Unread Asylums?

Jeremy Holmes, in a recent book review in this journal, wrote that ‘It is now nearly 50 years since the action–research sociologist Erving Goffman turned his insider-view daily notes into a devastating critique of the realities of mental hospital life. Back then, sociologists and psychotherapists were natural allies rallying to the flag of community psychiatry, united in opposition to the hegemonic medical model’. Now, however, according to Holmes ‘all has changed. Neuropsychiatry rules; Asylums (1961) lies unread; the few remaining sociologists are in search of new targets for radical assault’. ^{Reference Holmes1}

Whether or not neuropsychiatry rules is one thing, but Asylums ^{Reference Goffman2} has been in print continuously since 1961 – hardly the marker of a unread text. Whether it is read by psychiatrists or not is another question. As a psychiatric trainee, I encountered it mainly via those bald summaries learnt off for exams, in a potted version that went something like this: Goffman went undercover in a large state asylum and in so doing invented institutionalisation and such concepts as ‘the funnel of betrayal’, ‘total institutions’ and the like. It was another work lumped in the general category of antipsychiatry, linking Goffman with Laing and Szasz and Foucault and sundry others – a useful reference for the old MRCPsych part II essay paper, and even a signpost on the progression from wicked old asylum psychiatry to the sunlit uplands of biopsychosocial, community-based mental health practice.

Reading Asylums 50 years on

Reading Asylums today, with the anniversary alluded to by Holmes even closer, is a very different experience from what might be expected from this brief caricature. The condensed version is not entirely false. Famously, Goffman went undercover as an assitant to the physical education instructor at St Elizabeth's Hospital, Washington DC, a study which it is doubtful would get through an ethics committee today. In the introduction to the book, Goffman thanks in particular the psychiatrists who were clinically in charge of St Elizabeth's, for their encouragement and facilitation of his work. His insights into institutionalisation and the ‘underlife’ of any total institution were sharp, and he leaves little doubt that little that could be described as therapeutic was found in the asylum. However, although he refers occasionally to his field notes, his sources are as much literary as experiential, with lengthy illustrations from Behan, Orwell, Melville, Thomas Merton and T. E. Lawrence. Furthermore, the concepts of institutionalisation and the total institution had a lengthy sociological history pre-dating Goffman.

Asylums is, above all, a text that humanises a dehumanised group of people. The book is divided into four parts, each of which reads equally well (unlike some others lumped into the ‘antipsychiatry’ camp, Goffman always writes lucidly and entertainingly) in its own right. The first, ‘On the characteristics of total institutions’, is the most famous and most cited. Along with the second essay, ‘The moral career of the mental patient’, it is where many of the phrases associated with Goffman and asylums are derived from. Goffman analyses at length ‘total institutions’ – those social settings in which every aspect of the inmates is dictated and controlled including, as well as the asylum, prisons, boarding schools, ships and monasteries.

Divided into sections on the pre-patient and in-patient phases, ‘The moral career of the mental patient’, begins with a consideration of the ‘relatively small group of prepatients [who] come into the mental hospital willingly… this view of oneself would seem to be one of the most pervasively threatening things that can happen to the self in our society’. This humanistic response to distress underlies the essay, and indeed the book as a whole. For Goffman, the majority of pre-patients are not willing, and he describes the process whereby complainants – they ‘who retrospectively appear to have started the person on his way to the hospital’ – and mediators – ‘the sequence of agents and agencies to which the prepatient is referred and through which he is relayed and processed on his way to the hospital’ force the individual into a moral career. This process is a continuing series of betrayals, as the individual is promised that successive deprivations of liberty and autonomy are ‘for their own good’.

Reading this chapter today, one hopes that truly voluntary admission does indeed occur in more than a minority of cases. For Goffman, admission is necessarily coercive, necessarily not only a deprivation of liberty but a humiliation. Elsewhere in the book, his irony casts doubt on almost all the supposed palliations of the harshness of the asylum regime. It is hard not to smile at his descriptions of asylum theatricals and publications – and then to pause and wonder if our own practice may not at times betray a similar tin ear for the real needs and desires of our patients.

Strangely, for a work whose reputation lies on Goffman's covert fieldwork, there can be an abstract quality to his assertions and observations. Occasionally he quotes from case notes and describes his own experiences, but in general there is a somewhat detached, even dogmatic tone to his writing.

Certainly the reception of Asylums in this journal has been to locate it within the antipsychiatric spectrum, diametrically opposed to the medical model. Siegler & Osmond placed Goffman firmly in the camp of the ‘conspiratorial model’ of mental illness as a conspiracy of social control. ^{Reference Siegler and Osmond3} Wing praised Goffman's literary skill and ability to describe the role-playing of many arenas of public interaction, but also damned with the faint praise that ‘Goffman's genius is anecdotal, and what he contributes, apart from a colossal erudition and an apparently inexhaustible supply of relevant examples, is a primitive classification of types of social role and of the social mechanisms whereby roles need to be supported’. ^{Reference Wing4}

Although, in contrast to Laing (whose Self and Others Wing was ostensibly reviewing), Goffman's ‘observations are so rich and his imagination so fertile that his books could supply social scientists with hypotheses for another generation to come’ that perhaps it takes the sting off Wing's use of the word ‘anecdotal’; there is a sense in his review that Goffman would be a fascinating dinner-party companion and little else.

Goffman certainly sees mental illness as socially constructed – writing, ‘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 clamour for new ones; and these true clients of the mental hospital would demand an institution to satisfy their needs’. However, from the perspective of a reader 50 years on, the age of the supposed triumph of neuropsychiatry, medications feature little, unsurprisingly maybe since they had only been recently introduced. Physical treatments in general are hardly discussed at all. Electroconvulsive therapy is briefly mentioned as being used as a threat. In Asylums at any rate, Goffman is not critiquing some neurochemical paradigm of psychopathology but the overall relationship structure within the asylum.

Even though the final chapter, ‘Notes on the tinkering trades,’ is explictly presented as a critique of the medical model, what Goffman has in mind is not the medical model as it is often critiqued today – a reductionist, primarily biological formulation focused on illness – but a model based on expertise and of unrelievedly unequal power relations, and whether the prescription is for chlorpromazine, psychotherapy or some social intervention, and whether the formulation of a case is reductionist or holistic, the structure of these roles is the same.

Asylums and false dichotomies

Are ‘community psychiatry’ and ‘the dominant medical model’ really the opposed forces implied by Holmes? Socially or psychologically inclinced psychiatrists should not read Asylums with any more equanimity than more biological ones. And whereas the massive institutions and the grosser abuses seem to be things of the past, this relationship structure is eerily familiar to anyone who has any experience of in-patient psychiatry. Goffman is a mordant observationalist, a phenomenologist even, rather than a polemicist or prophet. And his most mordant observations are on the dehumanising effect of not only institutionalisation, but any social system that reduces some individuals to a role.

Asylums is a much richer and more stimulating text than bald summaries, or its recruitment on either side of a purported war between neurohawks ^{Reference Blewett5} and neurophobes, ^{Reference Bullmore, Fletcher and Jones6} might suggest. There will be a moral career for an individual with mental health problems whether a long-term resident in the most brooding asylum or in the most demedicalised, home-delivered community-based service, and we forget individual experience at our peril. Re-reading Goffman today should not be an exercise in self-congratulation on how far we – or some subset of ‘we’ – have come. It remains a text that all involved in the management of mental illness, whatever point of some imagined biological–social continuum they are on, can read with interest and profit.