This is the essay I refer to in my "Self Help" posting. A bit academic in places but should be of interest to anyone who lives or works in a hospital or in Residential Care.
Discus Goffman’s concept of “Total Institution” and the implications of “Total Institution” for Social Work Practise.
Brian Barefield. CQSW Year 2 Dec. 1991
Goffman, ("Asylums" 1961 p17), perceived; "A basic social arrangement in modern society - (to be that) - the individual tends to sleep, play, and work in different places, with different co-participants, under different authorities, and without an overall rational plan.” The antithesis of this arrangement was the "total institution"; " - 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.” (ibid p11).
Here Goffman's work will be placed in its historical and societal contexts before discussion of the actors passage into the habitat of total institution leads to discussion of the concept of "total institution". Goffman's emphasis on psychiatric institutions will be duplicated here through reference to the writer's clients' experiences1. Discussion of the implications for social work within total institutions will lead into a broader examination of the implications of Goffman's work for the social worker, this examination based on current alternatives to total institution and with reference to the observations of Szasz, the anti psychiatry movement, and what Pearson (1975) terms the "misfit" sociologists. This discussion implies a political role for the worker which will be discussed at the conclusion of the essay.
Total institutions provide a logical solution to problems of deviance as perceived by the functionalist paradigm which is historically and currently the dominant ideology of most capitalist societies. The Interactionist school, which began with Mead and rose to prominence in the 1960's, provided alternative theories of deviance and in so doing produced the "labelling" and "stigma" theorists such as Goffman who emulated Mead in challenging the positivist definitions of Durkhiem and Parsons. The interactionist’s purport that deviance is a socially constructed phenomenon that needs separating from "delinquency" if it is to be understood.
Specific to the relationship of deviance to psychiatric illness Aubrey Lewis2 calls for a distinction to be drawn between the two on the grounds that; " - mental illness and deviance - differ in their referents, - mind and behaviour respectively - ."
Distinction also needs to be drawn within mental illness definitions for, as Szasz pointed out, (Busfield 1986 p81), psychiatry may have a place in the treatment of psychotic disorders but the neurotic and the "managed" psychotic patient are abused by psychiatry's systems. One abuse of such patients is admission into total institutions via a path which is now discussed.
Goffman claimed that the career of the mental patient falls into three phases, those of the prepatient; the inpatient; and the expatient. In discussion of the first and last of these he illustrated the power of total institutions to exert influence beyond their physical boundaries.
In the case of the prepatient this power manifests itself through the "betrayal funnel", a conspiracy of family, health professionals and other helping agencies to seduce him into the institution through a series of linked stages each of which " - tends to bring a sharp decrease in adult free status - ", ("Asylums" p131).
[An example of one component of the funnel was given to me by X. At his initial hospital interview his 15-minute interview preceded a 1-hour discussion between his wife, who had her own reasons for wanting him "away", and HIS psychiatrist. X, who had been encouraged to attend the "preliminary" interview by all of the agents involved with his case, did not return home from it].
Illustration here of Goffman's contention (p136) that; "The last step in the prepatient's career can involve his realization - justified or not - that he has been deserted by society and turned out of relationships by those closest to him.". He is also left with a clear perception of the power of the total institution, the all-encompassing nature of which will now be discussed.
Jones and Fowles (1984 Ch1) claim that the reader of "Asylums" should remain aware of four points. First: Goffman's main focus was on the inhabitants of the institutions rather than the institutions' physical components. Second: his research centred on the patient rather than on the staff. Third: whilst he identified five types of total institution Goffman did not claim to present a list of features for all cases but a set of features which are present in most cases, and: Finally: that Goffman did not purport to provide a guide for action.
Goffman described four major facets of total institution living which are categorised by Jones and Fowles, (ibid), as "Batch Living"; the "Institutional Perspective"; "Binary Management"; which creates the divisions between the "staff world" and the final facet; the "Inmate World". Discussion of these facets will now be made commencing with the concept of "batch living".
Batch living implies that "each phase of the member's daily activity is carried out in the immediate company of a large batch of others, all of whom are treated alike, and required to do the same things together."3. It is characterised by a bureaucratic management whose rules and regulations mean a tight schedule with little free time and no choice of living companions for the inmate.
[X, a Moslem, was refused recognition of his cultural or dietary needs. His protestations were attributed to his psychiatric problems, (looping), by staff who encouraged him to concentrate on the "positive" attributes of the institution. To adopt the institutional perspective which is now discussed].
Through his adoption of the institutional perspective the inmate is socialised into the belief that the institution is a beneficial and nice place to be. Staff: who sanction "removal activities" such as sports days, and "ceremonies" such as Christmas parties: combine with relatives: who through their reluctance to receive the patient home, or who cannot face their own feelings of failing the patient, repeatedly tell him how much good the institution is doing him: in practises which Goffman perceived to be well suited to a Durkheimian analysis, ( p102), and which hold the divided society together.
The division of staff from inmate, and the stereotypical imagery of each by the other that this facilitates, is characteristic of the "Binary Management" of total institutions. No matter how well the inmate is socialised into an institution's culture he will still encounter the social distance that exists between the two worlds. It is a distance which excludes him from decision taking and which keeps him ignorant of his own condition and fate. The ultimate achievement of his socialisation will be a movement between wards (Y related that status in the resident community is enhanced by the occupation of certain wards] but regardless of added status the inmate is still a puppet to the whims of the "staff world".)
This "staff world" is now explored.
Goffman highlighted a contradiction between what institutions say they do and what they actually do. Central to his observation was the fact that the staff who make policies are not the staff who implement them. It is lower echelon staff and not their managers who are the "tradition carriers" of the institution ( p107) as typified in a recent newspaper article 4 in which a Broadmoor hospital staff member of twenty years standing criticised a new, less militaristic uniform on the grounds that; "The old uniform was a symbol of authority.".
[Y perceived a dramatic change in personality when probationary staff changed from a yellow uniform to the blue one of a full staff member after 3 months].
It is such tradionalists who socialise new recruits into the role of the worker, a role which is more than just the "prescribed duties and reciprocal rights attached to a position.", (Goffman5).
Support for Goffman's [and Y's] observations of the detrimental effect on the inmate of the socialisation of the worker into role is implicit in Hudson's, (1982 p170), warning to hospital social workers not to become socialised into the institution's culture, that; " - being hospital based - carries the risk of losing some of the very qualities that make the social worker's contribution so valuable: awareness of things social, knowledge of ordinary life and resources in the community.".
Support for Goffman's "partial evidence" (Jones and Fowles p25) of these phenomenon is chronicled by Pearson, (ibid), and especially by Martin, (1984 pp.28/9), and Shepherd (1984 pp.85/91)6.
Goffman's assertion (p88) that some staff will suffer problems of conscience is typified in the previously mentioned newspaper article by a second officer who argues in favour of the new uniform that; "We are custodians of the mentally ill, not prison officers.". Evidence suggests however that this dilemma, which will be seen to be mirrored for the social worker, will not deter workers from affecting other's perception of the inmate through their subjective contributions to case conferences, to informal discussions about patients, and to patients' records.
They will use sanctioned violence against the inmates person and his will and they will employ the tactics of "looping", "tyranization" and "regimentation" to keep the inmate in his place and to preserve the social distance between inmates and themselves.
These tactics also play a crucial role in socialising the patient into the "Inmate World", the next facet of total institution to be discussed. Inmates are socialised into the inmate culture through a "mortification" process which comprises a series of systematic violations and degradations
[Y was strip searched and then forced to bathe while observed by three officers on her admittance to a "special" psychiatric provision]. Given names are replaced by staff or inmate attributed ones and "disculturation" is facilitated by "contaminative exposure", looping and a "privilege system" [going to the toilet unobserved was a "privilege" in Y's institution].
From within her world the inmate develops her "career line", establishes her place in the "underlife" hierarchy and develops her own "removal activities"
[Y would feign "intransigence" in order to receive an injection which "got my head out of there for three days" ].
The acquisition of the "institutional lingo" facilitates communication as the inmate proceeds through the four "secondary adjustments" which Goffman perceived to be developmental landmarks of her career. These adjustments, namely "withdrawal", "intransigence", "colonisation" and "conversion", further socialise the inmate into a way of being which is ultimately less acceptable to society than the "symptoms" of her original "illness" may have been; " - total institutions disrupt or defile precisely those actions that in civil society have the role of attesting to the actor and those in his presence that he has some command over his world.", ("Asylums" p47).
Support for Goffman's perception of the negative attributes of institutional care proliferate social work literature in guises such as "Institutional Neurosis"7, "Institutionalism"8, and "Social Breakdown Syndrome"9.
Such evidence would seem beg an end to institutional care, but, as Goffman (p124) observed, for some people, "entrance to the mental hospital can sometimes bring relief.". Shepherd (p10) relates that some inmates were identified by Mann and Cree to be "asylum seekers"; that is inmates who prefer the security of institutional life to the unpredictability of the outside world. These inmates accounted for 5% of psychiatric inmates in a sample taken in 1976. Additional support for the existence of total institution for some psychiatric patients is provided in Hudson's (p166) observation that; "some psychiatric patients need the surveillance, rest from stress and responsibilities, and intensive treatment that only an inpatient facility can provide".
After arguing that the major role of the social worker inside such institutions is to "contribute in helping to reduce the ill effects, and maximise the benefits of hospital care." Hudson provides insight into how this may be done, (pp.166/70). She also perceives a political role for the worker in effecting policy change (p170), and it is in this context that she issues the warning quoted earlier against the social worker becoming socialised into the institution and thus less effective in this role. A warning to the worker implied by Goffman's observations would be to take account of the consequences of the "deference" which the inmate will show to her position. ("Asylums" pp.107/8).
Here we reach the conclusion of discussion of the concept of "total institution" and the implications of that concept for social work practice within asylums.
Two areas of consequence emerge from the discussion, the first client orientated and the second worker orientated. Simply; the first requires the worker to adopt a political stance which argues for the patient’s rights and against stigmatisation from as early as is possible in the patient’s career. The second set of consequences beg social work to look to itself. In this second context social workers should remember that they too are members of an institution which " - captures something of the time and interest of its members and provides something of a world for them; (which) - has encompassing tendencies.", ("Asylums" p12). For this reason the following discussion of social works community role with the mentally ill, though alluding to casework practice, will concentrate on the less well defined roles which are implicated by the analysis of the concept of total institution and which have implications for social work practice during all three patient phases.
For some, "halfway house" therapeutic communities offered an alternative to total institution. Goffman however perceived the limitations, and the potentially damaging effects of the communities which were set up within total institutions (p139) by exponents of this philosophy such as Maxwell Jones, (1968). The therapeutic communities which were set up in the wider community were also perceived to embody a social control function in which "contaminative exposure" and "the piston effect" are instigated in the name of "therapy" with greater frequency than would occur in "total institutions", (Sharp 1975).
Other community-based social work with psychiatric patients has evolved as a consequence of consecutive mental health acts since the 1950's. Martin (Ch.1), and Busfield (Ch.10), both perceive this evolution to have been facilitated by the discovery of the psychotropic drugs and to be driven by financial expediency rather than by any altruistic reasoning. Changes in legislation led to an end to compulsory admission of patients in most instances. The new legislation also facilitated a mass evacuation of long-term inmates into the community. With the implementation of each of the new acts new roles were designated for the social worker culminating in 1983 with the advent of the "approved" social worker and the acquisition by the profession of the ultimate responsibility for sanctioning the compulsory admittance of non-delinquent psychiatric patients. This legislation threw the "approved" social worker in at the deep end of the social control or social welfare dilemma.
Busfield (p8) locates the beginnings of this dilemma in the 1960's when; the problem was "less any inherent defects and deficiencies of medical practice than the application of medical ideas and techniques to this particular sphere:". She claims (p10) that Szasz, Laing, and Scheff; " - offered alternative ways of thinking about psychiatry and mental illness in which mental illness is generally viewed as a form of social deviance and psychiatry as a form of social control.". While Martin (p28) saw the implications of Goffman's work at this time to be separate from the arguments of Szasz and Laing, Busfield does not and the link from medical to interactionist philosophy is clear in her contention (p87) that; "While Szasz points to the social control that psychiatry effects in the name of care and cure, his objection is not to the control of behaviour as such, but to the fact that the control is hidden and unacknowledged, and is exercised by others rather than the individual. If there is to be social control - - then its real nature should be visible." Pearson (p126) sums up the dilemma for social work thus; "Very loosely, it is possible to say that social work is faced with the problem of whether it is an agency which enlarges human freedom or restricts it, - ".
The dilemmas posed in implementing community care are not only ethical ones however. When Martin (Ch.2), chronicles the progress of community provision for the mentally ill from the 1950's to the 1980's he perceives the social work contribution during this time to have been marred by workers and administrators who directed their talents and their finances respectively towards the more attractive client groups. He cites evidence. At the beginning of the 1960's only 25% of social workers in this field were trained and that figure had risen to only 50% by 1972. This apathetic approach was mirrored by administrators who by 1970 had employed only half of the perceived optimum number of workers, never neared the recommended number of community facilities, and concentrated financial resources in other, more visible, areas. [For example Berkshire Social Services allocate only 4% of their annual budget to this client group despite the fact that 1 in 7 of people in its area are potential clients10). This apathy continued throughout the 1970's (Martin Ch.3) alongside a recurring passion for self-analysis that continually altered the focus of social work with the consequence that; " - there developed among psychiatrists and many of their colleagues an almost universal impression that the mentally ill receive scant attention from the reorganized services - (due) - to the emergence of entirely different and unanticipated priorities." (op.cit. p38). Of the advent of the approved social worker following the 1983 mental health act Martin (p64) hopes for a political role for this worker but warns, in the light of previous experience "of the overloaded social worker" that one should "guard against over optimism here".
Ann Davies and Lynne Muir (1984) examine the perceived community role of the approved social worker. In a section of the book subtitled "Issues relating to the delivery of service" they outline the practice issues relating to the development of community services. In the light of the experience of X which was discussed earlier it is pleasing to note that Muir (Ch.14) perceives the social worker to have a particular role in educating multi-disciplinary teams in the needs of ethnic minorities. Martin is critical of social works ability to fulfil its functions claiming that as a consequence of its ill-defined role social work has little benefited the client group in question, (p96).
Other commentators are critical of social works ability and motivation to deliver. They also criticise social work for its introspection; "Social work emphatically embraces human subjectivity and regards itself as a carrier of the humane tradition of compassion: it also sometimes behaves as if it were the only carrier of that tradition, and critics have taken social work to task for this." (Pearson p128). Busfield (pp.368/9) locates social workers amongst a group of "new mental health professionals" who are challenging the psychiatric stronghold but who she laments have already allowed themselves to be subordinated within a medical hierarchy. Hudson claims, (pp.172/4) that the profession leaves itself vulnerable to relegation to subordinate positions because of the reluctance of its workers to make detailed study of relevant research; "If we believe that it is part of our responsibility to seek change at any level, then it is a matter of professional ethics to keep up with research." (p173).
It can be seen that social work is perceived to be failing in its application of client targeted solutions to the implications of Goffman's observations. Discussion now follows of the political implications of those observations for social work practice.
From her critical analysis perspective Busfield sums up the argument of all the professions implicated here when she says; "The argument is that instead of directing all our resources and attention on to disturbed individuals, important though it is to ameliorate their situation, we need also to look beyond the individual to forms and levels of intervention which would make mental disorders less likely for the population as a whole, or for particular groups within it." (p369). One strategy is implied through Pinkners (1971/6 p174) assertion on behalf of the stigmatised client that "Concepts like "the caring society" and the "welfare state" are subjectively meaningless to those who have not achieved citizenship in an authentic form. It may be that effecting changes in the consciousness of ordinary people is now becoming more important than further changes in the statute book.". Martin, however, exposes the futility of expecting public opinion or parliamentary intervention to assist in the fight, (p27), " - there is no particular reason to suppose that mental health issues ever assumed a burning importance for the majority of citizens, any more than they did for the majority of their parliamentary representatives.". Martin also argues (Ch.12) that successful political lobbying is best achieved by unified social groups. He is particularly critical of the political. indifference of social workers which sees only 40% of them in their own professional association, a fact which renders them politically impotent not only at the macro level but also at the micro level in discussion for patient rights with medicines professional bodies. The need for a unified approach by workers against the positivist political and medical definitions of the problems of this client group, which are implicated by Goffman's examination of total institutions, is implicit in Busfield's (p370) contention that it is " - a political matter and requires debate and action in the political arena. It is political interests and political opposition to more radical social interventions that maintains the curative approach.".
Identification of this less obvious, but most important, political social work role brings to a conclusion discussion of Goffman's concept of "total institution" and a consideration of its implications for social work practice.
In the first part of the essay examination of Goffman's concept of "total institution" revealed an anti-social, potentially damaging environment which in addition to its damaging effects for the in-patient, also had the power to affect the quality of life of both the pre-patient, through a "betrayal funnel", and the ex-patient, through stigmatisation. It was clear that "Processes of secondary socialisation and remobilisation reinforce feelings of inferiority in so far as they have more time in which to take effect. Institutionalisation adds the dimension of intensity to that time.", (Pinker. ibid.).
As the implications of "total institutions" for social "casework" were discussed a perceived political role for the worker inside such institutions was highlighted. For, as Martin (p171) says; "The concerted action of a professional group, or at any rate of a significant and vocal fraction, may be a necessary precondition of change; and in the case of community mental health services, this commitment has been conspicuously lacking - ."
Discussion of the community role for the worker which is implicated as an alternative to "total institutions" also led to the identification of an informed political role for the social worker. Hudson (pp.173/4) argues; "Social work as a profession has a duty to add its contribution to the general store of knowledge that will sooner or later lead to more humane and more effective services." She argued that this contribution should stem from social work research obtained through a research function which should be added to the social work task.
Social work’s uninformed position was one aspect of criticism when reference was made to the views of anti-psychiatry, psychology, and "misfit" sociology. Examination revealed a universal cynicism of social works application to the implicated issues. A perceived impotence to serve the client effectively was seen to emanate from the apolitical culture of a fragmented profession.
In conclusion the major implication of the concept of "total institution" would appear to be a need for social work to agree its place in the social welfare, social control debate from which much of its practice emanates. If that agreement endorses the provision of community alternatives to "total institution" social work practice should encompass the role of politically motivated advocacy for its non assertive client group, not least because sociological evidence " - suggests that localities vary markedly in their capacity to meet their own inhabitant's social needs, and that the concept of the self supporting community is peculiarly fictional - " in some areas, (Martin p94).
References
1. The writer has worked with psychiatric patients during each of the three phases identified by Goffman in both the voluntary and the professional sector for the past sixteen years. Most recently this work took place in a therapeutic community which sought to rehabilitate psychiatric patients who had spent significant periods of time either in prison or in "special" psychiatric hospitals. X is a composite of the males who resided there and Y is a composite of the females.
2. Here quoted by Busfield (1986) pp.94/5.
3. Goffman, here quoted by Jones & Fowles (1984) pp.13/14.
4. "A Mail on Sunday reporter", "Broadmoor puts on the caring style." The Mail on Sunday, November 18th 1990. Page 29.
5. Goffman in "Where the action is" (1969) here quoted by Stephenson (1978)
6. Relates the research of Jack Tizzard who "operationalised" Goffman's ideas.
7. Russell Barton. Related by Jones & Fowles (1984) pp.71/77.
8. Attributed to Wing & Brown (1970) by Shepherd (1984) page 6.
9. Attributed to Gruenberg (1967) by Shepherd (1984) page 6.
10. Figures obtained during interview of the A.D.D. Mental Health, Reading Social Services, by the writer for his social policy project, C.Q.S.W. course, April 1990. The 1 in 7 ratio comes from figures supplied by MIND and relates to patients in all three patient phases across the country.
Bibliography
Busfield. J. "MANAGING MADNESS: Changing ideas and practice." Hutchinson & Co. London. 1986.
Davis. A. "Developing Comprehensive Local Services." Chapter 12 in Rolf Olsen. (1984)
Davis. A. "Working with other professions." Chapter 15 in Rolf Olsen. (1984).
Muir. L. "Working with volunteers and self help groups." Chapter 13 in Rolf Olsen. (1984).
Goffman E. "Asylums" Pelican
Books. England. 1961/8Hudson.B.L. "Social work with psychiatric patients." Macmillan Press. London. 1982.
Jones.M. "Beyond the therapeutic community." Yale. U.S.A. (1968).
Jones. K. & Fowles. A.J.
"Ideas on Institutions" Routledge & Kegan Paul. London. (1984).
Muir. L. "Teamwork" Chapter 14 in Rolf Olsen. (1984).
Pearson. G. "The Deviant Imagination: Social work and Social Change." Macmillan. London. 1975.
Pinkner. R. "Social Theory and Social Policy." Chapter 4. "Exchange and Stigma."
Heinmann. London. 1971/6.
Rolf Olsen.M.(Ed) "SOCIAL WORK AND MENTAL HEALTH a guide for the approved social worker." Tavistock. London. (1984).
Sharp. V. "Social control in the Therapeutic Community." Saxton House. 1975.
Shepherd. G. "Institutional care and rehabilitation." Longman. England. 1984.
Stephenson. G. "Social Behaviour in Organizations" Chapter 13 in :
Tajfel. H. & Fraser. C. (Eds).
"INTRODUCING SOCIAL PSYCHOLOGY" Penguin. England. 1978
Martin. F.M. "BETWEEN THE ACTS. Community mental health services 1959-1983." Nuffield Provincial Hospitals Trust. London. 1984.
Footnote.
The reader may be interested in the backgrounds of the major authors (Goffman excepted) who are quoted in this text.
Joan Busfield is a trained clinical psychologist who now lectures in sociology. Barbara Hudson is an ex psychiatric social worker who now lectures in applied social studies.
F.M Martin is a professor of social administration
Geoffrey Pearson is an ex social worker who now lectures on Human Socialisation.
