Total Institution

Summary

A total institution, as defined by the sociologist Erving Goffman in Asylums (1961), is a place of residence and work where large numbers 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.[goffman-asylums-1961-ch01-001] Goffman identified five types — homes for those deemed incapable and harmless (orphanages, homes for the elderly), facilities for those deemed incapable and dangerous (mental hospitals, tuberculosis sanitaria), prisons, worklike establishments (military barracks, boarding schools), and religious retreats (monasteries, convents).[goffman-asylums-1961-ch01-002] The concept emerged from Goffman’s fieldwork at St. Elizabeths Hospital in Washington, D.C. during 1955-1956, and became one of the most influential analytical frameworks in twentieth-century sociology and psychiatric reform.

The Concept

Breakdown of Social Barriers

The central feature of total institutions is the collapse of the barriers that ordinarily separate the three spheres of modern life — sleep, play, and work — which are normally conducted in different places, with different co-participants, under different authorities, and without an overall rational plan.[goffman-asylums-1961-ch01-003] Goffman treated all five types as a single analytical category, calling them “forcing houses for changing persons” and “natural experiments on what can be done to the self.”[goffman-asylums-1961-ch01-004]

Mortification of Self

Upon entry, new inmates undergo what Goffman calls mortification of the self — a systematic, though often unintentional, process of self-stripping through admission procedures that involve abasement, degradation, and humiliation.[goffman-asylums-1961-ch01-005] These procedures include photographing, fingerprinting, numbering, undressing, bathing, disinfecting, haircutting, issuing institutional clothing, and instructing inmates on rules — a process Goffman termed programming, by which the new arrival is shaped and coded into an object that can be fed into the administrative machinery.[goffman-asylums-1961-ch01-006]

The Staff-Inmate Divide

Total institutions are characterized by a fundamental split between a large managed group (inmates) and a small supervisory staff.[goffman-asylums-1961-ch01-007] Inmates tend to feel inferior and powerless while staff tend to feel superior and righteous; social mobility between the two groups is grossly restricted, and social distance is typically formal and great.

Adaptation and Resistance

Inmates develop characteristic modes of adaptation that Goffman documented as secondary adjustments — practices that do not directly challenge staff but allow inmates to obtain satisfactions or avoid deprivations in unauthorized ways.[goffman-asylums-1961-ch01-009] After prolonged confinement, inmates may experience what Goffman calls disculturation — an untraining that renders the person temporarily incapable of managing features of daily life on the outside.[goffman-asylums-1961-ch01-010]

The Moral Career of the Mental Patient

Goffman introduced the concept of the moral career to describe how the social fate of individuals entering mental hospitals is shaped by contingencies — who gets committed depends less on the severity of symptoms than on the patient’s social circumstances, the tolerance of those around them, and the availability of institutional facilities.[goffman-asylums-1961-ch02-001] He documented what he called the betrayal funnel, in which the pre-patient is guided into the institution through the actions of others — family members, physicians, police — who present themselves as acting in the patient’s interest while in fact facilitating confinement.[goffman-asylums-1961-ch02-002]

The psychiatric case record, Goffman argued, does not so much describe the patient as construct a past consistent with the current diagnosis, retroactively rewriting the patient’s biography to justify institutional status.[goffman-asylums-1961-ch02-004]

Critique of the Medical Model

Goffman’s fourth essay directly challenged the application of the medical model to mental hospitalization, arguing that psychiatry attempts to fit mental patients into a service model borrowed from general medicine — a model designed for a relationship between a voluntary patient and a professional — but this framework does not describe what actually happens in institutional psychiatry.[goffman-asylums-1961-ch04-001] He observed that in mental hospitals, the patient’s interests and the institution’s interests are routinely conflated, with psychiatrists treating involuntary confinement as therapy, stripped autonomy as treatment, and resistance as further evidence of pathology.[goffman-asylums-1961-ch04-002]

Medical Control in Institutional Contexts

Conrad and Schneider extend Goffman’s analysis by tracing the legal and therapeutic machinery that authorized medical control within institutional settings. The parens patriae doctrine — originating in English common law as the king’s duty to care for those unable to care for themselves — provided the legal foundation for the therapeutic state’s expansive control over deviant behavior, giving the state a parental and therapeutic role toward those deemed incapable of self-governance.(Peter Conrad and Joseph W. Schneider, 1980) Nicholas Kittrie identified the resulting “therapeutic state” as a framework in which crime became a medical or scientific problem solved by neutral medical technology, making the major confrontation between state power and individual rights “less visible” — the fact that crime reflects a conflict between those who make laws and those who violate them becoming further obscured by an overriding concern for the “health” and “cure” of law violators.(Peter Conrad and Joseph W. Schneider, 1980)

The therapeutic ideal within total institutions carried a danger Conrad and Schneider describe as “therapeutic tyranny”: the replacement of the diversity of political, social, moral, and religious values with a monolithic health standard, exemplified historically by involuntary sterilizations, lobotomies, and Nazi Germany’s use of therapeutic language for political persecution.(Peter Conrad and Joseph W. Schneider, 1980) Physicians in total institutions occupy one of two roles: in settings such as schools for the intellectually disabled or mental hospitals, they are usually the administrative authority; in prisons and military facilities, they are employees of the administration — a structural position that places medical professionals between institutional power and the patient’s interests.(Peter Conrad and Joseph W. Schneider, 1980)

Behavior modification programs represented a significant extension of medicalized control into carceral settings. Although behaviorism explicitly denied the medical model — behavior was caused by environmental stimuli, not psychological or physiological problems — Skinnerian operant conditioning was integrated into the therapeutic framework and became part of what Conrad and Schneider call the “biomedical armamentarium,” treating socially unacceptable behavior much as a physician treats the symptoms of a disease he cannot cure.(Peter Conrad and Joseph W. Schneider, 1980) The START (Special Treatment and Rehabilitation Training) program, operated by the U.S. Bureau of Prisons, used solitary confinement, sensory deprivation, and aversive conditioning on federal prisoners under the guise of operant conditioning; it was ruled unconstitutional in 1974 when the Supreme Court found its selection procedure violated due process.(Peter Conrad and Joseph W. Schneider, 1980)

Influence on Psychiatric Reform

Goffman’s analysis contributed to the deinstitutionalization movement that gathered momentum in the 1960s and 1970s. Andrew Scull notes that the sociological critique of asylums — particularly Goffman’s demonstration that institutional behavior attributed to mental illness was often produced by the institution itself — provided intellectual ammunition for those arguing that community care was both more humane and more effective.(Andrew Scull, 2015) Community care arguments drew directly on these demonstrations: if the behaviors used to justify confinement were artifacts of confinement itself, then the institutional case collapsed from the inside. (Andrew Scull, 2015) The total institution concept remains analytically influential wherever questions arise about the effects of confinement on identity, the relationship between institutional power and medical authority, and the social construction of deviance.

Goffman’s was not the only major critique of institutional psychiatry published in 1961. Thomas Szasz’s The Myth of Mental Illness, issued the same year, denied that mental illness was a real medical entity at all — reframing psychiatric diagnosis as a metaphorical extension of disease language into the domain of social deviance.(Andrew Scull, 2015) Where Goffman analyzed the institutional machinery that processed patients, Szasz questioned the conceptual legitimacy of the category itself. The two attacks operated at different levels: Goffman was a sociologist documenting how institutions worked; Szasz was a psychiatrist challenging whether the entity the institution claimed to treat actually existed.

Historical Precursors: The Question of Confinement

Goffman’s analysis presupposed a world of large custodial institutions, but the history of confining the mad is more complicated than the institutional world of the 1950s might suggest. Michel Foucault’s Madness and Civilization (1961), published the same year as Asylums, proposed a “Great Confinement” beginning in the seventeenth century, in which the mad were swept into institutions alongside criminals, the poor, and the idle. Scull argues directly against this thesis: in most European cities, only tiny numbers of the mad were institutionally confined, with the vast majority remaining with their families.(Andrew Scull, 2015) In Montpellier, a city of some 30,000 people, barely twenty mad folk occupied twenty-five cells on the eve of the French Revolution. The large-scale institutional confinement that Goffman analyzed was primarily a nineteenth- and twentieth-century phenomenon, not the centuries-old pattern Foucault described.

See Also

• medicalization — the broader process by which social deviance becomes medical diagnosis
• medical-authority — the professional power Goffman’s critique challenged
• erving-goffman — the author’s person page
• thomas-szasz — parallel 1961 critique of psychiatric diagnosis
• anti-psychiatry — the broader intellectual movement

Sources

• Goffman, Erving. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Anchor Books, 1961. (source_id: goffman-asylums-1961)
• Scull, Andrew. Madness in Civilization. Princeton University Press, 2015. (source_id: scull-madnesscivilization-2015)
• Conrad, P., & Schneider, J. W. (1980). Deviance and Medicalization: From Badness to Sickness. St. Louis: Mosby. (source_id: conrad-schneider-deviancemedicalization-1980)