Views & Reviews Medical Classics

Asylums: Essays on the Social Situation of Mental Patients and other Inmates

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b4109 (Published 07 October 2009) Cite this as: BMJ 2009;339:b4109
  1. Séamus Mac Suibhne, senior registrar, Louth Mental Health Services, St Brigid’s Hospital, Ardee, County Louth, Ireland
  1. Seamus.MacSuibhne{at}ucd.ie

    “Deinstitutionalisation” has become one of the stated aims of modern, establishment psychiatry. Somewhat like motherhood and apple pie, it seems to have become a concept that is nearly impossible to criticise. Whether institutionalisation was ever exactly like its critics described it is a moot point; another is whether what we have seen since the move to community psychiatry is really “transinstitutionalisation”—with those patients who formerly would have been in asylums now in prison or homeless—rather than deinstitutionalisation. Goffman’s Asylums, a key text in the development of deinstitutionalisation, anticipated and indeed predicted some of these developments.

    Asylums deserves the status of a classic text in the literature of psychiatry and medicine as a powerful indictment of the old asylum system—and it is also a far richer and more subtle work than its reputation as a simple attack on institutionalisation would suggest. It is more concerned with illustration and interpretation than with either justification or attack (although Goffman’s trenchant asides show that he had no very high opinion of the therapeutic benefit of psychiatry or psychotherapy). Not one for emollient language, he describes a world of alienation, bitterness, and anger, where therapeutic language was used to mask a more brutal reality of power, coercion, and control.

    Goffman analyses at length “total institutions,” those social settings in which every aspect of the inmates’ lives is dictated, such as the mental hospitals of Goffman’s time but also prisons, boarding schools, ships, and monasteries. He also explores the “moral career of the mental patient” and the “betrayal funnel” by which liberty and dignity are stripped away, while the patient is repeatedly reassured that things are happening for his or her own good. Famously, Goffman went undercover as an assistant to the physical education instructor at St Elizabeth’s Hospital in Washington, DC. However, while 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.

    Goffman certainly sees mental illness as socially constructed: “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, Goffman is not critiquing some neurochemical paradigm of psychopathology but the overall relationship structure within the asylum. Although the massive institutions and the grosser abuses seem to be things of the past, Goffman’s description will be eerily familiar to anyone who has any experience of inpatient psychiatry.

    Notes

    Cite this as: BMJ 2009;339:b4109

    Footnotes

    • Asylums: Essays on the Social Situation of Mental Patients and other Inmates

    • Erving Goffman

    • First published 1961