Perspectives on Erving Goffman’s “Asylums” fifty years on
Erving Goffman’s “Asylums” is a key text in the development of contemporary, community-orientated mental health practice. It has survived as a trenchant critique of the asylum as total institution, and its publication in 1961 in book form marked a further stage in the discrediting of the asylum model of mental health care. In this paper, some responses from a range of disciplines to this text, 50 years on, are presented. A consultant psychiatrist with a special interest in cultural psychiatry and mental health legislation, two collaborating psychotherapists in adult and forensic mental health, a philosopher, and a recent medical graduate, present their varying responses to the text. The editors present these with the hope of encouraging further dialogue and debate from service users, carers, clinicians, and academics and researchers across a range of disciplines.
KeywordsInstitutionalisationMental healthAsylumsPsychiatryMental illnessHospitals
2011 sees the 50th anniversary of the publication of Erving Goffman’s “Asylums: Essays on the Social Situation of Mental Patients and Other Inmates.” Seen as a key text in the process of deinstitutionalisation, “Asylums” consists of four essays—analysing at length the “total institution”, “the moral career of the mental patient” and medical models of psychiatric care—written with a clarity and force that ensured the book a popularity and influence well beyond academic sociology or purely psychiatric circles. Goffman went undercover as an assistant to the physical education instructor at St Elizabeth’s Hospital in Washington, DC, and this experience further informed his account of the power relations within the asylum.
For this fiftieth anniversary, the authors have assembled a range of perspectives on Goffman’s text. We have endeavoured to elicit as wide a range of disciplinary, practitioner and service user responses as possible; however due to the logistical challenges that a paper of this nature presents, we are at this point only in a position to present the papers below. This article comprises brief papers from a philosopher, a consultant psychiatrist, a recent medical graduate, and two collaborating psychotherapists working in a therapeutic community. All were given the simple injunction to respond to Goffman’s text, 50 years on, in whatever way they saw fit. Some tackle the text directly; others reflect on contemporary practice. We look forward to a further opportunity to present more perspectives, and would also welcome the responses of readers of the journal. It is the editor’s belief that Goffman’s text is not simply a critique of institutionalisation, or another blast against biomedical models of psychiatric care, but primarily a clarion call for the humanisation of what was called “mental patients”, and a rejection of totalising, hegemonic accounts of mental illness from whatever field. All the perspectives contained herein reflect and deepen our understanding of Goffman. The editor would welcome responses and critiques from all those interested in the field, within and without the academy and the clinic.
Séamus Mac Suibhne
Beyond these walls: the “Total Institution” of homelessness
John Adlam, Christopher Scanlon
ALEXANDER: Dost thou not know that I am able to give thee a kingdom?
DIOGENES: I know thou art able, if I had one, to take it from me; and I shall never place any value on that which such as thou art can deprive me of.
[Henry Fielding, A Dialogue between Alexander the Great, and Diogenes the Cynic, 1743]
When Goffman wrote about ‘total institutions’, he had in mind those intra-mural spaces in which people are separated from wider society either through the nature of their work (barracks and monasteries) or because of incapacity, disadvantage or dangerousness (orphanages, mental hospitals and prisons). The total institution was identifiable by the impermeability of its inherent “barrier to social intercourse with the outside and to departure” (Goffman 1961: 15). Processes and rituals of admission to the institution across its separating boundary were accompanied by varying degrees of humiliation and often catastrophic losses of role and identity. The ‘key fact’ of a total institution was related not to the primary task of the institution itself but to the bureaucratic management of those subject to its authority, “whether or not this is a necessary or effective means of social organization” (Goffman 1961: 18). He held that “every institution has encompassing tendencies” (Goffman 1961: 15) and noted that staff employed in such institutions were set up, like so many miniature Alexanders, with immense arbitrary power over those in their charge.
We would like to pay homage to Goffman’s ideas by wondering if the concept of the ‘total’ nature of an institution can also apply extra-murally to the bureaucratic management of incapacitated or disadvantaged persons outside the perimeter wall. We have previously noted how, in response to a fear and loathing of the ‘violence and madness in, and of, the community’, the ‘housed’ increasingly lock themselves intoalarmed houses in gated communities or behind high walls, because there is nothing so frightening as having ‘them’ in our backyards (Foster and Roberts 1998) and nothing so reassuring as the ‘beggar at the gate’ (Scanlon and Adlam 2008). The Italian philosopher Giorgio Agamben (2003) analyses ‘states of exception’, whereby sovereignty is paradoxically asserted over sections of a population by virtue of their being excluded from the rights and legal frameworks of citizenship that sovereignty exists to uphold and within which an experience of social inclusion is defined. Hannah Arendt, reporting on the trial of Adolf Eichmann in Jerusalem (1963), showed how the totalitarian nature of the Nazi state and the fascist state of mind was defined by its capacity to place Jews and other constructed ‘sub-species’ outside the frame of citizenship and the rule of law. The junta in Argentina in the early 1970s first created a quasi-legal category of ‘non-Argentinians’ before causing the ‘disappearance’ of thousands of their number (Bell 2010). Processes of ‘extraordinary rendition’ and the extra-legal status of Guantanamo Bay are contemporary examples of how ‘others’ are rendered persona non grata.
Fielding’s imaginary dialogue between Alexander and Diogenes, cited above, epitomises this issue of the ‘total’ nature of sovereignty and how one is never in greater peril than when apparently placed outside sovereignty’s bounds. Diogenes sees that the risk of accepting Alexander’s gift of a kingdom (or a house) is that, in so doing, he does not become less vulnerable but more so. At the time of writing the UK government continues to refuse voting rights to prisoners: the Prime Minister David Cameron has said that “it makes me physically ill even to contemplate having to give the vote to anyone who is in prison. Frankly, when people commit a crime and go to prison, they should lose their rights, including the right to vote” (Hansard 2010). In the USA, Gilligan (1996) has powerfully shown how male rape is a systematic instrument of terror deployed by the State against those who are, in effect, placed outside the State’s protection by being incarcerated. We suggest that these victims of intra-mural institutional violence are a priori subjected to the extra-mural violence of the wider societal total institution that has excluded them. We might also note Declerk’s (2006) critique of the urban west’s hostility to the homeless. The bureaucratic control of the homeless and the stateless; the humiliations attendant upon their transition to those ‘outside’, excepted states; the speed with which individuals become deskilled when administratively stripped of that which previously oriented them to the world; the disorienting jargon and vernacular of the inside or outside; all of these exclusions on the ‘outside’ echo the routines and rituals of passage that Goffman describes in relation to the forced inclusions on the ‘inside’ of his total institutions (see also Brown and Walker 2010; Brown et al. 2011).
Bion’s theory of basic assumption states of mind in groups and society (1961; see also Hopper 2003, 2012) may perhaps shed some light on how these ‘disturbances of groupishness’ extend the traumatising dynamics of the total institution to excluding (dis)organisations (Scanlon and Adlam 2011) and indeed to whole populations. Goffman’s total institution is located in an age dominated by what Bion called a ‘dependent basic assumption’, where what was expressed was a desperate wish for a benevolent leader who would administer and control the deviance and violence of the fascist state of mind. It was a time when it was still possible to speak positively about communalism (Rapoport 1960) as a benign, developmental opportunity and about socialism as a democratic means through which it might be achieved; when the promise of houses for heroes had yet to lose its lustre. The tension lay between this wish for a more benign and re-assuring dependency and a manic hope—which Bion might have understood as a ‘pairing basic assumption’—invested in an aspirational modernity within which there would be meaningful ‘care in the community’: a hope rooted in a mad idea that the community is willing to care about those who find themselves living at its edge.
We have elsewhere borrowed Levi-Strauss’ concepts of anthropophagic (abolishing difference by incorporating) and anthropoemic (abolishing difference by evacuating) responses to that which is experienced as ‘other’ and sought to apply them to an analysis of traumatised social systems (Levi-Strauss 1955; Scanlon and Adlam 2008, 2011). In these terms, the old asylums and criminal justice systems were predominantly anthropophagic in nature, forcibly incorporating, in order to neutralise, the threatening difference of the mad, bad, sad and indigent (Foucault 1961; Adlam et al. 2010; Scanlon and Adlam 2012). However, as we are describing here, the landscape of social care and control was, and is, also characterised by anthropoemic responses that result in a denying of asylum, such as punishment by transportation of offender, the deportation of asylum seekers and the denial of other ‘intra-mural’ services for other excluded and worth-less groups such as the homeless, the chronically sick, the elderly and disabled (Dartington 2010) and the unemployed (Adlam and Scanlon 2010; Adlam et al. 2010).
Now, in our liquidly modern world (Bauman 2000), some of the old-style would-be helping total institutions have fallen out of fashion and favour so that those who might have been helped are now anthropoemically vomited out into the sick-bucket of incohesive, ‘metropolitan’ social systems (Hopper 2003, 2012). The world of benign dependency has failed and in its failing the needs of the vulnerable are denied—perhaps because, literally and metaphorically, we cannot ‘afford’ to think about them (Hopper 2003; Cooper and Lousada 2005; Dartington 2010). Most of us live beyond the fortress walls in an aggregated, individualistic world where we experience the potentially lethal consequences of quick fixes, instant gratification and envious competition for scarce and dwindling natural and social resources (see e.g. Wilkinson and Pickett 2009; Dorling 2010).
The liquidly modern ‘total institution’, in contrast to the manifest social terror of the walled asylums, can then be understood as the apparently ‘invisible’ background of objective violence out of which ‘individual acts of terror’ emanate (Zizek 2008). Diogenes’ protest against the excluding/excepting nature of Metropolitan ancient Greece was to identify himself as a Cosmopolitan citizen of the world, thus rejecting the tyranny of inside and outside that is established by ‘limit concepts’ (Agamben 1995) such as city walls and state boundaries. In the post-war period and up until the fairly recent past, a nostalgic longing for totally reliable and benevolent (and dependent) metropolitan social institutions was juxtaposed against and oscillated with the manic hope that in a caring community the included and the excluded could really ‘get it together’ (Bion 1961). In the aggregated, liquidly modern and incohesive world that we are evoking, to survive is perhaps to accept that homelessness as a bodily state, or ‘unhousedness’ as a state of mind, is the norm of the modern ‘total institution’. The challenge is how best to position oneself in order to find meaningful relationships with others in a world where there is an ever-present danger: where, to borrow from O’Brien (1939), ‘a pint of plain is your only man’ and Diogenes’ barrel is the only refuge.
Erving Goffman’s Asylums; the perspective of a recent medical graduate
In Asylums; essays on the social situation of mental patients and other inmates, Erving Goffman seeks to explore the various aspects of inmate life. Psychiatric hospitals have drastically changed since this book was first published in 1961, and there are many worldwide initiatives to move closer to community-based psychiatric care. While Goffman’s work contains much which is of value to patients, public and healthcare professionals alike, one of the fundamental weaknesses in this book is given away as early as in the title.
Goffman goes to great lengths early on to establish the various aspects of a total institution and to justify why such institutions can be considered together when dealing with matters of sociology. The thrust of Asylums is concerned specifically with mental patients; however, the majority of the examples used are not from a healthcare setting but rather from other total institutions. While some pieces of analysis clearly apply to all forms of total institution, others are particular to their own specific circumstances and by considering all of these together to make judgements on the nature of the situation in which psychiatric inpatients find themselves, Goffman opens himself to accusations of bias by not also acknowledging the aspects of total institutions which separate each from the others with the same verbosity with which he links all such institutions together.
For example, when considering the degree to which the minutiae of a patient’s life can be organised for them by their supervisors, Goffman gives examples first from a Nazi concentration camp (assaults at the hands of the SS for offences as minor as having unshined shoes), before proceeding to a psychiatric hospital where the examples include limited supplies of toilet paper being provided only when requested, and the humiliation of having to ask, sometimes repeatedly, for necessities such as linen. While the latter examples are undoubtedly troubling and worthy of concern, it is surely unfair to consider them in the same context as the former. The pattern in this book is an observation (“minute segments of a person’s line of activity may be subjected to regulations and judgements by staff”), followed by several examples escalating in severity, concluded by an extrapolation regarding the nature of life in a mental hospital. Other total institutions included in Goffman’s analysis in this way include military barracks and Chinese thought-reform camps; by including extraneous examples such as these he reveals either his own inability to distinguish between these varied situations or his pre-existing bias towards psychiatric institutions. Precious little time is spent examining the therapeutic function of the hospital and what patients stand to gain from their treatment there.
What Goffman apparently neglects when considering all total institutions is the context—the reasons why inmates and staff are present in their given environments—not to mention the stated aim of the institution and the professional ideology of the staff. If considered, such background information draws divisions between the various institutions which must raise questions as to the validity of the comparison. While some comparisons between various total institutions can legitimately be made, for example regarding the level of control held by staff over inpatients and the lack of contact with the outside world, it does not seem fair to conclude that the experiences of both sets of inmates are so similar that they can be considered together. Prisoners are most likely aware of crimes that they have committed whereas mentally ill patients may have no insight into their own condition or may only be able to perceive it as an abstraction at best; prisoners are detained against their will, while many psychiatric patients remain in hospital voluntarily. Most crucially, patients are present in the modern psychiatric hospital not for purposes of punishment or duty but rather for purposes of treatment and, where possible, cure. Unlike other total institutions, psychiatric hospitals exist specifically to serve the needs of those under the care of the staff. This fundamentally changes the dynamic between inpatients and staff, as well as between inpatients and the institution itself.
It is worth noting that the institutions described by Goffman are the psychiatric hospitals of the 1960s which may not have universally maintained the same standards to which we have become accustomed in the modern healthcare setting. Many did conform to the stereotype depicted by Goffman and were threatening places, easy to get into and hard to exit, ruled with a lack of oversight by people whose brief was control, not cure, and certainly not compassion. Even allowing for the changes which have occurred in psychiatric care over nearly 50 years since Asylums was published, some of its central points remain relevant. Goffman contends that a psychiatric inpatient loses “certain behaviour opportunities” by virtue of their being in a new, restricted environment which may result in what he calls “disculturation” and may result in difficulty adapting to life outside the hospital on discharge. While many of the initiation procedures that inpatients in the 1960s experienced (e.g. confiscation of all personal belongings, allocation of a serial number instead of a name) have not persisted to the present day, the concept of “mortification of self” is one that could be argued to exist even in the modern psychiatric setting, and to a greater extent than it exists in other types of hospital. Goffman also eloquently details the dilemma faced by staff, and nurses in particular, when dealing with patients whose actions are obviously self-destructive; in attempting to preserve the patient’s own best interest, he describes how staff may occasionally be forced to physically intervene, thus “creating an image of themselves as harsh and coercive”, an image which they would have sought to avoid at all costs but one which is unavoidable in their efforts to care for their patients.
However, throughout the book, Goffman almost totally ignores the reality of the mental illnesses suffered by the patients whose situation he attempts to describe. The notion that patients might benefit from the treatment on offer in psychiatric hospitals is never considered; neither is the idea that patients might actually favour receiving treatment over their situation in the outside world where their mental illness had caused them to lose opportunities which might become available to them again on their discharge. Notably, the matter of how patients came to be admitted in the first place is scarcely mentioned. While psychiatric hospitals have changed since the 1960s, studies undertaken at the time indicate that a majority of psychiatric inpatients in fact held favourable attitudes towards their hospital, were not forced to be admitted and saw the potential benefit of their treatment, even allowing for the limitation of the hospitals when held to the standards of the modern era. Goffman’s work has long been a key part of a shift in attitudes towards psychiatry which has much popular support and is now causing a shift towards the development of community psychiatry. It is debatable how much of this is due to sound research and evidence and how much is due to public perception and stigma; it should not be forgotten that inpatient psychiatric treatment has a valuable role to play for many patients. Goffman’s priorities in his critique are the maintenance of the patients’ sociological health; however, if due care is not taken to protect the mental health of patients whose care may be affected by his theories then those patients stand to benefit very little from his contribution.
What is it like to be a mental patient?
Shane N. Glackin
Since Asylums was published, Erving Goffman’s work has been widely influential, from his home field of sociology to psychiatry, queer studies, and literary theory. In this context, his comparative lack of impact among philosophers is curious. Since our collective aim here is to examine Goffman’s enduring influence, I shall not have room to subject his claims in the book to extended critical analysis. Rather, I will seek to illustrate one way that some of those claims—if accepted—provide a significant resource for particular currents in contemporary Philosophy of Medicine.
Goffman opens Asylums with the seemingly commonsensical assertion that “a good way to learn about [patients’ lives] is to submit oneself… to the daily round of petty contingencies to which they are subject.”1 Seminal though the observation was for sociologists, the practice has not been widely adopted by medical and psychiatric professionals. Perhaps this is unsurprising; the salient aim of the physician or psychiatrist is not to learn about the patient’s life, but to cure her ailments. For this purpose, the patient need not be considered a person at all; in purely functional terms, she is a locus of maladies to be treated, a set of professional puzzles awaiting solution.
The patient, on this view, is treated as an object of study, an instance of some disorder, rather than as a subject in her own right. “(T)he nature of the patient’s nature,” argues Goffman, “is redefined so that, in effect if not by intention, the patient becomes the sort of object on which a psychiatric service can be performed.”2 Yet illness is, in a crucial sense, subjective; “illness is not simply a problem in an isolated physiological body part,” Havi Carel noted recently, “but a problem with the whole embodied person and her relationship to her environment.”3
The reductive view of the patient can greatly exacerbate the felt impact of illness upon her life. Carel relates the “near-universal” complaint; “why am I not treated as a person?”4 The experience of alienation from one’s body, from one’s environment, and from the physical capacities one uses to negotiate and master that environment may be hugely traumatic. Yet the trauma of that alienation is only worsened by the failure of medical professionals to attend to the patient’s lived experience. She becomes, as Goffman chronicles, an extra mouth to feed, an extra stop on the rounds, an extra set of forms to fill, of shots to be administered, of relatives and visitors to be placated. “Surgeons prefer to work on slender patients rather than fat ones,” he notes, “because with fat ones instruments get slippy, and there are extra layers to cut through.”5 The cumulative experience of medical bureaucratic institutions, for an already-debilitated patient, is frequently belittling, dehumanising, and humiliating.
Whether the picture Goffman presents is fair or not to medical practitioners is, in a sense, irrelevant. What is important here is that Goffman’s patient-level sociological analysis, like Carel’s more personal and recent account, indicates a persistent sense of alienation on the part of patients. A particular case of some ailment is often described as “textbook.” But one thing Ervin Goffman’s work makes clear is that the patient themselves, the person afflicted, exists in no textbook; and their affliction is—for them—importantly unique. The medical and psychiatric professions, Carel argues, have typically understood illness almost exclusively in the third person; and must now attend to the subjective first-person experience, the phenomenology of the ill self.
Of course, we may nonetheless query these charges, on a number of grounds. The very impact of Asylums’ initial publication had a significant impact on the treatment of patients, and there is assuredly no shortage of sympathetic, humane medical professionals. To “take the first-person perspective” of another is, in any literal sense, a matter of profound epistemic and conceptual difficulty; not for nothing has the “problem of other minds” vexed philosophers for centuries.6 And it is far from clear that any such immersion in the patients’ point of view, even were it possible, would be prudent; to experience without detachment the individual emotional traumas of scores of patients daily would surely prove intolerable.
Still, we need not literally adopt such a perspective in order to take it into greater account, and the concerns raised by Goffman’s inquiries continue to require urgent attention. The depersonalisation of the inmate does not pertain only to her physical and mental wellbeing; in the particular case of mental hospitals, where an adult patient may be detained against her will, failure to recognise her as a human person, who bears the full measure of legal and moral rights, carries serious ethical consequences.
The ethical debates about involuntary detention are well-worn, and need not be repeated here. Substantial consensus exists, however, that it may be used at most as a last resort, never as a punitive measure, and that it involves dangerous restrictions to human freedom.7 To justify committal, we must pay the highest attention to the patient’s capacities to understand, and to consent to or refuse, the treatment regime. But Goffman’s observations in Asylums suggest that inmates will find any such concern for their personal autonomy decidedly atypical, not through any lack of care on the part of practitioners, but as a side-effect of the internal bureaucratic and social logic of such institutions.
On page after page, we read of the experiences of patients who seem to exist as impersonal cogs in the large bureaucratic system which is—or was at the time of writing—a modern mental hospital. As far as the inmate sees, the logic of bureaucracy is to regard her as a part of the machine, an automaton. This may make organisational sense; but it seems impossible to square with our moral obligations of transparency and rational justification to involuntary patients. Even a patient entering voluntarily, observes Goffman, “starts out with at least a portion of the rights, liberties, and satisfactions of the civilian and ends up on a psychiatric ward stripped of almost everything.”8
The perceived pragmatic strategy of considering the patient as an object of treatment, then, obscures her moral status. This may make mental hospitals more efficient; but it does so at the dual cost of significantly worsening the lived effect of illness, and of severely compromising our moral responsibilities to involuntary patients. After 50 years, Goffman’s challenge to understand in genuinely empathetic fashion the lived experience of patienthood has still not been taken up in anything like sufficient measure by the medical profession.
Erving Goffman’s Asylums 50 years after publication: the perspective of a consultant psychiatrist
Brendan D Kelly
Any psychiatrist who works in an inpatient facility will find Goffman’s (1961) descriptions of institutions “eerily familiar” (MacSuibhne 2009, p. 867). All psychiatric wards, like medical wards, boarding schools, prisons, and well-run family homes, have some of the qualities of Goffman’s “total institutions”: they are regulated environments in which there are explicit rules, desirable behaviours, unspoken absolutes, recognized hierarchies and myriad underworlds intermittently accessible to overlapping sub-groups.
But Goffman wrote about total institutions, in which the individual is profoundly betrayed, totally regulated, absolutely confined and deeply disempowered. Do such “total” institutions still exist? There is certainly plentiful evidence that they did exist and that the practice of psychiatry was especially strongly linked with them. The history of psychiatry in Ireland provides an especially good example of this, as the history of mental health care from the early nineteenth century onwards is essentially a history of Goffman-ian “total institutions”.
At the start of the nineteenth century there was minimal provision for the mentally ill in Ireland, who tended towards lives of vagrancy, homelessness and destitution (Robins 1986). The first systematic change occurred in 1787, when the Prisons Act empowered Grand Juries to establish lunatic wards in houses of industry (workhouses). From the outset, then, psychiatric care was institutional care, with a legislative base in an Act concerned with criminals and a geographical base in institutions for the poor.
The need for more extensive provision for the mentally ill was highlighted in 1804 by a Select Committee of the House of Commons which recommended the establishment of a network of public psychiatric institutions (O’Neill 2005). In 1814, Ireland’s first large institution for the mentally ill, the Richmond Asylum, was opened in Dublin (Finnane 1981; Reynolds 1992). It was quickly followed by many more (Williamson 1970): in 1851 there were 3,234 individuals in Irish asylums and by 1891 there were 11,265 (Inspectors of Lunatics 1893).
This dramatic increase in inpatient numbers was attributable to (a) greater recognition of mental illness; (b) changes in diagnostic practices; (c) mutually re-enforcing patterns of asylum-building and committal, underpinned by legislative change; (d) possible epidemiological change owing to socio-demographic changes in population structure and/or unidentified biological factors increasing rates of illness (Kelly 2008a). The “total institution” was the defining feature of the entire, elaborate system: all admissions were involuntary and once an individual had spent 5 years in an institution, it was virtually inevitable they would die there (Walsh 2004).
There were similar problems with high committal rates in other countries, including France, England and the United States of America (US Bureau of the Census 1975; Shorter 1997), but Ireland’s admission rate was especially high at its peak, and especially slow subsequently to decline (Kelly 2008b). This led to the establishment of several commissions of enquiry (Kelly 2008c) including the Commission on the Relief of the Sick and Destitute Poor including the Insane Poor (1927) which recommended the establishment of auxiliary mental hospitals in old workhouses, development of outpatient clinics and introduction of a voluntary admission status (O’Neill 2005).
Notwithstanding the advent of the Mental Treatment Act 1945, which introduced both voluntary admission and outpatient care, district mental hospitals remained large, over-crowded institutions which single-handedly dominated local economies: in 1951, the town of Ballinasloe had a population of 5,596 people, of whom 2,078 were patients in the asylum (Walsh 2006). Admission rates continued to increase well into the twentieth century: by 1961, one in every 70 Irish people above the age of 24 was resident in a psychiatric institution (Lyons 1985; Healy 1996).
Change came slowly, in response to governmental, professional and public concern: in October 1968, the Irish Times published an especially influential series of articles by Michael Viney highlighting the large numbers still in psychiatric institutions (Viney 1968). In 1950 Ireland had signed the European Convention on Human Rights and in 1973 Ireland joined the European Economic Community, both of which moved Ireland towards a “culture of human rights” by the 1990s (Bacik 2001).
In 1984 a new mental health policy aimed to end the dominance of Ireland’s psychiatric institutions (Department of Health 1984) and, in 2001, the government finally passed the Mental Health Act 2001, which introduced automatic, independent reviews of detention and a framework for improving quality of care (Kelly 2007). As the closure of psychiatric institutions proved both complex and slow (Kelly 2004), another policy was published in 2006, re-affirming the government’s commitment to community care and promising renewed vigour in dismantling the reminder of Ireland’s institutional psychiatric past (Expert Group on Mental Health Policy 2006). The coming decade will provide a clear demonstration of governmental commitment, or otherwise, to this policy (Kelly and Guruswamy 2006).
What would Goffman have made of these developments? Notwithstanding the rhetoric about de-institutionalization, Goffman would undoubtedly have wished to see for himself, and to assess personally the progress (if any) from the point of view of those who are committed to institutions, as well as those who work there. In this context, it is interesting that Goffman posed as an “assistant to the athletic director” (Goffman 1961, p. 7), and not a patient, when he researched his iconic Asylums at St Elizabeth’s Hospital, Washington DC. It is equally interesting that St Elizabeth’s actually had an athletic director in 1955: today, in times of deepening public sector austerity, there would be little prospect of employing such an individual, let alone an assistant to one, in any public psychiatric facility.
This, as Goffman was only too well aware, highlights the central, troubling paradox of the large psychiatric institutions of the nineteenth and twentieth centuries: while some were de-humanising “total institutions” (Penney et al. 2008), others offered real asylum, at least to some of their residents (Payne and Sacks 2009). Sometimes this simply meant asylum from a cold, rejecting society that was only too eager to deposit the mentally ill at the institution, and leave them there for decades. And, while the over-arching frameworks of compulsion were undoubtedly cruel, individual carers often were not, and some, including some psychiatrists, were even enlightened: Goffman acknowledges the “open- and fair-mindedness of psychiatrists” who facilitated his research at St Elizabeth’s (Goffman 1961, p. 9).
Goffman neatly captured this distinct research method with his recommendation that, in order to learn about a social group, one should “submit oneself in the company of the members to the daily round of petty contingencies to which they are subject” (Mays and Pope 1995, p. 182).
Patients do complain frequently about mental hospital treatment on [the] grounds [outlined by Goffman]. Perhaps we are apt to forget that some patients as well as doctors and nurses have read Goffman, or picked up some of his arguments at second hand (Jones 1978, p. 328).
Why do these total institutions continue to exist? Is there any other economical, ethical, or therapeutic alternative? What sort of people choose to become keepers? What are the long term consequences of being a keeper? (Furnham 1991, p. 667).
These are difficult questions which find their roots in the work of Goffman and remain unanswered some 50 years after he wrote. Moreover, whilst the numbers detained in psychiatric institutions are falling, most institutions are less “total” than they were, and most codes of legal protection are improving, there are, nonetheless, persistent concerns about certain practices in certain psychiatric institutions, especially in specific countries such as China (Munro 2006).
In addition, there is enduring concern about the best methods of caring for individuals with profound mental illness (e.g. catatonic schizophrenia) who may lack capacity to make decisions for themselves. This tiny, voiceless, vulnerable group is possibly the most stigmatised, neglected, misunderstood and forgotten minority in society. Their lack of capacity places their wellbeing in the hands of the State and this, in turn, demands strong safeguards for their dignity and human rights, especially in the context of institutions. The central contribution of Goffman’s Asylums is that it articulates clearly the darker sides of what can happen in all institutions, especially to vulnerable individuals such as these. For this insight and illustration, we owe Goffman an unending debt of gratitude.
Asylums is, however, a more complex text than this simple, though vitally important, conclusion might suggest. Asylums is, in the end, an admirably obstinate, thrillingly resolute text that defies simplification. In this respect, Asylums is not unlike the psychiatric institutions themselves: troubled, troubling, complicated and not readily amenable to simple understanding. On the fiftieth anniversary of Asylums, the best advice is still that offered by Merriman (2002, p. 817) almost a decade ago: “Revisit Erving Goffman”.