“The patient’s concrete society is itself the sick individual”: Review of Psychotherapy and Materialism, Part 1

François Tosquelles in the garden of the medical director’s house at the Saint-Alban clinic, around 1944–45. Romain Vigouroux / Ou-Rabah Tosquelles Family Collection.

Contemporary events—whether cuts to lifesaving programs for drug users and the unhoused in the US and Canada, the morphing of the UK’s Labour party from the party of workers to the party of “work,” the cutting of disability benefits as a matter of “British values,”1 or the denial of trans life in political and medical fields—suggest that spaces of health and social care are central to emergent fascisms directed at those deemed least productive for capital: the mad, the sick, and the poor. Recent publications including Pirate Care (2025) by Valeria Graziano, Marcell Mars, and Tomislav Medak and Health Communism (2022) by Beatrice Adler-Bolton and Artie Vierkant draw our attention to this, citing the (increasingly criminalized) struggles of health care users, workers, and their allies, and calling for definitions of health that “lay bare the violent and eugenic assumptions at its foundations.”2 In different ways, these texts suggest a reworking of historical and contemporary notions of militant care drawn from the experiences of the lumpen, or “surplus populations” subjected to regular ravages of neglect and punishment.

Psychotherapy and Materialism: Essays by François Tosquelles and Jean Oury, a small collection edited by Elena Vogman and Marlon Miguel, joins this list, shedding historical light on the struggles against fascist tendencies within care institutions in France in the postwar period. In contrast to Health Communism’s focus on outsider groups like the German patient’s collective SPK, or Pirate Care’s chronicling of contemporary defectors (or “pirates”) from the carceral and negligent dimensions of weaponized health provision, Psychotherapy and Materialism offers a genealogical reading of how institutions of care might be both thought and reorganized around an analysis of fascism rooted in the psychosocial, epistemic, micropolitical, and practical dimensions of institutional articulation. It offers a conjunctural reading of two historical moments that are key to understanding our own relationship to fascism, highlighting certain professionalized roles that foster fascist tendencies and desires in institutions.

The book takes as its starting point the material, intellectual, and social conditions that contributed to the praxis of institutional psychotherapy (IP), founded in the 1940s in France and later developed in North Africa and elsewhere. It contains a thoroughly researched introduction and new translations of talks by two key IP figures: the first by François Tosquelles, a militant Catalan émigré psychiatrist recruited from a refugee camp in Lozère to work at the Saint-Alban Clinic, and the second by Jean Oury, a French psychiatrist who trained at Saint-Alban and subsequently founded the infamous La Borde Clinic. The book is important insofar as it offers insights into IP’s lesser-known Marxist philosophical underpinnings and its pragmatic modes of clinical experimentation. It is also instructive as to some of the yet unresolved tensions in the praxis of IP provoked by the problems of the present.

For those new to institutional psychotherapy, the term refers to a field of practice that arose in the 1940s in France around the notion that mental illness can (at least in part) be attributed to the rituals, repetitions, procedures, performances, and modes of enunciation that shape our experience of institutions. As Jean Oury said in relation to the La Borde Clinic, it is “not the patient but the hospital that is sick.” In the talk by Oury included in this volume, “Institutional Psychotherapy From Saint-Alban to La Borde” (1970), he defines IP in a way that relates it directly to the “concentrationist” logics that were prominent in postwar state institutions—in the aftermath of Nazism and the Vichy regime. He describes IP as “the act of setting up all kinds of mechanisms to fight, every day, against all that could turn the whole of the ‘collective’  toward a concentrationary or segregationist structure.”3  

Contrary to the impression one might draw from the book’s foregrounding of the perspective of two psychiatric doctors (a problem/tendency in the history of IP that will be taken up in Part 2 of this review), Oury suggests that IP’s focus on “concentrationism” and segregation emerged from an analysis of both patients and psychiatric nurses. As a result of their experience of camps and clinical incarceration during the war, patients and nurses were highly attuned to the contradictory dynamics of care inherent to institutions that married support and incarceration. Allied with patients but uncertain how to work with them in a nonauthoritarian way, nurses turned to the radical pedagogical practices of the “modern school” of psychiatry that started in France in the 1930s, using its established Centers for Active Learning Methods to become conscious of the processes in their training that produced authoritarianism, conformity, and paternalism. They learned how to work alongside patients and to understand their own psychic investments in the institutional practices that  had prevented them from doing so before. This work was difficult, and often isolating, says Oury, but the cross-institutional networks developed at the training centers emboldened nurses to work against ordering and enunciative conventions and their own desires to please.

“Institution” here, due to the term’s arguably more plastic meaning in French than English, is understood not as a static and totalizing entity but as collective, processual ensembles that can either perpetuate containment, “concentrationism,” and segregation or generate the conditions for a more radical, circulatory, and democratically enunciative existence, through interventions including patient-staff committees, patient-led journals and cultural activities, and role rotation amongst workers and residents, which was intended to challenge professional subjectivation and oedipal reward systems. Madness is understood equally as a response to modes of institutional confinement and social segregation (experienced by staff and patients alike) and as a potentiated aptitude for institutional creativity—for instituting mechanisms of social desegregation between classes, between professionals and nonprofessionals, and between the clinic and its wider localities. “Analysis” is no longer defined as a doctor’s pursuit of a cure but rather as a collective praxis in the face of institutional conflicts and contradictions.

Anglophone readers may have encountered the history of IP in small and somewhat mythical fragments, first in the 1990s after the popularization of the work of philosophers Deleuze and Guattari, who make short but positive reference to it in their Anti-Oedipus. Félix Guattari was activity director at La Borde for twenty years, his work there contributing to key concepts in his writings both alone and with Deleuze, including the term “transversality,” which adapted the notion of transference—a psychoanalytic term concerning the relationship between patient and therapist—onto institutional terrain. More recently, translations of the psychiatric writings of Frantz Fanon, a practitioner of IP who trained at Saint-Alban and went on to work at the Blida Joinville Clinic in North Africa, have been referenced by Françoise Vergès, David Marriott, and others as an important backdrop to his anti-colonial political thought. Key figures in IP have also been the subject of a small but important number of exhibitions, films, and research projects exploring its dynamic assemblage of patients, medical professionals, militants, and surrealist artists like Paul Éluard, as well as its redefinition of aesthetic paradigms and the relationship between this history and key revolutionary moments like the Spanish Civil War, May 1968, and anti-colonial movements.4

The book’s introduction lays out the conditions in which IP came to be named, pointing specifically to the historical conjuncture of the Second World War. Its authors consider how psychiatric clinics as spaces to which the mad, misfits, vagabonds, the poor, refugees, and artists had been relegated were, during the Nazi occupation, subjected to a eugenicist program of extermination that left thousands to die without food or medicine. Whereas other commentators have contextualized IP as a practical and ideological critique of the institution and its normative assumptions about madness, here we read that its practices also evolved as a response to this period of violent neglect, where accepting the conventional ordering of the clinic would result in certain death. The radical reinvention of institutional practices that took place at Saint-Alban can be understood as a mode of material and psychic survival. The intellectual and practical lessons drawn from Tosquelles’s own experience as a militant in the Workers’ Party of Marxist Unification (POUM) in Spain, where he also worked with anarchist psychiatrists,5 here intermingle with the mobilization of anti-fascist resistance, Marxism, and an increasingly social reading of the psyche to support the necessary collective survival activities of the malade, a term whose English translation to the comparably passive “patient,” as we are told by the translators of Oury’s talk in the book, misses its meaning in French as the “irreducibly socially active experience of the sick person.”  

At Saint-Alban, the polyvalent groups applying social therapeutic approaches, including doctors, nurses, orderlies, patients, and people from the surrounding area, survived the war by communalizing food production and medical supplies, generating local trade economies, and reimagining social life beyond the limits of the nuclear family. As a result, Saint-Alban, as we learn from Miguel and Vogman, was not only a pivotal site for the invention of IP but had the fewest deaths of any psychiatric clinic in France during the occupation. (Across France,  over thirty thousand people died at psychiatric clinics in this period.)

Tosquelles argues that activities connecting “head and hand” were a crucial dimension of psychiatric practice, working against the otherwise confined and stationary life in institutions that normally separated their scientific/medical, experiential (patient), and administrative dimensions.6 When there was a blockage or “illness” in the sociality of patients at Saint-Alban, they would organize a football match. When the uniforms and dehumanizing clothing of patients led the staff to treat them in a carceral manner, they would organize a sewing group to make new clothes for everyone. Tosquelles’s own history of working with radical psychiatrist Emilio Mira y López in Spain, who emphasized the “intimate relationship between muscular activity and social and mental activation,” was complemented by his reading of early Marx on the concept of activity—like in Theses on Feuerbach, where Marx critiques one-dimensional notions of materialism that limit the latter to objects rather than “sensibly human activity, practice.” Following Marx, Tosquelles tells us that “the individual is the social being,” and existence “is social activity” that  “bears witness to the human being’s active presence in the world.”

The book’s editors are quick to point out, however, that the notion of activity, or “ergotherapy” as it is known in therapeutic contexts, could itself be read in a contradictory continuum with fascism. This continuum stretches from to the resistance practices of patient empowerment, as at Saint-Alban, to eugenicist tendencies mandating the active (working) body. The latter was articulated by Hermann Simon, whose Aktivere Krankenbehandlung in der Irrenanstalt (More Active Patient Treatment in the Mental Asylum), published in 1929, was highly influential for Tosquelles as one of two books he brought with him to France (the other being Lacan’s doctoral thesis). Simon himself became associated with social Darwinism and later embraced Nazism. Echoes of this notion of “activity” can be heard in the UK Labor government’s proposed cuts to support programs based on the perceived aversion towards “productive” activity on the part of the sick, disabled, and mentally ill.

IP’s attunement to the possibility that the conditions of care can foment illness is born of its approach to the dialectic, derived from its philosophical relationship to Marxism as indicated in the title of Tosquelles 1947 talk “Psychopathology and Dialectical Materialism.”

This talk came at a moment in the relationship between Marxism and psychoanalysis that was by no means simple. The French Communist party (PCF) throughout the 1940s denied the relevance of psychiatry to a communist position, viewing it as bourgeois and unscientific. The moment also coincided with a wider rejection in the PCF of Marx’s earlier works in which concepts like estrangement and alienation, social totality and praxis—key to Tosquelles’s thinking—were rejected in favor of a notion of the dialectic based in nature.7 Psychoanalysis itself had a fraught relationship with Marxism, the Freuds (both Sigmund and Anna) having famously shunned the later work of Willhelm Reich, who made powerful arguments for the importance of Marx’s analysis of social relations to a libidinal theory of consciousness (and fascism).8

Tosquelles takes passages from Marx’s Economic and Philosophical Manuscripts as a starting point to suggest the importance of the dialectic in undoing epistemic psychiatric conventions such as “taking processes in isolation” and thinking illness separately from “other determining factors,” like the social relations of production and the contradictions revealed through social action. Conflicts born of experimental changes made to the institutional ordering of roles and activities were not read as failures but as “analyzers.” “Causality” here is not “a one-way movement.” Instead, argues Tosquelles, “we must learn to see a fact not only as the outcome of its antecedent, but also as the starting point of its cause.” Fundamentally, says Tosquelles, IP shares political goals with Marxism in its commitment to the “human being’s disalienation.” 

Alienation here is understood not as an individual phenomena but as based on social relations born from the “inter-projection” of private property. The use of the term “inter-projection” is a liberty taken by the translators in order to "mark the inter-human character" of private property in Tosquelles's understanding. (Tosquelles in fact uses the term “interjection,” which the translators suggest to be a typo for “introjection,” a concept developed by Léopold Szondi and others to describe the internalization of collective characteristics). It is with this notion of alienation in mind that Tosquelles rejects a therapeutic practice based on an interiorized understanding of consciousness, arguing instead that the “the patient’s concrete society is itself the sick individual.” Treatment must consist in the “dis-alienation of the total fact of madness: the sick person, the asylum, and the psychiatrist at once.”

This tripartite understanding of how to address the enclosures of institutional practice was developed in the postwar period in France, as we can read in the translation of Jean Oury’s 1970 talk, delivered nearly thirty years later, in the aftermath of the 1968 uprisings. Part 2 of this review will suggest how these two conjunctures—fascism in World War II and in the post-68 context—generate instructive lessons for our own historical moment.

Continued in Part 2