Erving Goffman is an often-forgotten pioneer in the science and practice of mental health care. Perhaps it was because he was trained as a sociologist (not a psychologist or psychiatrist), or maybe because his research methods were hard to replicate and he therefore could not cultivate a wider following while he was alive. His writing seemed more journalistic than academic. However, despite—and likely because of—his outsider tendencies, Goffman produced some of the most bold and lasting insights into the nature of many social systems, including mental health institutions (particularly hospitals). Some of his insights are worth reproducing here as they are still broadly relevant and instructive in how we think about the state of mental health care moving forward. In this blog piece, I will recap the final chapter, titled “The Medical Model and Mental Hospitalization”, of Goffman’s book on Asylums. I should state here that Goffman gathered his conclusions from three years of doing field work with the National Institute of Mental Health, including one year of field work (between 1955 to 1956) in St. Elizabeth’s hospital in Washington, DC. I will describe 5 models that Goffman presents to help us understand the state of mental health care; as it was, as it exists today and where it might be heading.

The first and primary model that Goffman introduces to help the reader better understand the industries of mental health is the service model. Here, Goffman further describes a division between the “servers” (i.e., mental health professionals) and the “served” (i.e., clients or patients). The servers, according to Goffman, render their service in three basic forms: a technical form (i.e., providing factual information on symptoms, diagnosis and treatment); contractual form (i.e., information regarding cost, times, length of treatment etc.); and a sociable form (i.e., containing courtesies, focused attention, warmth). Goffman points out that server-served relationships are actually triangular. That is, the server is not only responsible to the served, but also to the “object” that the served are seeking service for. In the case of a mechanic, the object is the car; for the physician, the object is the diseased body part; for the psychologist, the object is the client-patient’s mental distress.

Goffman recognizes at least two serious limits to the service model, when applied to mental health. One, is that the servers are not simply responsible to the served and their diseased “object” but also to the society of which they are a part of. A mental health service cannot be performed without some basic regard for the safety of the public. For example, if a client-patient intends to hurt someone in the community, then the treating therapist may have an obligation to report this information to the appropriate authorities or warn the intended victim. This type of social responsibility goes well beyond what typically constitutes a service contract in other professions. A mechanic, for example, is not concerned with the competence of the driver. A plumber does not concern himself with the resource consumption of his client. The second limitation is that the environment itself may be the primary cause of the client-patient’s suffering rather than any inherent deficiency in the treated object. For example, a client may be suffering traumatic stress from an abusive marriage or workplace injury. It is not that they are inherently defective; however they might be abreacting to a highly provoking situation. This type of regard is not necessarily present in other service professions. A mechanic, for example, is not concerned with the conditions of the road or other drivers when he fixes the body of a vehicle. A plumber does not generally concern herself with building codes or occupancy bylaws then fixing a broken line. However, the mental health professional/server frequently considers the family, community and cultural environments of their client-patient and whether these milieus contribute, worsen or even cause pathology. Goffman’s challenge is to image a truly communal psychology in which mental health servers are employed in massive public works to enhance the social organization, infrastructure, economic mobility, service availability and political potency of at-risk places. Nearly 60 years later, his vision is still as radical and unrealized as ever.

This was, and remains, a radical admission by someone from a national research institution. Goffman however, who had received an NIMH grant and was graciously invited by the head staff to do field work at St. Elizabeth’s hospital, really felt no imperative to play the social role of the institutional scientist. Instead, he really tried to write from the patients’ viewpoint and his conclusions, he admitted, probably do reflect some of their biases; however, they also stand as a singular counter-narrative to what we typically hear from the institutions themselves. In this quote, Goffman is alluding to the programs, funding and contracts that tether an institution such as a hospital to other broad fiscal, research and political commitments. Goffman observes that, in a matter of speaking, it is exceedingly difficult to consistently serve two masters. Although there may be large degrees of confluence between the goals of the institution and the principles of health-oriented service, this is not always or necessarily so. In fact, where there is disagreement between the comforts and conveniences of the staff/institute and those of the client-patient, it is usually the former that wins out. He notes that this is not atypical of service institutions, however in health care, the client-patient is often present (especially in a residential or inpatient setting) to witness the institutional priorities seconded over their own.

Along with the limitations already illustrated with the service model, Goffman describes two other models that further challenge the claims to “science” and “rationality” within the mental health industries. The first is called the normative model; this describes a mandate for services to not only benefit the client-patients but to also maintain a minimal standard of legitimacy in the eyes of the public. To take an example, consider the extensive charting and paperwork requirements that require (in many cases) the majority of the practitioners’ working time to complete. Practitioners themselves frequently complain that these charting activities are often redundant and take time away from client-patient care; yet the practices persist because they serve an important assurance to the public that the minimal standards of attention and communication are being met. The other model is the maintenance model. This model is most relevant when clients are also tasked with performing some essential service (i.e., like workers in workers’ compensation claims). Here, the job of the practitioner is to not only treat the client-patient but also to restore them to some form of prior service. Military personnel, for example, are treated by the unit psychiatrist who is tasked with the goal of not only alleviating their mental distress but also with the aim of returning them to active service. The maintenance model can also distort the principles of health care when, for example, the environment that the worker finds himself returning to is directly contributing to his state of dysfunctionality.

Hairdressers, dentists, mechanics see a variety of different clients with different problems–however, they all have a basic model of service in mind and the differences between say, sets of teeth, or models of car, are thought to be secondary to the specific services being offered (e.g., crown filling, oil change). Today however, we increasing find that services are developing boutique practices catered towards specific diversities within their clientele. We have, for example, black hair barber shops and mental health providers that specialize in treating say, South Asian female clients. However, in the main, mental health service providers are trained to overlook cultural and social differences and to describe the client-patients problems in terms of (mostly Western) models of mental health and illness. Although the ability to translate unique idioms of distress into well-known models of illness can be therapeutic (e.g., validating); there is always a risk that cultural, economic and social differences will simply be glossed over.

There are two other models Goffman mentions. The first is the governance model and this is mainly applied inside of residential or inpatient settings where resident-patients cannot leave voluntarily and must be discharged by staff. Here, the patient is responsible for not only getting healthy but is also responsible for learning the rules of conduct within the institution and earning, as it were, their freedom. Goffman takes care to describe the social roles and social games that are played between the governed (i.e., resident-patients) and the governing (i.e., staff). The details are worth reading in his book. The other model is the moral model.

The moral model, according to Goffman, “consists of holding the sins of the patient up to him and getting him to see the error of his ways.” There is historical precedent for this. In pre-scientific times, mental illness was often considered to be some form of spiritual suffering. The treatment, naturally, would involve some form of religious ritual and atonement on behalf of the patient-sinner. Even today, the apprenticeship of mental health servers involves them learning from their mentors about what constitutes “responsible” behaviors in marriages, parenting, and work arrangements. In outpatient settings, client-patients who exhibit some form of deviant behavior are gently coached (if not sermonized) to admit the error of their ways and follow a more “responsible” path. In residential or inpatient settings, the moral burden is much more significant: “...failure to be an easily manageable patient–failure, for example, to work or to be polite to staff–tends to be taken as evidence that one is not “ready” for liberty and that one has a need to submit to further treatment.” Often, however, it is the client-patients themselves who ask the mental health server if their behaviors are moral. This is, after all, the anxiety underlying the oft-heard question: “Am I normal?”

Goffman provides yet another valuable insight. Throughout history, the wellbeing of an individual was thought to be deeply connected to the wellbeing of their family, home, and community. The South African term ubuntu describes an indigenous philosophy that was recognizable to much of the pre-industrialized world. That is to say, a person is made whole, healthy and fulfilled through their social connections and obligations to one another. They are also made distressed and diseased—even losing their personhood—through fractured bonds with others and their lived environments. However, throughout Western history, there has been a steady trend towards the development of a self-identity in which one’s very nature is thought to consist of an internal core that is somewhat removed from the external world. Ideas like ‘authenticity’ and ‘responsibility’ and ‘actualization’ are reflective of this sense of self; our inner workings are thought to be heavily determined by our own moral and biological dispositions. We are made people, not through our relationships with others, but rather through the substance of our own (separate and private) actions and thoughts. One resulting consequence of this shift in attitudes is that social factors such as poverty, mistreatment, and even the violence of institutions (e.g., as they carry out their duties of governance) are frequently minimized–like the differences of race, gender, marital status etc.–and are generally considered far less impactful than the workings of the one’s own internal world.

Goffman further notes that the logic of mental institutions tends to be totalizing; that is, it justifies its own existence. For example, a patient is considered “ill” just by being admitted to the hospital. If he claims to be faking or placed there by mistake, it may be taken as all the more evidence to confirm that he is truly detached from reality. If a patient is discharged, then she is “cured.” The fact that her improvement may be due to other life circumstances is nearly always disregarded–it is the workings of the institution–so goes the logic–that has cured her.

Goffman’s work lays bare some serious critiques of mental health institutions–particularly what he called total institutions that feed, clothe and house the patients–however, Goffman does profess a respect and even reverence for these institutions and the models by which they operate. He ends the book by noting that the applications of the service model can be useful to patients, and may be the best model we have developed to date. Goffman also notes that the service model also serves to correct some natural and human biases that doctors and other attendants might otherwise carry into their work. Servers are after all implored to leave their personal prejudices and anxieties at the door. However, Goffman does clearly illuminate five models by which we can better understand the logic—with all of its inconsistencies—in the mental health industries of today. He also helps us better observe and understand the unintended side-effects that these models may carry such as a crushing moral burden, servitude to institutional ideals, ignoring social realities, playing nice–all of which actually hinder the wellbeing of both practitioners and the client-patients. For those of us involved in the mental health care system—as either server or served—we are tasked with taking his insights forward and developing forms of care that address the limitations of the five models presented here.