“NOTICE: this is the author’s version of a work that was accepted for publication in Nurse Education Today Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in Nurse Education Today 33 (2) 2012 Big Ideas Erving Goffman and the 'Total Institution' The four essays in Erving Goffman's work Asylums: Essays on the Social Situation of Mental Patients and Other Inmates were published in 1961, and anyone who has both read the book and seen the film One flew over the cuckoo's nest will not fail to make the connections between the two. The vivid depiction of institutional life in the film may be considered a relic of history, and Goffman's account of life in a 'mental hospital' a bygone era. Asylums may have been demolished and the care of vulnerable adults transferred to community settings. However, we may wish to reflect upon the degree to which the social processes of total institutions also lie in ruins, to be replaced by respect, dignity, autonomy and beneficence. Of course, the answer has to be that total institutions in health care are no more: we consider that we have banished paternalism and 'institutionalising' practices to the dustbin of history. However, given the reports of poor quality care in too many care organisations (and not just in the UK), we might want to revisit Goffman and ask ourselves: ‘To what degree have modern healthcare organisations moved on in the mode of delivery and bureaucratic control of patients and clients in their care, or is there something inherently totalising in the very fabric of their being?’ We might want to consider the obvious point that although the total institution was manifest (often literally) in concrete form, its social processes are not. They arise from human interaction, which itself both constructs and is constructed by individuals based on their values, culture and taken-forgranted social practices. As Foucault, among others, reminded us, these also operate within a matrix of power relationships. Thus, demolishing the concrete does not necessarily demolish the social; the totalising processes may simply transfer to new concrete settings. Total Institutions are characterised by the bureaucratic control of the human needs of a group of people, and it operates through the mechanism of the ‘mortification of self’. Goffman outlined 5 types of institution (prisons, asylums, military barracks and certain religious orders), and for our purposes these include nursing homes and hospitals where vulnerable people who may or may not be a threat to themselves and society are controlled for the purposes of treating or managing an illness or condition, be it chronic or acute. Goffman defines total institutions as social arrangements that are regulated according to one rational plan and that occur under one roof. The 'total institution', then, is a ‘living space’ in which people who share a similar social situation (for example those in need of health and social care) are cut off from the wider society for a considerable time. They lead an enclosed, 'formally administered round of life' (p11) encompassing many of their activities of daily living such as sleeping, eating, working and playing. In civil society we work, play and sleep in different places with different persons under different authorities. In total institutions these three activity spheres of life lose their separate boundaries in various ways. First, life is experienced and controlled in the same place by the same central authority. Second, activities of daily living are conducted often in the presence of a large group of people in similar circumstances. These others may be treated very similarly and may be required to do the same things jointly. Third, all phases of daily activities are carefully planned, with one activity leading 1 into the next at a prearranged time and often to meet organisational rather than individual needs. The social processes of the ‘mortification of self’ evolve and develop over time, and thus very short episodes of care that quickly lead to discharge may avoid totalising and bureaucratic control. Totalising is also related to the degree to which the patient or client is excluded from knowledge of the decisions taken about them concerning their treatments. A person's self is mortified by the following processes: 1. Role dispossession. One loses the various roles played out in civil society and instead becomes the patient or client, which is sometimes allied to the expectations of the ‘sick role’. 2. Programming and identity trimming. The self is reduced to often numerical data to be held in the data base and files of the organisation. 3. Dispossession of property, name, and one’s ‘identity kit’, i.e. those artefacts that identify who we are. 4. Imposition of degrading postures, stances, and deference patterns often justified on the grounds of the necessity of medical or nursing interventions. 5. Contaminative exposure. This occurs when the organisation offers little or no private space so that our private activities are hard to conceal. One may experience interpersonal contact which results in ‘status-contamination’, i.e. the forced mixing of different statuses and ages which occurs for example in mixed sex wards. One may also lose the ability to differentiate one’s status when a more formal style of address is lost and the staff use terms of ‘endearment’ or epithets such as ‘my love’, ‘dearie’ or ‘sweetie’. 6. The disruption of the usual relationship between the individual and their actions/behaviours. This occurs when there are organisational rules for individual actions which otherwise would be under the individual’s control. For example, making a cup of tea at one’s home occurs at one’s total discretion, whereas in a nursing home the organisation may set out rules and procedures for such an activity. 7. Restrictions on self-determination, autonomy, and freedom of action. It becomes difficult or impossible to develop and pursue interests, make choices or associate with others of one's own choosing. This is not just because of one’s physical or mental frailties, it also results from the organisation’s bureaucratic controls. What can we learn from Goffman’s typology? The first point is that the patients’ and clients’ experience results from taken-for-granted organisational processes that professionals (the ‘tinkering trades’ p281) may not at first think are totalising. Second, that this typology may be a continuum in that a particular organisation may exhibit certain processes, but not all of them, which then may predispose it to exhibiting degrees of totalising practice. Third, that we cannot assume that the demise of large asylums has meant the demise of totalising organisational social systems. Fourth, that staff could be socialised into these practices by organisational processes that act both upon patient and staff member. Fifth, that as health and social care needs of an increasingly elderly population unfold, the pressures on the current system may lead to more rather than less of a totalising process in certain organisations. Sixth, privatising health services delivered by ‘any willing provider’ may have objectives which militate against an individual’s freedoms and 2 autonomy: e.g. increasing shareholder value, profit and bureaucratic control exercised through an overall management plan. Seventh, individuals who undergo this mortification of the self are receiving by definition poor quality care. Eighth, are our current regulatory systems robust enough to identify totalising institutions? Finally, do we accept that some health care delivery processes are naturally totalising either through clinical need and/or through the design of their concrete structures and social processes, or have we the foresight or funding to redesign those structures and processes? These points need critical examination and evidence. However, there may be signs that the current health and social care delivery systems in many countries lay the foundation for totalising organisations to develop. According to Boseley (2012) there are 376,250 people living in 10,331 care homes in England, “many are frail and vulnerable, with more health needs than most of the population. Around 40% have dementia, many are on cocktails of medication, and the average lifespan when they get to a care home is one to two years” (based on reports from the Care Quality Commission and the British Geriatric Society). The suggestion here is that the United Kingdom’s National Health Service has disengaged from this group of people, assuming that they are being cared for when in fact there are large variations in the care they receive from the NHS across the country. This does not mean that these care homes are total institutions, but it does illustrate ways in which this group of patients may become hidden from civil society and the health system. As they are hidden, they may experience processes of ‘mortification of the self’ to various degrees. Goffman states that the process of mortification of the self, when analysed, ‘can help us see the arrangements that ordinary establishments must guarantee if members are to preserve their civilian selves’ (p24). Max Weber warned of bureaucratic control as a feature of modern societies; perhaps we should be vigilant and re-examine the social systems we have designed to provide health and social care for vulnerable adults. References Boseley, S.(2012) NHS forgetting the needs of care home residents warns review. The Guardian March 7th http://www.guardian.co.uk/society/2012/mar/07/nhs-care-home-residents-review Goffman, E. (1961) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Anchor Books. New York. (direct quotes are from the Penguin Edition). 3
