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François Tosquelles, Saint-Alban, and the Invention of Institutional Psychotherapy
Institutional psychotherapy was born during the Second World War in a small and remote village in central France called Saint-Alban-sur-Limagnole. Since 1821, the castle of Saint-Alban had served as an asylum for the LozĂšre region, housing approximately six hundred patients by the turn of the century (fig. 1.1). Managed by administrators who were, according to the testimony of Marius Bonnet, a nurse who arrived at Saint-Alban in 1931, more interested in âminimizing costs and troublesâ than in the welfare of the patients, the asylum slowly deteriorated.1 Without heat, drugs, and basic sanitation, the inhabitants of the Saint-Alban asylum lived in miserable conditions.2 As Bonnet recalls, the patients slept in haystacks that also served as their toilets, amongst screams, foul smells, chronic illness, and death. They were âconstantly locked up, day and night, without electricity, in complete inactivity, without ever seeing the doctorâ or anyone else from the outside world, since visits were forbidden.3 In 1914 a fire destroyed much of the building, and in 1936 a typhoid epidemic ravaged the institution. Both crises highlighted the pressing need to modernize the insalubrious facilities and to implement serious hygienic measures.4 This was the context in which Paul Balvet assumed the directorship of the asylum, which, in 1937, was declared a psychiatric hospital. It was also the context in which François Tosquelles, one of the most important theorizers and practitioners of institutional psychotherapy, arrived at Saint-Alban, where he worked from 1940 to 1962.
The second argument that I wish to develop in this chapter is that Tosquellesâs psychiatric work was fundamentally shaped by his activism in radical politics in Catalonia and by his experience during the Spanish Civil War, first as a doctor for the Republican army at the front and later as a refugee in a French concentration camp. This experience of physical occupationâwhether this occupation came in the form of Spanish nationalism, Stalinism, Fascism, Vichy, or World War IIâconvinced Tosquelles of the intimate link between political and psychic oppression, between political and psychic freedom. Consequently, politics and psychiatry needed to work together to âdisalienateâ subjects and âdisoccupyâ their minds. Marx and Freud were thus complementary figures for Tosquelles, the two sides of one same struggle in what he called a âpolitics of madnessâ (une politique de la folie). Whereas Marx was necessary to grasp social alienation, Freud was essential for diagnosing psychic disaffection.6 As Tosquelles explained in a 1984 interview: âFrom age ten, I already knew what I wanted to do: bring Freud to the asylum, and bring psychoanalysis to the patients. Later, I understood that without Marx, a psychiatrist is nothing. Marx talks about the problems of man as a social being and Freud talks about the psychopathology of man, why he is condemned to suffer. Without them, we cannot understand anything about man, let alone about the mad. This is what all these biological psychiatrists refuse to understand when they think that they can cure the world with a pill.â7 It is this process of bringing together the theories of Freud and Marx and applying them to the asylum that I explore in this chapter.
Marx and Freud in Catalonia
Marx and Freud were indeed the two most important references for Tosquelles before he left Spain and sought refuge in France in 1939. Born in 1912 in Reus, a city south of Barcelona, Tosquelles was deeply marked by the Catalan political and cultural effervescence of the turn of the century. With the electoral victory of the ERC (Esquerra Republicana de Catalunya), which advocated socialism and Catalan independence, Catalonia became the first region of Spain to proclaim itself a republic in 1931. These were vibrant years for the labor movement, which was marked by strong anarchist and syndicalist currents.8 The CNT (ConfederaciĂłn Nacional del Trabajo), founded in Barcelona in 1910, anchored itself in the important neighborhood-based sociability and reciprocity networks that had emerged in the last decades of the nineteenth century. Significant philosophical and tactical disagreements divided the myriad workersâ collectives during these years, but many on the left bonded over their disillusion with the PCE (Partido Comunista Español), the official communist party, which they perceived as too subservient to Moscow, too eager to accept integration and centralization. Instead, the CNT and many groups on the radical left advocated federalism and decentralization, worker solidarity and self-management, and consciousness-raising, particularly through culture.9
In 1935, activists from two of these subgroups, the ICE (Izquierda Comunista de España) and the BOC (Bloque Obrero y Campesino) under the leadership of Andreu Nin and JoaquĂn MaurĂn, founded the POUM (Partido Obrero de UnificaciĂłn Marxista). Nin and MaurĂn, who had both begun their political activism within the CNT, embraced its vision of society as federated communes. Having traveled to Russia, both were also very much attracted to the thought of Leon Trotsky and his idea of permanent revolution. Most important, the POUM supporters were adamant about their opposition to Stalinism and to the centralized, antidemocratic, authoritarian, and bureaucratic turn that the Soviet Union had taken.10 As its leaders stated in a 1936 manifesto âWho Is the POUM and What Does It Want?,â the POUM fought for âa revolution committed to democratic-socialist ideals, workersâ alliances, the recognition of regional nationalisms and the creation of an Iberian Union of Socialist Republics that would replace the centralized nation, and the right to criticize the policies of the leaders of the USSR when they were counterproductive for the march of the world revolution.â11
The POUMâs advocacy of federalism, regionalism, and anti-authoritarianism clashed with the Cominternâs directives for socialist movements throughout Europe and with Stalinâs foreign policy, which had become increasingly obsessed with the notion of sabotage and treachery after successive defeats in Germany, Estonia, Bulgaria, and China throughout the 1920s. As the POUMâs leaders reiterated, Stalinâs Comintern was a perfect example of ideological colonialism, a âgrotesque attempt to impose the map of Russia over that of Spain.â12 Although Stalin immediately denounced the POUM as a âTrotskyite organizationâ filled with âfascist spies,â the POUM eventually broke with Trotsky who, in their eyes, also sought to force a Russian framework onto Spain. The POUM thus refused to adhere to Trotskyâs Fourth International, preferring to remain politically independent. It is this spirit of critique that pushed the POUM to stand alone amongst international leftist organizations in denouncing the Moscow show trials, and in particular the execution of Lev Kamenev and Grigori Zinoviev in 1936.13
In view of the special structure of Catalonia, we chose the comarca, which in this region possesses well-defined geographic and economic characteristics and, because it represents an unheard-of abundance of creative energy and new vitality, it could renew so much of the archaic health care system. We were persuaded that the form of the future revolutionary social organization would be the comarca. In the new Catalan anatomy, it will enjoy a new flowering of life, it will be a palpitating organ in the regional whole, and its warmth will expand the great comarcal capitals which will become the cultural and economic mirrors of the comarca reflected in them, instead of the way things were in the past, when these cities were socioeconomic deserts of little vitality in which, from time to time, an oasis bloomed with false splendor.18
In many ways, the comarca system laid the foundations for what would later be called in France psychiatrie de secteur, a movement that Tosquelles and his associates first developed at Saint-Alban and that was eventually adopted by the French Ministry of Health and generalized to the rest of the national territory after 1960.
Among the most important actors in this Catalan psychiatric reform movement of the early twentieth century was Tosquellesâs mentor, Emilio Mira y LĂłpez.19 Like Tosquelles, Mira was actively involved in leftist politics, and he was one of the founders of the Catalan-Balearic Communist Federation. But Mira was also a psychiatrist who worked at the Institut Pere Mata in Tosquellesâs hometown, Reus (fig. 1.2). Tosquelles, who was already well acquainted with the Pere Mata clinic through his uncle, who was also a doctor there, joined the medical team soon after finishing medical school. Mira, who was a prolific writer and who held the first chair of psychiatry at the Uni...