Erving Goffman

Erving Goffman (1922—1982) was a Canadian-born sociologist whose work on social interaction, institutions, and identity permanently changed how medicine thinks about the hospital, the patient, and the clinical encounter. Three books published between 1959 and 1963 established the conceptual architecture: The Presentation of Self in Everyday Life introduced the dramaturgical model of social life; Asylums demonstrated how psychiatric hospitals manufactured the very conditions they claimed to treat; and Stigma analyzed how societies mark and manage those who deviate from expected norms. Together these works supplied the vocabulary — total institution, impression management, spoiled identity, front stage and back stage — that medical sociology, nursing theory, and psychiatric reform still use to describe what happens when people enter institutional care.

The Dramaturgical Model

Goffman frames his book The Presentation of Self in Everyday Life (1959) as a dramaturgical analysis: individuals manage the impressions others form of them through performance, using theatrical principles.(Goffman, 1959)

The framework rested on a distinction between two kinds of communicative activity: the expressions an individual “gives” (deliberate verbal symbols) and those he “gives off” (the wide range of actions others treat as symptomatic, performed for reasons other than the information conveyed).(Goffman, 1959) The gap between these two channels — between what is intentionally communicated and what is inadvertently revealed — creates the fundamental asymmetry of social life: participants cannot fully verify each other’s claims and must rely on inferences drawn from conduct rather than direct access to facts.

Goffman argued that social encounters rest on a “working consensus” — an agreement not about what is actually true but about whose claims will be temporarily honored. Real agreement concerns the desirability of avoiding an open conflict of definitions rather than the accuracy of those definitions.(Goffman, 1959) In service occupations, this consensus takes a characteristic form: the specialist maintains an image of disinterested involvement while the client responds with deference to competence.(Goffman, 1959)

The medical relevance extends well beyond analogy. Goffman’s analysis of “front” and “back” regions — the spaces where performances are maintained versus the spaces where they are relaxed — maps directly onto the clinical world: the consultation room is a front stage, the nurses’ station a back stage, the ward round a performance sustained by the coordinated efforts of a medical team. Goffman himself used clinical examples throughout: nurses prefer operating-room work to ward duty because the anaesthetized patient cannot witness weaknesses in the team’s performance, allowing them to relax dramaturgical vigilance and focus on technical demands.(Goffman, 1959) Once a patient is under anaesthesia, a “ghost surgeon” can be brought in to perform tasks that others present will later claim to have performed — an extreme instance of backstage substitution that the conscious patient could never permit.(Goffman, 1959)

The professional’s claim that only the colleague group can judge whether occupational skills have been properly applied insulates the clinical performance from audience scrutiny entirely.(Goffman, 1959) Goffman treated hospitals and psychiatric wards as “social establishments” — places surrounded by fixed barriers to perception in which a particular kind of activity regularly takes place — that could be analyzed through the dramaturgical perspective.(Goffman, 1959) When a surgeon and nurse both turn from the operating table and the anaesthetized patient rolls off to his death, the consequences fall at the level of social structure: “the reputation of the doctor as doctor and as man, and of the hospital, may be weakened.”(Goffman, 1959)

The Presentation of Self in Everyday Life (1959)

Performances, Fronts, and the Sincerity Problem

In the first chapter of The Presentation of Self, Goffman described a continuum of performer attitudes, from those who are completely taken in by their own performance to those who are wholly detached from it.(Goffman, 1959) Medical education offered him a particularly clear illustration of movement along that spectrum: medical students typically begin with idealistic orientations, set them aside during the examination-focused first two years and the disease-classification years that follow, and reassert their original humanitarian ideals only after graduation.(Goffman, 1959)

Goffman found in shamanism a cross-cultural illustration of the same sincerity-cynicism blend. Field ethnographers consistently reported that shamans who knowingly add sleight-of-hand to their curing nonetheless believe in the powers of other shamans and consult them when they or their own children fall ill — what Goffman called “a pious fraud” in which awareness may not penetrate deeper than the foreconscious.(Goffman, 1959) The shaman example is not an ethnographic curiosity; it establishes that the performer’s sincerity about one dimension of a performance is compatible with deliberate manipulation of another.

A performance requires more than a willing performer: it requires a stage. Goffman distinguished between “setting” (the scenic parts of expressive equipment — furniture, décor, physical layout) and “personal front” (the items the audience associates with the performer’s person: insignia of rank, clothing, sex, age, posture, facial expressions, speech patterns).(Goffman, 1959) Appearance signals social status; manner signals the expected interaction role. In clinical life, both elements of the front are tightly managed. The white coat, the stethoscope, the consulting room with its framed diplomas are setting; the controlled cadence of speech, the studied gravity or deliberate warmth are personal front.

Goffman argued that performances tend to emphasize the officially accredited values of the social setting more fully than does the performer’s behavior as a whole. Drawing on Durkheim and Radcliffe-Brown, he treated such idealized performances as ceremonies — expressive reaffirmations of community values.(Goffman, 1959) The clinical consultation, on this reading, enacts not just a diagnostic exchange but a ritual renewal of the social contract between medicine and its public. The consultation should look like what medicine claims to be.

That idealizing pressure created a systematic gap between front and backstage. Professionals routinely conceal “dirty work” — the tedious, degrading, or morally ambiguous parts of the occupation — and support this concealment with what Goffman called a “rhetoric of training”: licensing bodies require practitioners to absorb a mystical range of preparation, in part to maintain a monopoly but also to sustain the impression that the licensed practitioner has been reconstituted by learning and stands apart from ordinary persons.(Goffman, 1959) Goffman’s example was pharmacy: practitioners felt the four-year university course “good for the profession” while admitting among themselves that a few months’ instruction covered the practical ground.

The idealization extended to the individual encounter. Doctors project an image of uniquely attentive care toward each patient, yet the routine character of the performance must be concealed. The patient “remembers everything” and cannot believe the doctor does not carry in the forefront of his mind the exact tablets prescribed at the previous visit; the doctor must therefore simulate a memory that clinical volume has not preserved.(Goffman, 1959) General practitioners referred patients to specialists for reasons that mixed collegial obligation and financial arrangement with technical judgment, but presented the referral to patients as purely on technical grounds.(Goffman, 1959)

The repertoire of medical performances was wider than the doctor-patient dyad. Goffman observed that nurses doing invisible observational tasks — monitoring a patient’s color and breathing while appearing to chat — faced a distinctive dramaturgical problem: “medical nursing” requires trained attention to signs that cannot be displayed, while “surgical nursing” involves visible interventions that naturally communicate competence.(Goffman, 1959) When a nurse checks breathing patterns, “he thinks she is just visiting. So, alas, does his family who may thereupon decide that these nurses aren’t very impressive.” The problem of “dramatic realization” — making genuine work visible enough to be credited as work — runs through professional life wherever important activity leaves no visible traces.

Goffman also analyzed how professional fronts are not invented but inherited from a pre-existing social vocabulary. The anesthesiology specialty had to argue, against existing institutional norms, that its practitioners warranted “the ceremonial and financial reward given to doctors” rather than the subordinate front nurses occupied, regardless of the technical complexity of what they actually did.(Goffman, 1959) Status, in this account, is a dramaturgical achievement that may or may not correspond to technical function.

Maintaining a professional front often requires what Goffman, following Kenneth Burke and Charles Cooley, called mystification: the deliberate use of social distance to generate awe in the audience. Authority has historically surrounded itself with “forms and artificial mystery,” Cooley observed, “whose object is to prevent familiar contact and so give the imagination a chance to idealize.”(Goffman, 1959) The physician who remains formal and bounded, who speaks sparingly and at careful intervals, performs this mystification as much as any feudal lord. Goffman did not dismiss it as manipulation; he treated it as the standard mechanism by which any status is communicated. A status is not a material possession; it is a pattern of appropriate conduct that must be enacted — Sartre’s waiter who plays at being a waiter, moving with a precision slightly too rapid, bowing with a gravity slightly too solemn, is playing his role faithfully.(Goffman, 1959)

Teams, Secrets, and the Medical Institution

A “performance team” is any set of individuals who co-operate in staging a single routine; team membership creates bonds of reciprocal dependence and a form of enforced familiarity.(Goffman, 1959) Medical teams co-operate in staging performances for interns: two staff internists split chart preparation to ensure a “good staff showing” at the intern’s expense.(Goffman, 1959)

The maintenance of team consensus required active work to suppress visible disagreement in front of subordinates.(Goffman, 1959) Army officers show consensus before enlisted men; nurses show consensus before patients; managers before workers.(Goffman, 1959) When the subordinates are gone, open criticism may occur freely — but in their presence, the performance of solidarity is as obligatory as any other element of the front.(Goffman, 1959) [GAP: Need evidence that teaching principals felt obliged to back their teachers before angry parents, as the cited card only mentions a study of the teaching profession without specifying that obligation.]

The information-management requirements of the medical team were equally elaborate. When a hospital wished to prevent cancer patients from inferring their diagnosis from their ward assignment, it scattered them throughout the building — paying a cost in staff travel time to maintain a definition of the situation in which patients could not learn what they had not been told.(Goffman, 1959) Medical professional etiquette, Goffman argued, formalized these arrangements: a consultant must never say anything in the patient’s presence that would “embarrass the impression of competence that the patient’s doctor is attempting to maintain,” a norm Everett Hughes characterized as the body of ritual that preserves “before the clients, the common front of the profession.”(Goffman, 1959)

Goffman gave the team a characterization that sharpened its clinical relevance: teams are essentially secret societies. The audience may know who constitutes the team, but what it does not know — and what the team works to conceal — is exactly how the members are cooperating to maintain a particular definition of the situation. “Since we all participate on teams,” Goffman wrote, “we must all carry within ourselves something of the sweet guilt of conspirators.”(Goffman, 1959)

Regions, Backstage, and Clinical Space

Chapter III systematized the front/back region distinction and populated it with hospital examples. The back region is defined not by physical location but by its functional relation to a given performance: it is where the impression fostered by the performance is “knowingly contradicted as a matter of course.”(Goffman, 1959) Goffman extended this to the spatial organization of clinical institutions. Doctors’ increasing dependence on hospital settings meant that fewer could treat the workplace as a space they could “lock up at night” — the elaborate scientific stage essential to professional front was now provided by institutions rather than individual practitioners.(Goffman, 1959)

Service trades ask the customer to leave their car, watch, or radio so that the tradesman can work in private, thereby concealing mistakes, the number of attempts, and facts that would allow the customer to judge the reasonableness of the fee.(Goffman, 1959) Likewise, undertakers must keep the bereaved out of the workroom where corpses are drained, stuffed, and painted, to give the bereaved the illusion that the deceased is in a deep and tranquil sleep.(Goffman, 1959)

The transition between back and front regions is not merely spatial but behavioral. George Orwell’s account of restaurant work gave Goffman one of his most vivid illustrations: a waiter who seconds before was screaming in the kitchen in fiery Italian rage walks through the dining-room door and his shoulders alter, the dirt and hurry drop off instantly, and he glides across the carpet “with a solemn priest-like air.”(Goffman, 1959) The backstage does not simply permit relaxation — it supports a whole alternative behavioral register. Goffman catalogued the standard backstage language of Western society: reciprocal first-naming, profanity, open sexual remarks, elaborate griping, rough informal dress, mumbling, belching — all the conduct proscribed in front regions.(Goffman, 1959) In clinical life, the nurses’ station, the coffee room, and the corridor outside the patient’s door are sites where this register is active.

Psychiatric hospitals exhibited the front/back dynamic with particular clarity. Mental hospital staff managed visitors by restricting their access to specially furnished visiting rooms with well-dressed, well-behaved patients, keeping them away from chronic wards where institutional conditions would contradict the therapeutic impression.(Goffman, 1959) On the wards themselves, attendants performed “make-work” — appearing industrious when supervisors were present and reserving genuine relaxation for unobserved periods — while also learning on their first day not to be “caught” striking a patient.(Goffman, 1959)

Audience segregation was a further spatial strategy. When incompatible impressions must be maintained for different audiences, the physical separation of those audiences does the work that no single performance could accomplish alone. Goffman noted that the use of two examining rooms was “increasingly popular among American dentists and doctors,” allowing a practitioner to dart from one to the other and sustain different impressions for patients who never encounter each other.(Goffman, 1959)

Discrepant Roles and Out-of-Character Communication

Chapters IV and V examined the roles that complicate the neat performer-audience distinction. Performance management requires systematic information control. Goffman distinguished several categories of secrets that teams protect: “dark” secrets (facts incompatible with the self-image the team maintains), “strategic” secrets (intentions and capacities concealed to prevent audiences from adapting to forthcoming actions), inside secrets (marks of group membership), entrusted secrets (held on behalf of individuals), and free secrets (known to the audience but not supposed to be acknowledged).(Goffman, 1959)

Goffman noted that impersonating a person of sacred status — a doctor or a priest — is treated as an “inexcusable crime against communication,” while impersonating someone of low or profane status draws far less censure.(Goffman, 1959)

Service specialists — lawyers, accountants, doctors — learn backstage secrets without sharing the risk or guilt of the performance they have observed; professional ethics respond to this asymmetry by obliging the specialist to discretion.(Goffman, 1959) Psychotherapists, who “vicariously participate so widely in the domestic warfare of our times,” are his clearest example: they are pledged to silence about what they have learned, except to their supervisors.(Goffman, 1959) Goffman noted the class dimension of clinical disclosure: “middle-class doctors on charity duty who must treat shameful diseases in shameful surroundings” make it impossible for lower-class patients “to protect himself from the intimate insight of his superordinates.”(Goffman, 1959)

The renegade colleague offered Goffman a particularly rich case. A doctor who published accounts of his colleagues’ fee-splitting, patient-stealing, and unnecessary operations supplied what Kenneth Burke called the “rhetoric of medicine”: the diagnostic equipment functions not only as apparatus but as imagery, and “if a man has been treated to a fulsome series of tappings, scrutinizings, and listenings, with the aid of various scopes, meters, and gauges, he may feel content to have participated as a patient in such histrionic action, though absolutely no material thing has been done for him.”(Goffman, 1959) Burke’s observation that medical apparatus “appeals as imagery” anticipated several decades of sociological analysis of medicalization.

Chapter IV also introduced the non-person role: a category of those present who are treated as if they were not there.(Goffman, 1959) The very young, the very old, and the sick are the standard examples — persons whose presence does not require the full performance that a full social actor would warrant.(Goffman, 1959) The go-between role — occupied by mediators, factory foremen, and others who learn the secrets of both sides while presenting an appearance of exclusive loyalty to each — has a clinical analogue in the physician who mediates between a patient’s family and the medical team, managing incompatible definitions of what is happening.(Goffman, 1959)

On experimental metabolic wards where the prognosis was hopeless and the work demanded close patient observation, the usual sharp line between doctor and patient was blunted: “Doctors respectfully consulted with their patients at length about symptoms, and patients came to think of themselves in part as research associates.”(Goffman, 1959)

Backstage derogation of absent audiences was a regular feature of service settings.(Goffman, 1959) In the Shetland Hotel kitchen that provided Goffman with his first ethnographic material, guests were referred to by belittling code names, their speech and mannerisms imitated, their foibles analyzed with “scholarly and clinical care.”(Goffman, 1959) Medical teams followed the same pattern: in the absence of a patient, doctors might refer to him as “the cardiac” or “the strep,” assimilating the person to an abstract category.(Goffman, 1959)

The integrity of clinical teams was fragile in ways the backstage-derogation pattern made visible. A nurse who allowed her “sexual needs to be met in an overt way by the patient” altered the patients’ attitude toward the entire nursing group, making “the nurses’ therapeutic role a less effective one.”(Goffman, 1959) In group therapy, patients might attempt to catch the doctor’s eye when another patient said something that sounded “crazy,” seeking to establish a secret bilateral understanding that would fracture the group’s working consensus; since the dangerous byplay was characteristically non-verbal, “the doctor must especially control his own non-verbal activity.”(Goffman, 1959) Bruno Bettelheim’s Orthogenic School required “staff coherency” for an analogous reason: children in the therapeutic community would attempt to play one staff member against another, re-enacting an oedipal strategy, and “children who have used this technique with particular success are especially handicapped in their ability to form unambivalent relationships later on.”(Goffman, 1959) Stanton and Schwartz provided what Goffman considered the most detailed published account of the consequences when the line between two hospital teams is crossed.(Goffman, 1959)

Milieu therapy represented a deliberate and more sustained attempt to dissolve the usual clinical working consensus: Maxwell Jones’s unit “avoided the white coat, prominent stethoscope, and aggressive percussion hammer as extensions of our body image” in an attempt to reduce the status distance between doctors and nursing staff.(Goffman, 1959)

Total Institutions

Goffman defined a total institution 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.”[goffman-asylums-1961-ch01-001]

The central feature of total institutions is the breakdown of the barriers ordinarily separating 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] In a total institution, all aspects of life are instead conducted in the same place, under the same single authority, in the company of the same batch of others, with all activities tightly scheduled and the sequence imposed from above [goffman-asylums-1961-ch01-004].

[GAP: Explanation of why Asylums was devastating to institutional psychiatry] The process began at admission with what he called the “mortification of self” — a systematic stripping of the self through admission procedures.[goffman-asylums-1961-ch01-005] Admission procedures might be called trimming or programming because the new arrival allows himself to be shaped and coded into an object for the administrative machinery.[goffman-asylums-1961-ch01-006] [GAP: Discussion of secondary adjustments as unauthorized activities and staff interpretation of them as pathology]

Goffman identified four principal lines along which inmates adapt to total institution life. In “situational withdrawal,” the inmate pulls attention and interest from everything except immediately surrounding events, a pattern clinical staff typically classify as psychotic withdrawal. In “the intransigent line,” the inmate intentionally challenges the institution, which staff read as combativeness. “Colonization” involves maximizing available satisfactions within the institution and treating it as a comfortable home base — read by staff as evidence of improvement, but representing an accommodation to confinement rather than preparation for life outside. “Conversion” is the wholesale adoption of the staff’s view of the ideal inmate, performing the expected recovery. A fifth response, “playing it cool,” combines elements of the others as circumstances require.[goffman-asylums-1961-ch01-009] The typology demonstrated that the same behaviors carried entirely different meanings depending on whether one read them through a clinical lens or a sociological one.

The “moral career” of the mental patient, as Goffman traced it, followed a trajectory in which a person’s pre-patient identity was progressively reconstructed to fit the institutional narrative of illness.[goffman-asylums-1961-ch02-001] Each phase of the career involved betrayals by those closest to the patient — family members who arranged commitment, doctors who ratified the label, staff who enforced compliance. The patient’s sense of having been betrayed was, in Goffman’s analysis, not paranoia but an accurate reading of what had happened.[goffman-asylums-1961-ch02-002]

The medical model, as applied to physical illness, involves a service relationship in which the patient seeks help, the practitioner diagnoses and prescribes, and treatment is oriented toward the patient’s own welfare — what Goffman called the “tinkering trades” model, drawing an analogy to mechanics and plumbers.[goffman-asylums-1961-ch04-001] Mental hospitals, he argued, institutionalize “a kind of grotesque of the service relationship”: the person served is often not the one who sought help, the patient’s interests are subordinated to those of family, community, or employer, and the treatment may itself constitute the harm.[goffman-asylums-1961-ch04-002]

Stigma

Stigma: Notes on the Management of Spoiled Identity (1963) extended the analysis from institutions to the social world at large. Goffman traced the term to the Greeks, who used it for bodily marks cut or burnt into the flesh to advertise that the bearer was a slave, criminal, or traitor — a blemished person to be avoided in public places. Over time the term shifted from the physical mark to the disgrace itself.(Goffman, Erving, 1963)

Goffman identified three types of stigma: abominations of the body (physical deformities), blemishes of individual character (mental disorder, addiction, imprisonment), and tribal stigma (race, nation, and religion) – all of which share the property of reducing the bearer “from a whole and usual person to a tainted, discounted one.”(Goffman, Erving, 1963)(Goffman, Erving, 1963)

What made the stigma analysis particularly acute was Goffman’s observation that the stigmatized person typically holds the same identity norms as the wider society. He regards himself as a normal person deserving equal treatment — yet perceives, usually correctly, that others do not genuinely accept him on equal grounds. The standards he has absorbed from the surrounding culture equip him to be “intimately alive to what others see as his failing,” and those standards may cause him, at moments, to agree that he falls short of what he “really ought to be.” Shame, Goffman argued, becomes a central psychological possibility for the stigmatized — not as neurotic sensitivity but as a structurally produced response to a structurally produced situation.(Goffman, Erving, 1963)

The concept of “spoiled identity” proved especially productive for medical sociology. Chronic illness, disability, and psychiatric diagnosis all create situations in which a person’s social identity is redefined by a condition. Goffman’s framework gave researchers a vocabulary for describing how patients manage medical information, negotiate the boundary between disclosure and concealment, and resist the reduction of their identity to a diagnostic label. Kleinman’s later work on illness narratives drew explicitly on this vocabulary, extending it into clinical anthropology.(Goffman, Erving, 1963)

Influence on Medical Thought

Scull places Goffman alongside Thomas Szasz as the two figures whose 1961 publications most powerfully challenged institutional psychiatry. Where Goffman demonstrated that psychiatric hospitals manufactured and perpetuated mental illness through stigmatization and dependency rather than curing it, Szasz denied that mental illness was a real medical entity at all.(Andrew Scull, 2015) The distinction matters: Goffman was a sociologist analyzing institutional processes, not a philosophical critic of the disease concept. He did not deny the reality of distress; he questioned whether the institution designed to address it was making things worse.

Erving Goffman’s 1961 Asylums introduced the concept of “total institutions” and argued that psychiatric hospitals manufactured and perpetuated mental illness through stigmatization and dependency rather than curing it, while Thomas Szasz’s The Myth of Mental Illness the same year denied mental illness was a real medical entity at all.(Andrew Scull, 2015)

Beyond psychiatry, Goffman’s concepts penetrated nursing theory, medical education, and the sociology of the clinical encounter. The dramaturgical model gave researchers a framework for studying how clinicians present competence, how medical teams coordinate performances, and how patients learn to perform the role expected of them. His analysis of institutional stripping anticipated later work on the dehumanizing effects of hospitalization that nursing reformers would cite in campaigns for patient-centered care.

See Also

• total-institution
• medicalization
• illness-disease-distinction
• anti-psychiatry
• medical-anthropology
• stigma
• thomas-szasz
• franco-basaglia

Sources

All claims cite evidence cards from:

• Goffman, E. (1959). The Presentation of Self in Everyday Life. New York: Anchor Books. [Source ID: goffman-presentationself-1959]
• Goffman, E. (1961). Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Anchor Books. [Source ID: goffman-asylums-1961]
• Goffman, E. (1963). Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice-Hall. [Source ID: goffman-stigma-1963]
• Scull, A. (2015). Madness in Civilization. Princeton: Princeton University Press. [Source ID: scull-madnesscivilization-2015]
• Kleinman, A. (1988). The Illness Narratives. New York: Basic Books. [Source ID: kleinman-illness-narratives-1988]

Editorial Notes

Gaps the encyclopaedia compiler flagged for future evidence work, collected from inline markers in the body and frontmatter.

The Dramaturgical Model

• [GAP: specialist source needed — Burns’s Erving Goffman (1992) and Lemert/Branaman’s Goffman Reader (1997) not in Library; biographical detail awaits acquisition]

Influence on Medical Thought