health problems. In cases of compulsory detention, a new legal framework was introduced to ensure compatibility with the provisions of the HRA (Human Rights Act) of 1998. The 2018 review of the MHA was carried after May identified the parlous state of mental health services as one of the ‘grave injustices’ that existed in the country. There is wider public discussion and acknowledgement of the impact of mental illness. Stigma and fear remain but the physical segregation in asylums has gone. In addition, psychiatry, mental health social work, nursing and other disciplines have a wider range of interventions to alleviate distress to offer. However, the policies and legislation which will impact on those in greatest need do not reflect these progressive themes. These paradoxes will be explored in the forthcoming chapters.
Introduction
This chapter will argue that the development of mental health policy was hugely influenced by conceptions of space and place. By the middle of the 20th century the asylum had become, in the public and sociological imagination, a Gothic institution of seclusion and abuse. This is not to suggest that there was no basis for this view. The chapter will explore the development of this representation of the asylum. The final representations of the asylum contrast dramatically with the original ones that saw the new institutions as modern and progressive. Deinstitutionalisation was to present the community in binary opposition to the asylum. Community based services would, almost by reason of their location, lead to the creation of a new form of inclusive mental health provision. This is based on an idealised notion of community. As the pressures on mental health services grew, a range of social policies that were introduced that meant that urban communities, in particular, became exclusionary rather than inclusionary.
Total institutions
Goffman is one of the most influential sociologists of the 20th century. Goffman’s work on stigma and the sociology of everyday life – the social practices that we engage in to structure and make sense of day to day social interactions – have left a rich legacy. It is interesting to note that the treatment and management of mental illness was a key area of analysis in his work. This area was representative of other stigma generating processes (Cummins, 2017a). Asylums (2017) is Goffman’s most important work in this field. It is an ethnographic account of life at the St Elizabeth’s Hospital in Washington DC. Goffman carried out his research when there were over 7,000 patients at St Elizabeth’s. The study is a landmark in ethnographic research. It also had a key role in the moves to tackle the abusive nature of the regime he described. Goffman’s portrait of the asylum was one dominated by essentially anti-therapeutic, dehumanising practices. Goffman’s work was part of the drive for reform but also had a key role in shaping the image of the asylum regime.
Before examining Asylums (2017), I will briefly outline Goffman’s broader theoretical approach to the questions raised by societal responses to mental illness. He examined these in his short essay ‘The insanity of place’ (Goffman, 1969). Goffman regarded mental illness as a challenge to normal societal rules of behaviour. It represents what he terms a form of ‘havoc’. Goffman uses the term to mean that individuals are no longer what he termed self-governing. The usual codes or systems which enable us to make sense of, or manage, our social realities are broken down. An example of this might be the impact of symptoms of bipolar disorder such as disinhibition. For Goffman, society manages havoc in one of two ways: the removal of the individuals from wider society, or the discrediting of them. Goffman outlined what he termed ‘gathering’ whereby the wider society – families, friends and institutions – attempt to deal with the havoc. As a former mental health social worker, I was involved in many gatherings in the form of Mental Health Act (MHA) assessments. I, my fellow mental health professionals and members of individuals’ families viewed Goffman’s gatherings as interventions that were seeking to ensure the safety of individuals rather than to discredit them. I also fully accept that my perspective may well be completely at odds with that of the person subject to the MHA assessment process. Alongside this, I accept that these processes include an inevitable element of discrediting and stigmatising the person subject to the assessment.
Goffman used the term ‘total institution’ to describe asylums. The term was coined by the American sociologist Everett Hughes who taught at the University of Chicago when Goffman was a postgraduate student. A total institution is one where the basic modern social arrangements whereby individuals sleep, play and work ‘in different places, with different co-participants, under different authorities, and without an overall rational plan’ (Goffman, 2017: 5–6) are broken down. Those living in total institutions are separated from the wider society. Barracks, monasteries, psychiatric hospitals, prisons and residential and nursing homes could all be regarded as total institutions or have features of total institutions. A total institution is not necessarily based on compulsory admission. This is important: people make a positive choice to enter a monastery. Not all admissions to psychiatric hospital are compulsory but the nature of the choice made is open to debate. Not all total institutions are based on a desire to exclude; they may be the result of a positive decision to reject aspects of modern society. The barriers that exist between three spheres of modern life – sleep, play and work – are broken down or disappear completely. The result is that residents/patients/inmates conduct all aspects of their lives in the same restricted physical and psychological environment. In Goffman’s psychiatric model, this environment is also a controlled one, dominated by a staff group that has power over the way that all aspects of the institution are organised and function. The regime is imposed by a system of explicit formal rules but also a second system of informal ones, overseen and imposed by the staff group. The aim of the regime is to control the havoc that led to the inmate/patient admission so that they can re-enter mainstream society.
In St Elizabeth’s, Goffman (2017) noted that the ward system was not based totally on clinical need. It had a clear disciplinary function. The ward system is an example of the way that staff exercise authority and control. For Goffman, the system was a purely behaviourist one. Behaviourism was a dominant approach in psychiatric institutions in this period. Those patients who cooperated were sent to the ‘best wards’. The most uncooperative patients were sent to the wards where the conditions were poorest. The total institution followed a clear system of rewards for good behaviour and punishment for acts seen as transgression. The rewards included improved conditions, but also access to TV and radio or cups of coffee. One of the sharpest insights that Goffman (2017) provides is into the way that individuals respond to the strictures and demands of the total institution. He recognises that within the limitations of the asylum regime, individuals attempt to – and in fact are driven to – maintain their identity. This inevitably involves some transgression of the asylum rules. Goffman highlights the way that the all-pervasive nature of the asylum regime means that behaviour in one area of a person’ s life is brought into another, providing evidence that the ‘spoiled identity’ assigned to them is a valid one. Rosenhan (1975) made a similar point when he argued that one of the most power aspects of diagnosis was that it became a prism through which all behaviour is examined and explained.
Asylums (Goffman, 2017) is, or should be, on the reading list for every mental health module on social work, sociology and social policy courses. The strength of the work is that it examines how response to mental illness becomes a form of social control. Scull (1986) also highlights this as the fundamental weakness of Goffman’s analysis. It does not allow for any therapeutic motivations. The cultural influence of Asylums can be seen in a number of representations of mental illness – most notably in Ken Kesey’s (1962) novel One Flew over the Cuckoo’s Nest (and Milos Forman’s 1975 multi Oscar winning film adaptation of the book). The
