A sociological and ethnographic examination of the social lives of mental patients in psychiatric hospitals.

Goffman, Erving. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books, 1961.

The four essays in Erving Goffman’s work Asylums: Essays on the Social Situation of Mental Patients and Other Inmates were published in 1961. The vivid description of institutional life and Goffman’s account of life in a mental hospital may be considered a relic of history now that asylums have been demolished and care of the vulnerable has been transferred to community settings. However, given the reports of poor quality of care in many care organizations, it may be relevant to revisit Goffman and ask ourselves: “To what extent have modern healthcare organizations moved on from the paternalism and bureaucratic control of patients and clients in their care?”

Goffman is thought to have coined the term “total institutions” to express the fact that the rules of everyday life outside no longer have validity for the inmates of psychiatric asylums, prisons, military barracks, and concentration camps. Inmates lack the usual accoutrements of identity: they can no longer control how they dress or how they look, they are stripped of their personal possessions and are given standard institutional clothing and basic items for the purposes of bathing and sleeping. Goffman notes that people come into total institutions with a conception of themselves that is made possible by social arrangements and relationships in their home life. Upon entrance, a person is stripped of that support. The person entering a total institution begins a radical shift in what Goffman describes as that person’s “moral career,” which is a career composed of the progressive changes that occur in the beliefs held about one’s self and significant others.

For Goffman, total (i.e., all-encompassing) institutions are characterized by the bureaucratic control of the human needs of a group of people. He defines total institutions as social arrangements that are regulated according to one rational plan and that occur under one roof. The total institution is then a living space in which a group of people share a similar social situation and are cut off from the greater society for a considerable amount of time. In normal society, we normally play, work, and sleep in different places with different people. However, in total institutions, these three activities of life lose their boundaries. In total institutions, life is experienced and controlled in the same place by the same central authority. The activities of daily living are conducted in the presence of a large group of people in similar circumstances. All phases of daily activities are carefully planned and monitored, with one activity leading into the next at a prearranged time and often to meet the organizational needs of the institution rather than the individual. The institution relies upon direct surveillance of an inmate by ever-present authority figures, a panopticon-like situation.

To meet the definition of a total institution, an inmate must arrive with a presenting culture derived from their home world. Simply put, they must come to the institution with “a way of life and a round of activities taken for granted until the point of admission to the institution” (p. 12). Institutions that do not involve this element (orphanages, for example) are not considered total institutions. One of the reasons for this is the importance Goffman places on a particularly distinctive character of total institutions: “role dispossession.” Role dispossession can be understood as the general mental changes that co-occur with the erasure of one’s culture prior to arrival as well as the rapid shift to a situation, in which one’s various roles—the different roles, which individuals normally voluntarily play in accordance with different life circumstances—collapse into a single role: that of an inmate.

According to Goffman’s model, there are five types of total institutions. The first can be defined as institutions that “care for persons felt to be both incapable [of looking after themselves] and harmless” (p. 4). An example would be a retirement home. The second is a variation on the first, but includes individuals who are felt to be both incapable of looking after themselves and an unintentional threat to the community. A salient example here would be a mental hospital. The third kind of total institution is one that “protect[s] the community against what are felt to be intentional dangers to it” (pp. 4-5). The primary example here would be a jail or a prison. The forth example are institutions that “[are] designed as retreats from the world” (p. 5) such as monasteries. Finally, the fifth type of total institution falls under the category of institutions that “[are] established…to pursue some work-like task and justifying themselves only on these grounds” (p. 5). An example cited by Goffman are boarding schools.

In total institutions, there is a split between a large managed group of inmates and a small supervisory staff. Inmates typically live in the institution and have restricted contact with the outside world whereas the staff often live outside the institution and operate on an eight-hour day. Each group typically views the other through the lens of narrow hostile stereotypes. Family life is usually incompatible with total institutions where inmates participate in “batch living,” working, eating, and sleeping in the presence of a group of people that are by definition not related to each other in the intimate way that characterizes familial relationships.

These total institutions are designed to have a major assault on an inmate’s psychological sense of self. Goffman refers to this as a mortification of the self. When an inmate first enters a total institution, they bring with them a conceptions of themselves that are constructed by certain stable social arrangements in their home life. Upon their entrance, the inmate is immediately stripped of the support provided by these social arrangements. The barrier that total institutions place between the inmate and the outside wider world is the first curtailment of the self. Staff generally employ what are called admissions procedures “such as taking a life history, photographing, weighing, fingerprinting, assigning numbers, listing personal possessions for storage, undressing, bathing, disinfecting, haircutting, issuing institutional clothing, instructing as to rules, and assigning to quarters” (pp. 25-26). Additionally, since an individual’s personal possessions have a special relation to self, they are quickly removed by staff. An individual usually has some control over how they appear before others through clothing and cosmetic supplies. However, an individual is likely to be stripped of their usual appearance and the tools by which they maintain it. Goffman calls this one’s “identity kit,” and it is standard among total institutions that “the individual is likely to be stripped of his [identity kit]” upon arrival, thus “suffering a personal defacement” (p. 20). Individuals are then issued institutional clothing that is usually “of a ‘coarse’ variety, ill-suited, often old, and the same for large categories of inmates” (p. 20).

In total institutions, inmates are “induced to do things not by reward but by [implied] threat of physical punishment” (p. 24). Furthermore, the inmate is also “excluded from knowledge of the decisions taken regarding his fate,” (p. 14) in the sense that the inmate in a prison is not aware of how much paperwork has been drawn up on them or when or where they may be moving next. As another example, mental patients are often not made aware of upcoming treatments such as electroshock therapy.

In particular, Goffman discusses mental patients entering the mental hospital. He points out that “in the degree that the ‘mentally ill’ outside hospitals numerically approach or surpass those inside hospitals, one could say that mental patients distinctively suffer not from mental illness, but from contingencies” (p. 135). What follows is a description of the ways a person can be stripped of their rights and freedoms without quite knowing what is happening and end up a patient in a mental hospital with a next-of-kin transformed into a guardian. Goffman talks about the “moral career” of the mental patient by which he means the regular sequence of changes that accompany hospitalization and the patient’s sense of self. These changes occur in both the prepatient and the inpatient phases of the patient’s moral career. In the prepatient phase, an individual comes to realize that they are losing their mind. In the inpatient phase, an individual comes to realize that they have been deserted by society. They are subjected to humiliating reductions in freedoms and liberties.

Goffman catalogues the ways that mental patients manipulate the facilities and resources of the hospital to their own ends, carving out the kind of autonomy and the kind of intimate relationships that are otherwise explicitly repressed. Partly in response to the mortification of self, inmates develop “secondary adjustments,” which are defined as “any habitual arrangement by which a member of an organization employs unauthorized means, or obtains unauthorized ends, or both, thus getting around the organization’s assumptions as to what he should do and get and hence what he should be” (p. 189). “These practices together comprise what can be called the underlife of the institution, being to a social establishment what an underworld is to a city” (p. 199).

The deprivations that the involuntarily committed suffer in total institutions today makes Asylums a compelling read even now. Just because we have gotten rid of total institutions in their concrete form, that does not mean that the social processes have disappeared. These social processes arise from human interaction, which itself both constructs and is constructed by individuals based on their values, culture, and social practices. Thus banishing the concrete does not mean banishing the social. These social processes may just transfer to new concrete settings.

However, it is apparent that Goffman downplayed the the medical dimension of mental disorders. The terms “mental illness” and “sickness” were often place in quotation marks, the scare quotes meant to communicate Goffman’s disparaging attitude toward psychiatry. Mental illness was, for him, a social construction, an identity that colluding others impose on the victim. He wrote, “mental hospitals are not found in our society because supervisors, psychiatrists and attendants want jobs; mental hospitals exist because there is a market for them. If all the mental hospitals in a given region were emptied and closed down today, tomorrow relatives, police, and judges would raise a clamor for new ones; and these true clients of the mental hospital would demand an institution to satisfy their needs” (p. 384). Missing in this work is an acknowledgement that psychiatric medical treatment may benefit patients. It is worth bearing in mind that at the time that Goffman was collecting his data at St. Elizabeth’s Hospital in Washington, DC, psychoanalysis was dominating psychiatry. The development of psychotropic benzodiazepines was in its infantry and their widespread use was still over a decade away. It is in this historical context that Goffman embraced the social constructionist view of mental illness. Along with many others, Goffman decried the biological view of mental illness and sought to expose the abuses of psychiatry in the United States.