The Freedom to Die
A new book sheds light on our monstrous treatment of the mentally ill
In 1961, the sociologist Erving Goffman published Asylums, a book of four essays on what the author called “total institutions.” Total institutions are places like army barracks, monasteries, or mental hospitals, in which residents’ daily lives are minutely controlled by the facility’s staff as a means of annihilating their previous sense of self. Inmates in total institutions, Goffman observed, are denied access to all of the tools by which, in the outside world, they could express their individuality: cosmetics, non-standard issue clothes, choice of haircut, nicknames, etc. They are forced to participate in the pre-arranged, structured activities of the institution’s rigid schedule. By way of this disciplinary regime, they are de-individuated and standardized. The inmate of the total institution, wrote Goffman, is “shaped and coded into an object that can be fed into the administrative machinery of the establishment, to be worked on smoothly by routine operations.”
Goffman was intrigued by total institutions because he was interested in how the individual “self” is not a fixed property, but is constructed through the daily course of social exchange. In every interaction we have with another, Goffman observed, we project a particular presentation of ourselves, one appropriate to the specific social context in which we find ourselves. At home, we are the loving parent, at work, the competent professional, at church, the pious neighbor. The rules and customs of polite social engagement — what Goffman calls “the traffic rules of social interaction” — are built around affording one another the leeway to project whatever presentation of ourselves each of us sees fit. To deny someone this entitlement is an act of rudeness. If a man is wearing a bad toupée, fooling no one in his self-presentation as someone who still has his natural head of hair, good manners require that everyone pretend not to notice. Saying, “That’s a lovely wig” in this situation is not a compliment; everyone immediately understands that denying the bald man the prerogative to present himself as he wishes, however unconvincing it may be, is an expression of flagrant disrespect. Same for the husband and wife at the dinner party whose exchanges barely conceal their festering mutual contempt; we all see what’s happening, and do our best to act as if we don’t.
These social niceties are banished from the total institution. Under its totalitarian system of control, one is allowed no other definition of oneself than that which the institution’s staff imposes upon you. In a prison, that role is the guilty offender; in an insane asylum, it is the mental patient. There is no escape from the label. Any protest or earnest performance of sanity is reflexively deemed yet another symptom of one’s psychiatric disorder. Over time, you come to accept the institution’s version of you as your “true” self. The insane asylum thus constructs the insanity that justifies its existence.
Goffman’s analysis was a pillar of the intellectual attack on the state psychiatric hospital system, an attack that contributed to the decades-long process of “deinstitutionalization” in the United States. Beginning in the 1950s and accelerating with the patients’ rights movement in the 1960s, asylums throughout the country emptied their beds of patients and shut their doors. At the time, activists, psychiatrists, and policymakers envisioned their replacement by a vast, dispersed system of treatment facilities embedded in communities. But aside from a short-lived, failed federally-financed experiment in “Community Mental Health Centers,” such a system never emerged. The gravely mentally ill were simply left to the public to manage, which meant that they largely ended up homeless or incarcerated.
Today, after three-quarters of a century of deinstitutionalization, the fate of the severely mentally ill in America is the opposite of what Goffman described. So total were the achievements of deinstitutionalization that the tyrannical control that the state psychiatric hospitals once exerted over their inmates is now a luxury good, available only to patients with families that can afford the services of private residential rehabilitation centers perched on Malibu cliffs overlooking the Pacific Ocean. If you’re poor and psychotic, thanks to a series of 1960s court decisions that severely restricted involuntary treatment, your autonomy is all but inviolable. You are allowed freedoms Goffman would never have dreamed of: the right to sleep in doorways, to be left alone when suffering a public psychotic break, to smoke methamphetamines on the sidewalk or in your government-subsidized apartment.