“NOTI CE: this is the author’s versi on of a work that was a ccept ed for publ icati on in Nurse Edu catio n T oday
Chang es re sulti ng from the publishing process, such as p eer r eview, editing, corre ction s, structu ral formatt ing,
and ot her quality co ntrol mechan isms ma y not be r eflec ted in th is document. Changes may ha ve been made to
this work since it was submitted for p ublic ation. A defini tive versi on was su bseque ntly publ ished in N urse
Educa tion Today 33 ( 2) 20 12
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-for-
granted 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
