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Preface
During the period of 1954 to the end of 1957, Erving Goffman (as a visiting member of the Laboratory of Socio-environmental Studies of the National Institute of Mental Health Bethesda, Maryland) briefly studied the ward behaviour in the National Institutes of Health Clinical Center  under a pseudo-employee, as an assistant to the hospital's athletic director. At this period, he also worked at St. Elizabeths Hospital in Washington, D.C, and gathered ethnographic data on patient’s social life.

The purpose of Goffman’s study and field work at St.Elizabeths was to understand the experience of the patients and how their psychological behaviour, state of mind and being shaped the patient in relation to the institutions and systems that contained them. While Goffman makes a point in emphasising the importance in immersing himself in the patient’s world to better understand the patient, saying “to submit oneself in the company of the members to the daily round of petty contingencies to which they are subject”, he also stresses both the limits, short-comings and bias in the study and essays. These biases rest in his own view, which he claims to be both of a middle-class male viewpoint and uses the lens of a psychiatrist. The limitations are due to a lack of specific data on a patient’s life, as well as the partial perspective from the patient’s point of view.

In this three page letter, Goffman acknowledges and thanks the freedom, opportunity and support of both the social scientist government workers, staff members and those who allowed him many opportunities and provided financial support for his research period.

Introduction
Goffman defines 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”, in which he includes prisons and mental hospitals as examples. He introduces the book as a collection of structured essays which are to stand on its own, and whose focus lie in understanding the inmate; the aim is to learn of the patient's psychological world and their development within the institution. He then provides a brief explanation of each section: 1) On the Characteristics of Total Institutions; 2) The Moral Career of the Mental Patient; 3) The Underlife of a Public Institution: A Study of Ways of Making Out in a Mental Hospital and finally, 4) The Medical Model and Mental Hospitalisation.

On the Characteristics of Total Institutions
Goffman describes total institutions as places where a large number of individuals are cut off from the wider society for a period of time, and emphasises the fundamental dichotomies between large managed groups called inmates, and small supervisory staff members. He provides asylums, prisons, boarding schools, concentration camps, monasteries, orphanages, ships and military organisations as examples. In these institutions, a single authority conducts aspects of life: daily activities are scheduled and tightly organised so that all members are regulated and treated in the same manner. The inmates live in the institution and have limited interaction with the outside world, while the staff members operate on an eight-hour shift and are connected to the outside social world. In total intuitions, Goffman claims bureaucracy and impersonal tendencies rule and dictate the ways in which large groups are managed and human needs are met. These two groups are aggressive and unsympathetic towards one another, often perceiving each other in hostile stereotypes. For example, staff members view inmates as bitter, secretive, untrustworthy, while inmates view staff as superior, condescending, highhanded, righteous and mean. These antagonistic stereotypes are preserved through the strict social boundaries that dictate that members of these groups are not to cross the constructed social divide.

Goffman explains that while occupying the same space, both groups in these institutions are part of different social and cultural worlds that develop through the institution’s practices. Goffman claims that total institutions are social hybrids: part residential community and part formal organisation. He categorises these worlds from various perspectives: the inmates, the staff world, and the contacts between the two.

The Inmate’s World
From the perspective of the inmate, Goffman makes it clear that patients have negative attitudes and experiences towards the hospital by emphasising the results of the characteristics of the institution: the loss of freedom, depersonalisation, mortification of self, staff abuse, social rejection, and loneliness. Before the inmate even enters the institution, there is already a particular kind of tension created between the home and the institution. Once the inmate has entered the institution, the process by which the inmate’s self is understood and regarded is categorised in a degrading manner:

The patient's self is also deprived of his identity by being stripped of their personal belongings and routines, and coerced to adjust their image of self to align with the institution’s image of them. Goffman draws multiple examples from military experience and concentration camps to show the parallels between the hospital and other total institutions. Through these examples, he illustrates the ways in which autonomy and act of self is violated.

These changes in self reinforces feelings of injustice, bitterness and alienation. The inmate is also burdened by a conscious effort to stay out of trouble (which requires persistent effort) and must be politically aware of his self by engaging in ‘correct’ behaviour so as to avoid punishment for the slightest offences. Goffman states that the privilege system is both a punishment and reward system in which staff members often abuse their position and make inmates perform degrading tasks for simple pleasures (for example, forcing inmates to say ‘pretty please’ for a cigarette).

The Staff World
Goffman claims that hospitals "present themselves to the public as rational organisations designed consciously, through and through, as effective machines for producing a few officially avowed and officially approved ends". This organisation is unique in the sense that the staff’s work is people-work; their work is to deal with people. In mental hospitals, the basis of human intelligence is constructed by the staff, who is considered to be a specialist in the knowledge of human nature. These professionals, Goffman argues, are often motivated by their own standards of morality in how to both view and treat subjects, and understand their role in the institution. Conflicts regarding both professional and personal have an impact on how the rational goals of the institution is realized and maintained.

The Moral Career of the Mental Patient
Goffman defines moral career as a social strand of a person’s course through life that allows them to move between two spheres: internal (image of self and felt identity) and public (concerning official positions and jural relations) and is directly related to the way of conceiving self. Through an institutional approach, the patient’s development of their moral career undergoes three stages: the prepatient phase; the period prior to entering the hospital, the inpatient phase; the period in the hospital, and the ex-patient phase; the period after discharge from the hospital.

Prepatient
Goffman argues that the prepatient phase mostly consists of individuals who are forced to enter the institution: individuals have been implored or threatened by their family, under law enforcement and escort, or under misapprehension purposely induced by others (usually adolescents), and very few individuals who come on their own free will. For these few ‘free will’ individuals who believe they are losing control of themselves and their minds, the institution is to be a haven that provides relief for a brief period. Often, there is a complainant, some figure who makes a record of some offense by the prepatient that leads to his/her hospitalisation.

The four elements of the prepatient phase includes: career contingencies; a set of contingencies that help determine whether the patient has grounds for hospitalization or discharge, circuits of agents; agents such as family members, friends and close associates who help with the transition of moving from the home atmosphere to the institution life, alienative coalition; which refers to the depth of betrayal the patient may feel towards his next-of-relations, and retroactive career; the final point of the prepatient’s career before he is admitted into the institution.

Inpatient
In the inpatient phase, the patient usually attempts to maintain anonymity followed by learning to settle down and become established in his new environment. As Goffman states: “the inpatient finds himself cleanly stripped of many of his accustomed affirmations, satisfactions, and defences, and is subjected to a rather full set of mortifying experiences: restrictions of free movement, communal living, diffuse authority of a whole echelon of people, and so on”. This process brings in various kinds of loss (including social interactions, identity, freedom, etc.) and mortification as well as learning to accept the ‘patient’ status, being a member of the institution and orienting themselves to the ward system, an internal hierarchy. The ward system changes the behaviour of the patient and institutionalises him to become accustomed to the privilege system: for being obedient, he will be rewarded through minor satisfactions; for being disobedient, he will be punished through loss of privileges. Goffman further argues that these institutionalised behaviours and systems are put in place and presented as a necessity and intentional part of the treatment.

The Underlife of a Public Institution: A Study of Ways of Making Out in A Mental Hospital
Throughout the book, Goffman critiques total institutions to be guilty of “stripping patients, inmates, or residents of their typical social selves or identities: their roles, personal appearances, individual ways of presenting their identities, reputations, and sense of personal space and privacy”. In this essay, Goffman explores the various methods in which patients reject and disassociate themselves from the social control of the institutional arrangements. The patients justify, attempt to maintain and carve out their own identity and self by distancing themselves from the institution as well as removing the institution’s perspective of significant meaning in the construction of self. This rejection is because patients try to recapture and maintain a sense of being a normal person after being released from the institution. This construction of self is characterized and identifiable through resistance and secondary adjustments. The maintenance and transformation of the self in the institution is adjusted so that patients are able to become normalized, classified and conformed into certain categories of identities. These transformations and identity adjustments are formalized into spatial dimensions which are often restricted and under surveillance. Goffman argues that there are spaces in which association is free and not under observation, which allows for behaviour to be completely different and informal. These private sites are breeding grounds for 'personal and group territories' and serve as free places that provide a framework in how secondary adjustments are experienced.

The Medical Model and Mental Hospitalisation: Some Notes on the Vicissitudes of the Tinkering Trades
In this section, Goffman is concerned with the institution’s practices and rationality. Tying back to the characteristics of total institutions, Goffman delves deeper into the ways in which professional service providers of total institutions deal with their treatment-seeking patients in the framework of the institution. Goffman understands this psychiatrist-patient relationship by assuming the patient voluntarily or involuntarily comes to the psychiatrist for their service: “Ideally, the client brings to this relationship respect for the server’s technical competence and trust that he will use it ethically- he also brings gratitude and a fee”. Understanding the relationship as a cycle of object (i.e. patient) in need of repair by the subject (i.e. psychiatrist), the institution is one that is based on rational-empirical treatment of the patients through assessment, diagnosis, prescription and treatment. This creates an unbalanced power position between the servers and clients in which the servers are privileged with more advantages and opportunities to evolve in their problem-solving mechanism. Goffman argues that it is this clear disadvantage that persuades hospitals to stabilise the medical-service situation by creating publicly appealing sentiments and attempting to show the validity of the practised methodology of medical professions and system maintenance. In The Social Thought of Erving Goffman, Jacobson states:

Goffman concludes that these therapeutic institutions are systems of social control and degradation of human selves.

Influence
Asylums is a key text in sociology of mental illness. Being one of the very first books to examine and discuss the effects of hospitals as institutions in detail, Asylums has been often quoted, referenced and cited by many academics. It has influenced the formation of mental policy decisions, has been cited in legal cases involving patients, and generally used in social work. Through an extensive collection of qualitative and ethnographic data, Goffman and other authors have popularised the criticism of the ways in which patients are being treated in mental hospitals.

In popular culture, the film One Flew Over the Cuckoo’s Nest, based on the novel by Ken Kesey, further popularised Goffman’s Asylums. This film accentuates Randle McMurphy, who is portrayed by Jack Nicholson, as a psychiatric patient who rebels against the culture of Goffman’s total institutions. Goffman’s work was also instrumental in creating a deinstitutionalisation movement, in which institutionalised care-giving systems was replaced by smaller and local community care. Asylum also played an active role in influencing the stigmatisation of mental illness, disability and related conditions. As Suibhne states, “Asylums is, above all, a text that humanises a dehumanised group of people”.

Reception
After being an immediate success, Asylums was translated into several languages and praised for its intellectual honesty and ‘good style’. Goffman’s analysis is described as ‘creative, provocative and insightful’.

Criticism
Goffman is suspected of being monolithic in his portrayal of the Asylum, not paying enough attention to the historical development of the Asylum and assuming a direct relationship by “simply linking the emergence of mental hospitals with the use of the medical model and public mandate for treating the insane”. Critics of Goffman also suggest that his role, position and responsibility in the study, as well as his inability to systematically and accurately collect data may have led him to see the patients as destitute victims of psychiatric practice and reinforce his reformist bias. It is also suggested that Asylum is more of a one-sided personal account (than a carefully controlled study) that relies on its attractive literary persuasion rather than powerful scientific evidence.

Inconsistencies of Describing the Institution
By placing mental hospitals in the same category as other total institutions, Goffman’s analogy of total institutions was criticised to be ‘overdrawn’ ‘exaggerated’ and 'spurious’, emphasising that Goffman was overlooking serious limitations in defining the concept of total institutions as a generic organisational type. Goffman is accused of reducing these institutions to a homogeneous prototype which includes characteristics that self-negate the features of the hospital by emphasising the nihilistic characters whilst disregarding the therapeutic or rehabilitative functions. Levinson and Gallagher argue that psychiatric hospitals attempt to forge and maintain a more ambivalent relationship that does not heavily rely on structural conditions and restrictions. More specifically, the patient’s own sense of freedom of choice in admitting, staying or leaving the mental hospital negates Goffman’s proposed negative results of institutionalisation and the hospital’s image of a domineering authoritarian. Rather, Goffman’s critiques of the features of total institution- the restrictions, deprivations, power of staff- are said to be essential to effectively 'resocialising' the patient.

Inconsistencies of Patient’s Perceptions
Siegler and Osmond argue that Goffman’s constructed images of the asylum are ‘misleading’ and ‘harmful’ since they are not clear as to under what circumstances the patient has been brought to the institute, and points out Goffman’s short-sightedness to see the patient as truly ill. Collecting primary research himself, Karmel points out that there is no negative decline in the mortification of self, a concept of Goffman’s Asylum that predicts a decline in a patient’s social identity once the patient has begun establishing their roles in the system. Townsend argues that Goffman’s perception of the mental hospital presenting itself as a domineering system that converts patient’s self-conceptions to the hospital’s conceptions of them is incorrect. Critics argue that while long-term patients saw a change in the patient’s conduct and mannerisms, this change was not strong enough to classify as being ‘converted’, and patients did not change their self-perceived concept of themselves to be mentally ill. Also, critics of Goffman accuse him of painting all patient’s experience within the hospital with the same brush: an experience of neglect, deprivation and abuse. In fact, multiple survey studies from the 1960’s show that patients, in general, have a positive attitude towards mental hospitals and their own institutions, and these results were not skewed by factors such as time of study or type of hospital. These studies revealed that patients responded positively to the hospital’s therapeutic value and organisational structures; the patients were motivated to turn to the hospital as a source of help for their emotional and behaviour problems and were satisfied with the help provided by the hospital's professionals.