256)

Some concepts in Elias’ historical analyses are invested with this double, descriptive and prescriptive function. One such concept is that of ‘psychologization’. This concept, which I discuss in more detail below, describes a historical process that accounts for how modern subjects perceive their ‘selves’, and their ‘minds’ in relation to their ‘bodies’. These perceptions are shown by Elias to be not universal and pre-given, but rather historically generated and often deceptive (when they are assumed to be ahistorical givens). But ‘psychologization’ also prescribes the route towards a second-order distancing on the part of the subject of future (more detached, more reality-congruent) knowledge. Thanks to this ongoing process, Elias hoped that,

We [would] one day succeed in making accessible to more conscious control these processes which today take place in and around us not very differently from natural events, and which we confront as medieval man confronted the forces of nature.

(Elias 1978b: xvii; see also Mennell 1989: 99)

There is thus a fundamental continuity for Elias between the subject of action whose characteristics he describes, and the subject of scientific knowledge whose characteristics he embodies. Both partake in the process of ‘psychologization’ and are shaped by this process. ‘Psychologization’ is a source of illusion; but further ‘psychologization’ enables illusions to be revealed for what they are. All branches of knowledge move in this direction, although detachment is more easily achieved at present in some fields than in others.

This makes Elias’ work problematic as a means for approaching the historical dimension of psychosomatic illness as a question for thought. For Elias, ‘psychosomatic illness’ is a feature of modern reality before being a construct of modern knowledge; knowledge comes to address psychosomatic illness because historical processes produce it as a phenomenon in its own right. It is one of those phenomena ‘which today take place . . . not very differently from natural events’, whose understanding and whose control are one and the same task. The theory of the civilizing process can indeed be read as a socio-patho-genetic theory of psychosomatic illness, that is, as an account of why modern subjects actually tend to fall ill in a specific way. Norbert Elias himself presented such a reading at a medical congress on psychosomatics held in Marburg in the 1980s, in a lecture entitled ‘Civilization and Psychosomatics’ (1982b). Elias’ approach constitutes a valid sociological complement to medical theories of psychosomatic illness. For this very reason, however, it cannot provide a critical vantage-point on psychosomatics as a form of problematization. Rather, it is an element within the horizon of that problematization.

This point can be maintained quite independently of the fact that Elias’ original theory was produced at a very significant time in the history of modern psychosomatics. Yet readers may find it useful to have a minimal reference to that context at this stage. The year 1939, during which the two volumes of The Civilizing Process first appeared in their original German form, is also the founding year of the journal Psychosomatic Medicine. This US journal still exists, and was created as a forum for a rapidly expanding field of research that had developed in the wake of work by Smith Ely Jelliffe, Flanders Dunbar, Franz Alexander, and others during the previous two decades. In Germany itself, during the interwar years and later, important debates were taking place as to the prospects of a medical reform in the direction of psychosomatics, exemplified by the writings of Viktor Von Weizsäcker and Karl Jaspers among others.

Returning to Elias, for our purposes his approach usefully describes the selfexperience of modern individuals in terms of the figure of Homo Clausus (‘enclosed man’). As a description, Homo Clausus is crucial in answering the question: for what kind of subject is the problem addressed in psychosomatic discourse a relevant problem? As an analytical concept, Homo Clausus designates a historically contingent form of self-perception, but also a concrete mode of organization of practices relating to the self. As such, the concept appears prima facie compatible with what Foucault named a ‘critical ontology of ourselves’ (Foucault 1984b). A critical ontology of ourselves involves an epistemological attitude that treats reality as a series of contingent, historical constructs; and yet that treats these constructs as, for all purposes, real in their effects (see Hacking 1986). It is an attitude that persistently refuses to search for general or fundamental truths behind the contingency of appearances. And it is an attitude that refuses to adopt extra-historical postulates as explanatory tools.

In what follows, I shall argue that Elias offers a valid, dynamic description of the passages that culminated in Homo Clausus as a modern form of self-perception. I shall also argue, however, that Elias grounds this description in general postulates concerning the nature of human beings as ‘social animals’. Precisely this kind of postulate must be foregone in order to free the historical account from any epistemological co-dependence on forms of knowledge (such as psychology, psychoanalysis, or biology) that will later become the object of this book. Thus, I propose to use Elias’description by rethinking it, recasting it, through the work of Foucault. In particular, I shall draw on Foucault’s proposal to give up the search for a theory of the subject that might form the basis of a ‘history of subjectivity’, in favour of the study of ‘forms of experience’ as these are made accessible by the history of thought. ‘Singular forms of experience’, Foucault writes,

may perfectly well harbor universal structures; they may well not be independent from the concrete determinations of social existence. However, neither those determinations nor those structures can allow for experiences (that is, for understandings of a certain type, for rules of a certain form, for a certain mode of consciousness of oneself and of others) except through thought. There is no experience which is not a way of thinking, and which cannot be analyzed from the point of view of the history of thought; this is what might be called the principle of irriducibility of thought.

(Foucault 1984c: 335)

Thus, for the analysis of changing forms of subjectivity in the course of Western history, Foucault does not rely on a general theory of subjectivity or human nature. On the contrary, general theories of the subject, in so far as they are products of knowledge, are themselves to be studied as part of a history of thought. Aside from this well-known negative starting-point, however, Foucault also offers a positive key for reading how forms of subjectivity have changed in the course of Western history. Subjectivity is ‘that which constitutes and transforms itself through the relationship with its own truth. No theory of the subject is independent of a relationship with truth’ (Foucault 1981a, unpublished). We can therefore study ‘subjectivity’ through and via the ‘truth’ that is its counterpoint. Crucial to this suggestion, naturally, is the status of the concept of truth. This is not defined as the content of universally valid knowledge, nor by any formal criterion, but rather as a ‘system of obligations’: truth is what obligates. This definition allows the notion of truth to be historicized and to serve as an inherently flexible, empirical reference for the study of how subjectivities emerge. To this I shall come back in due course.

Homo Clausus as the product of psychogenesis

Elias’ theory of the civilizing process describes a trajectory of transformations in the sphere of subjective experience that culminates in the modern form he calls Homo Clausus. Here I shall survey only this aspect of Elias’ comprehensive and multi-faceted historical argument. I shall therefore neglect all but the most general features of his theory of state formation and his detailed descriptions of developing networks of interdependence. In ‘Civilization and its discontents’ (1930), Freud proposed that the development of civilization involves an increasing transformation of external constraints into self-restraints. Despite the ways in which Elias can be set apart from Freud (ways indicated by Elias himself and to which I shall return below), this also constitutes the theme of The Civilizing Process (1978b). Changes in conduct and sentiment in a civilizing direction, according to Elias, stand in close relationship with the growing monopolization of physical force on the part of emerging state apparatuses. The monopolization process allows for, but also enforces, different forms of interaction between people. Within the newly pacified social spaces, interactions become less susceptible to the whims and fluctuations of individual tempers, but human beings face new and different dangers and pressures. The threat of random and unpredictable violence is gradually replaced by:

intrigue, conflicts in which careers and social success are contested with words . . . . Continuous reflection, foresight and calculation, self-control, precise and articulate regulation of one’s own effects . . . become more and more indispensable preconditions of human success.

(Elias 1982a: 271)

While in the simpler societies of the medieval world ‘affect directly engages affect’ (ibid.: 273), in the early modern world the modes of mutual engagement become more abstract, more subtle, and more complicated. This complexity reflects the lengthening of chains of social interdependence and a corresponding increase in the differentiation of social functions. Both of these require growing measures of ‘foresight’ (ibid.: 281) and of affective restraint.

As Elias remarks in the preface to his essay on time, it is a mistaken vulgarization to regard the civilizing process as consisting ‘solely [in] a continuous increase and reinforcement of self-restraint’ (Elias 1992: 25). The difference between patterns of self-restraint in people within simpler and more complex societies is qualitative rather than merely quantitative. In more complex societies, these patterns are remarkable for their evenness and calculability. They are more moderate than the severe ascetism that existed earlier, but also more uniform and inescapable. Thus, the type of self-control expressed in medieval ascetism is paradoxically passionate, in its deliberateness and superfluousness, by comparison with the ‘more dispassionate’ type of self-control required by ordinary life in the societies of later stages. With the monopolization of physical violence, ‘the controlling agency forming itself as part of the individual’s personality structure corresponds to the controlling agency forming itself in society at large’ (Elias 1982a: 240). It no longer corresponds, therefore, to the specificity of an individual choice or vocation.

Like in Freud’s well-known model for the development of the super-ego, in Elias the process of external pacification is complemented by a process of internalization of tension and conflict. In his own words, ‘the battlefield is, in a sense, moved within’ (Elias 1982: 242). The chief source of danger faced by individuals is no longer directly physical or external. Instead, it lies in their own loss of self-control. To illustrate this, Elias contrasts the typical road system of a warrior society with that of a modern city. The greatest danger in the medieval setting is represented by the high probability of sudden, violent attacks on the part of bandits. Such attacks would require of individuals a readiness to respond immediately with equal or superior violence. In a modern city, on the other hand, the probability of attacks of this kind is relatively low, but injury could easily result from collision with other vehicles. Everyone relies on their own and everyone else’s self-control to avoid accidents. And, should one occur, any impulse to respond violently must also be controlled for fear of a conviction. Thus, the loss of self-control carries also more long-term and less immediate dangers. The possibility of acquiring or maintaining a position within the network of interdependencies increasingly comes to rely on individuals’ ability to monitor and regulate their own behaviour. Correspondingly, the fear of an external threat becomes fear of a threat which is posed to the individual by aspects of his or her own self (Elias 1982a).

As Freud remarked, with internalization ‘the distinction between doing something bad and wishing to do it disappears entirely, since nothing can be hidden from the super-ego, not even thoughts’ (Freud 1930: 125). This can serve to clarify further the difference between the ascetism of less developed societies and the selfrestraint demanded by later stages of civilization. At later stages, according to Freud, ‘instinctual renunciation no longer has a completely liberating effect’ (ibid.: 127–8). More civilized individuals are therefore internally split and permanently engaged in a semi-automatic struggle with themselves, a struggle that, Elias agrees, ‘does not always find a happy resolution’ (Elias 1982a: 242). Freud’s assertion that ‘it is not merely a question of the existence of a super-ego but of its relative strength and sphere of influence’ (Freud 1930: 125, note 2) applies even more markedly for Elias. For both thinkers there is no zero-point before which one could say that the super-ego did not exist; it is rather a matter of gradual transitions and changing nuances. While Freud entirely neglected the historical details of this process, they were the object of Elias’ empirical scrutiny in the first volume of The Civilizing Process.

A key word for the description of changes in personality structure across the societal stages examined by Elias, and one which aptly catches the gradual nature of the process, is the term ‘psychologization’. Elias initially defines it as a form of foresight that develops among the circles of court life in the sixteenth century. It is the product of,

a more precise observation of others and oneself in terms of longer series of motives and causal connections, because it is here [at court] that vigilant self-control and perpetual observation of others are among the elementary prerequisites for the preservation of one’s social position.

(Elias 1982a: 274)

‘Psychologization’ describes a mode of perception of oneself and others that increasingly involves the assumption, on the part of the actors, that they possess an interiority that may be in contrast with an appearance or a mask. In the cognitive space or gap that comes into being through the process of psychologization, a new order of relationship becomes possible and is constantly being negotiated: the relationship between self and role, between the socially visible and the socially invisible aspects of the individual.¹ The constant activity of negotiation is still fully perceptible on the part of the actor within the context of court society, where the new restrainrs make themselves felt as an awkward and uncomfortable armour, as a mask that each and everyone is fully conscious of wearing. It is a declaredly ‘hypocritical’ stage, characterized by two-facedness and double play, where ‘the awareness that this control is exercised for social reasons is more alive’ (Elias 1982a: 272). At further stages in the process, as the socially visible and invisible aspects of oneself become increasingly distant and estranged from each other, a ‘wall of forgetfulness’ gradually consolidates between them, making each oblivious to the other. To the individual, they no longer appear as distinct opposites that are mostly in conflict. The mask merges with the face: it can no longer be removed at will. Self-controls thus acquire the universal appearance of a ‘psychological’ phenomenon that refers to the inner qualities of the person rather than to the dimension of the social. ‘Hypocrisy’ is no longer so clearly detectable at an interpersonal level because it has gradually become a form of self-deception, as Freud ‘discov...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgements
• Introduction
• 1: The Symptoms of Truth
• 2: Hide and Seek
• 3: The Vital and the Social
• 4: Does Psychosomatics Exist?
• 5: The Dispersion of Pychosomatics
• 6: Interpreting the Bodily Sign
• 7: Interpreting the Signs of Embodiment
• 8: Who is the Subject of Somatic Pathology?
• 9: Conclusions
• Notes
• Bibliography