I work as an independent consultant for various academic institutions and have considerable experience as a lecturer and researcher. I have a PhD in Sociology and Mental Health Studies, an MA in Counselling Psychology, a BA in Social Dimensions of Health and a Post Graduate Certificate in Education. Before becoming an academic I held various clinical and managerial posts in the NHS. Prior to my current role I worked as a Senior Lecturer in Counselling Psychology and held various lecturing and research posts in UK Universities, including that of Senior Research Fellow.

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An examination of Goffman’s work on total institutions

The work of Goffman
Charon (1979) observed that authorities might constantly subject members of society whose capacity for self-determination is undermined by some form of impairment to humiliation and manipulation. Consequently their self-concepts may be negatively influenced by these experiences. He cited Goffman’s work on total institutions as an example of the way that the individual’s self judgement is taken over by other people who have a great deal of control over the physical and social environment in which they are confined. The individual is progressively redefined in a process that isolates them from reference groups and significant others outside the institution. The environment is completely controlled by a small, powerful group of people, and interactions with them are directed by their collective social judgements, and their view of the self. As a result of this process the individual forms a new view of the self, one that is dependent on the behavioural expectations of others. Submission to authority is rewarded through approval, and a positive view of the self becomes dependent on compliance with institutional rules.

Goffman (1961) stated that rules are underpinned by moral judgements. He argued that psychiatry projects ideals of ethical neutrality because this is a requirement of clinical judgement and practice. However, he observed that these aims could not be realised within mental institutions because patient management involves the promotion of acceptable standards of behaviour, and the application of sanctions for misdemeanours. He concluded that moral judgements are implicit during nurses patient interactions associated with rule enforcement. He perceived that the staff viewed inmates as objects, and the rules as a symbolic negation of the healing function of the institution.

“Psychiatric staff share with policemen the peculiar occupational task of hectoring and moralising adults: the necessity of submitting to these lectures is one of the consequences of committing acts against the community’s social order”. p. 319

He conducted the research on which Asylums was based in a large American asylum many years ago, and as such the findings may not be generalisable to modern ward nursing regimes in the UK. However, his work influenced important developments within psychiatry since then (Haralambos & Holborn 2000). Therefore his study may provide a reference point for what emerges from the results of this thesis. He wrote about the institution from a symbolic interactionist perspective, and sought to define the social situation of patients rather than staff. He observed that prison-like conditions pertained within the hospital environment, despite the fact that patients had not committed any crimes. He portrayed ward-nursing regimes as harshly punitive with a total imbalance of power between patients and staff. He referred to the large asylum in his study as a total institution, and justified the use of this term as follows:

“A total institution may be defined as a place of residence and work where a large number of like situated individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of life”. p.11

Goffman observed that total institutions limit social contact with the outside world, and prevent escape through the use of physical barriers like high walls or locked doors. He held that the vital characteristic of this type of establishment is that the boundaries that demarcate work, sleep and recreation within the wider society are removed. He observed that total institutions restrict all the activities of inmates to the same place, and that they perform them with the same group of people. He argued that outside the institution these activities would be carried out in various places with different groups for differing reasons. He drew an analogy between hospitals, prisons, monasteries, military training schools, concentration camps and ships.  He observed that institutions such as asylums combine the functions of residential communities and formal organisations. Within such places inmates’ lives are regimented in conformity with an overall aim.

“In our society they are forcing houses for changing persons; each is a natural experiment on what can be done to the self”. p.22

He described how the institutional system managed large numbers of people. Methods of overall surveillance were used as a means of control, so that non-compliant patients could be easily identified because they stood out from the rest of the group. Goffman observed a basic split between patients and staff who perceived each other negatively.

“Staff tends to feel superior and righteous: inmates tend, in some ways at least, to feel inferior, weak, blameworthy and guilty”. p. 18

He observed restricted interaction between them, and noted that staff addressed patients in a particular tone of voice. He also observed that they restricted patients’ access to other members of the hierarchy, and excluded them from decision making about the plans that were made for their treatment. In Goffman’s view the staff concealed care plans to prevent patients’ adverse reactions, which might disrupt the smooth operation of the admission process. Goffman observed that patients were routinely assigned to the sick role on admission to hospital, and he viewed this process as a basic aspect of institutional control. This perspective fits with concepts of stigma as discussed previously, in that other aspects of the self are invalidated by the diagnosis of mental illness and confinement to hospital. 

“ Having to control inmates and to defend the institution in the name of it’s avowed aims, the staff
resort to the kind of all embracing identification of the inmates that will make this possible”. p. 82

He described how the process of admission to hospital caused changes in the patient’s self-perception because the usual social activities that support a sense of self-identity were removed.

“An analysis of these processes can help us to see the arrangements that ordinary establishments must guarantee if members are to preserve their civilian selves”. p. 24

He referred to the ‘pervasive house rules’, and a system of privileges. This process punished disobedience by denying patients access to better social conditions, and rewarded obedience with greater levels of freedom or access to improved facilities. Goffman was interested in the external activities that sustain the self-identity rather than with internal processes, such as reflection. He observed that individuals use protective mechanisms to maintain a view of themselves, which they present to others. He believed that communal life within asylums disrupted this process, and observed that patients developed various means of self-expression to preserve a sense of personal identity. However, these activities might be viewed as bizarre by the staff, and taken as further proof of irrationality. He provided many examples of this type of behaviour, and held that it could be interpreted as a rational reaction towards the way that institutional practices stripped patients of their identity.

Goffman argued that people are usually admitted to mental institutions because their behaviour has breached social conventions. He observed that an important factor in the development of what he called a ‘moral career’ was that the patients’ rights and relationships were mostly taken away during the admission process. He spoke about a ‘betrayal funnel’, and observed that during each stage of the admission process those who were involved might try to give patients the impression that they would not lose any more of the rights that they enjoyed in the community.

He maintained that the ability to compartmentalise various social roles is disrupted by admission to hospital, and he described what happens to the patient as ‘mortification’. He observed that respect for patients’ feelings was lacking, and that the staff discouraged emotional displays. He gave an example of this process, and observed that patients were expected to behave deferentially towards the staff when they were told what to do. He pointed out that although people may be expected to obey those in authority in the outside world, they do not have to display respect when they do so.

Mortification
Goffman observed that patients were thrown into contact with people that they might choose to avoid in the world outside the institution. They had to share personal hygiene facilities, and they were generally treated as a group rather than as individuals. They usually had to ask permission to perform activities that they could perform spontaneously at home, for example going for walks or making refreshments. During admission to hospital, personal possessions and clothing that maintain the self-image were normally removed from them.

He observed that other characteristics of mortification centred on the way that the psychiatric speciality views mental illness and behaviour. All of the patients’ activities were surveilled, and they might be recorded in the notes. In Goffman’s view these processes damaged patients’ previous perceptions of themselves because it was difficult to hide behaviours that might be interpreted as a further evidence of illness. For example in the outside world people may be distressed by events in their personal lives, and they may display anger or weep in private, but these reactions are not exposed to public scrutiny because they can hide them from others within the privacy of their own homes. They can escape to private areas in order to gain control over their emotions in other social contexts as well, while they are at work for example. However within the confines of the ward it is much more difficult to conceal, what Goffman referred to as role , from others. The private self is constantly exposed to public view, and this erodes self-esteem.

Goffman coined the term ‘looping’, and by this he meant that when patients reacted defensively to what they viewed as a personal attack then their responses became the target of the next staff criticism. For example he observed that if they obeyed orders sullenly, then the staff might interpret this behaviour as further evidence of disorder, because the patient had refused to admit that their definition of the situation was distorted. He defined this as one of the basic features of the mortification process in that patients were not allowed to spontaneously express their own definition of the situation. This meant that they had to react in a prescribed manner, or in a way that further consigned them to the sick role by a display of anger for example.  They were unable to maintain social distance from the staff, or preserve a sense of autonomy because this was destroyed during the interaction.

Reconstituting the self
Goffman wrote about the ‘ secondary adjustments’ that patients made in order to preserve a sense of self. He observed that these activities might be viewed as bizarre, and interpreted as further evidence of illness by the staff. However Goffman argued that if they were viewed from the patients’ perspective, these activities could be seen as ways in which patients distanced themselves from the institution. Goffman remarked that these activities are important for the maintenance of a self-identity within ordinary society. A sense of autonomy is important for all individuals and, for example, people may assert themselves by being rude or uncooperative when they are subjected to institutional control. However, he observed that when inpatients reacted in this manner they might be transferred to what he referred to as a ‘bad ward’.