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Psychiatry_ A Very Short Introd - Burns, Tom.rtf
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Erving Goffman and total institutions

  The Three Hospitals Study and Russell Barton’s institutional neurosis shook up the professions but they pale alongside the international shock wave caused by Asylums (1961) – a book by the American sociologist Erving Goffman. This groundbreaking study (he worked ‘undercover’ for a year as a cleaner in the wards of an enormous mental hospital in Washington, DC), his clear and radical thinking and, not least, his elegant writing simply stunned the establishment. Goffman described in convincing detail what really went on in an asylum – not what people thought went on. Doctors and nurses thought they shared a common understanding but Goffman showed that they did not – doctors judged patients using a disease and treatment model, whereas the nurses made judgements based more on behaviour and on patient motives. More tellingly doctors thought they ran the units but it was clear that for day-to-day life nurses, aides (and even other patients) set the rules and culture and held the authority. Goffman was not sympathetic to the asylum.

  He went further. He concluded that the dehumanizing and degradation of patients resulting from inflexible routines and the absence of individualized care were not simply the regrettable effects of poorly trained staff and lack of resources (the usual explanations). He argued that such institutions actively eroded individuality. This was particularly characteristic of what he called ‘total institutions’ such as asylums, prisons, and the army. These typically meet all their Members’ needs – e.g. food, shelter, company, leisure. They rely on rigid distinctions between staff and patients (or prisoners and warders, or officers and men) and on demeaning rituals to erode and suppress individual identity. He argued that they do this to enforce discipline and make large groups of people more easily manageable. In the hospital in which he worked he cited the highly structured admission process that included not only medical examination but delousing, bathing, and hair cutting for all patients as one such potent and symbolic degradation.

  Whilst (understandably) initially unwelcome to the professions Goffman’s writings have been a major force in driving the closure of the mental hospitals. His book Asylums is still the most quoted text in modern sociology 40 years after its publication. Ken Kesey’s 1962 book One Flew Over the Cuckoo’s Nest (and its enormously successful film adaptation staring Jack Nicholson in 1975) vividly portrayed the unacceptable face of such large impersonal asylums.

The rights and abuse of the mentally ill

  I have focused so far on the forces from within the professions that led to deinstitutionalization. However, just as with the origins of the asylums (Chapter 2), the social climate of the time was probably as influential, if not more so. Directly after the Second World War Europe burned with a spirit of change and a thirst for social justice. The old order was in disgrace and the rights of the common man were the priority of both returning soldiers and returned governments. Democracy and social inclusion (though not called that then) dominated the international agenda, whether in education, health, or housing. The rights of disadvantaged groups to take full part in this new society were strongly defended and the mentally ill were one such group. Their wholesale liquidation in Nazi Germany only served to underline their rights for protection. Nowhere is this so clearly demonstrated as in changes in Mental Health Law. In the UK, for example, the 1890 Lunacy Act focused on protecting the rights of the sane not to be judged insane (with scant regard to the rights or welfare of the insane) whereas the 1959 Mental Health Act focused on protecting the rights of the mentally ill by ensuring due process and review of their care and detention.

 

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