Faculty of Health
Department of Community Health and Social Work
Dip HE Nursing
Learning Disability Branch
The Effect of Institutionalisation
Resource Pack
Fiona Rich
Senior Lecturer
Asylums
The term ‘Asylum’ can evoke feelings of fear and dread in many of us,
however the interpretation and meaning of this term has undergone a
complete transformation over the course of the last 200 years (Skull, 1996).
The term asylum was originally associated at the beginning of the 1800’s with
the lunacy reform movement. The original interpretation of the asylum was an
institution which would serve as a humane and restorative retreat which the
‘mad’ would attend for rehabilitation. The asylum was intended to be a home
where the patient was to be treated as an individual and where his/her mind
was to be constantly stimulated and encouraged to return to its natural state –
to strengthen the mind and restore reason.
The concept of asylums became interpreted as dark, sinister dwellings in the
Victorian age. Local magistrates took advantage of the fact that it was more
economical to provide an environment of masses of people who were housed
together rather than provide asylum as a home where the patient would be
treated as an individual. As a result, there was an influx of ‘pauper lunatics’ to
asylums and the average size of county asylums grew yearly.
An excellent description of an institution is given in Chapter IV of the
novel ‘Human Traces’ by Sebastian Faulks (2006)
The degree of regimentation needed to administer institutions of 500, 1000
and more ensured that such asylums would be the complete opposite of what
they were originally intended to be. Now the term asylum was associated with
monotony where the needs of patients were secondary to the needs of the
institution.
Sheppard (1872) however defended the asylum against those who
questioned the benefits of asylum regimes as follows:
“I will venture to say that there is no class of persons in the United Kingdome
so well cared for as the insane. The best sites in the country are selected for
their palaces, within which a cubic space per lung is measured for them… The
fat kine of our fields are laid under contribution for them; the corn and wine is
stored for them; clothing of the warmest and supervision of the best are
provided for them. Every sort of indulgence within reasonable bounds is
theirs. Though a large number of them are of the most degraded type, and
have made themselves what they are by their own vice and wickedness, they
are equally (if not altogether wisely) sustained and sheltered. They are rained
upon by sympathy and sunshined by kindness. They are fenced about with
every sort of protection which the legislature can devise. Magistrates,
guardians, commissioners, friends inspect them, visit them, record their
grievances, register their scratches, encourage their complaints, and tabulate
their ailments”
(Sheppard, 1972 cited in Barham, 1992, page x)
Townsend (1962) however quotes a report of visits to workhouses by
members of the Royal Commission on the Poor Laws of 1909 which
describes the ‘institution’ in a completely different light:
The inmates, over 900 in number, were congregated in large rooms without any
attempt to employ their time or cheer their lives. There was a marked absence
of any human interest… it could not be better described than as a ‘human
warehouse’. The dormitories which in some cases accommodated as many as
60 inmates, were so full of beds as to make it impossible to provide chairs, or
to walk, except sideways, between them the… ‘home’ which we visited in the
afternoon seemed to us defective in every particular… the rooms were low, illlighted, and hopelessly overcrowded. The men were, in many cases, lounging
in the bedrooms, there being no chairs except in the dining hall, and there was
a total absence of books or newspapers – as far as we saw – and it is
impossible to conceive a more dismal and hopeless asylum for age. The
administration consists of but 2 officers for 268 inmates. The officer in charge,
however, stated that they had no difficulty in enforcing such discipline as was
necessary. The only outdoor space available for the inmates was an asphalted
roof yard, some 35 feet by 25 feet, up so many flights of stairs that a large
proportion of inmates were unable to mount it.
(Townsend, 1962 cited in Allot & Robb, 1988 page 10)
Skull (1996) notes that during the mid nineteenth century, there were between
25% and 40% of admissions who were discharged within a year of their
arrival. Each year however, a substantial number of patients were not
discharged and the population of long-stay patients in the county asylums
grew continuously. At the same time, annual admissions were reducing as a
whole. A large number of the asylum population were those who had lingered
year after year. The general public began to identify asylums with chronically
mentally ill, hopeless incurable individuals, the waifs and strays, and the weak
and wayward of society.
The Victorian view of madness was that it was an irreversible product of a
process of mental degeneration and decay:
“…psychiatric discourse exhibited a barely disguised contempt for those
‘tainted persons’ who it sequestered on society’s behalf”
(Skill, 1996, page 12)
The quality of the care provided was poor, and amounted to nothing more
than custodial care – the goals of the institutions were ‘control’ and ‘discipline’.
Patients were regarded as ‘objects’ to be ‘managed’ rather than individuals to
be treated and there appeared to be no therapeutic aim. Local authorities
were reluctant to provide funds for what was regarded as a custodial
operation and any funds which were provided were rarely more than what was
needed to supply a bare minimum of care.
Total Institutions
Goffman (1961) coined the phrase “total institution” and defined it 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”
(Goffman, 1961, page 11)
Goffman (1961) notes that prisons serve as a clear example of total
institutions where inmates who have broken the law live in an environment
where they are denied certain rights. Goffman (1961) also reminds us
however that:
“What is prison-like about prisons is found in institutions whose members
have broken no laws”
(Goffman, 1961, page 11)
Goffman (1961) refers to mental institutions, where upon admission to this
example of a total institution, the individual is immediately stripped of the
support previously provided by “stable social arrangements of his home
world”.
“He begins a series of abasements, degradations, humiliations and
profanations of self. His self is systematically, of often unintentionally
mortified… The inmate than finds certain roles are lost to him by virtue of the
barrier that separates him from the outside world… we generally find staff
employing what are called admission procedures, such as taking a life history,
photographing, weighing, assigning numbers, searching, listing personal
possessions for storage, undressing, bathing, disinfecting, haircutting, issuing
institutional clothing, instructing as to rules and assigning to quarters!
(Goffman, 1961, pages 24 - 25)
Goffman (1961) feels that the process of ‘disculturation’ or ‘role stripping’
renders the individual incapable of normal living until the person has been
‘reduced from a person with many roles to a cipher with one: the inmate role’
(Jones and Fowels, 1998 in Allot & Robb [Ed], 1998). This process,
according to Goffman (1961) suggests that because a total institution deals
with so many aspects of its inmates’ lives, there is a need to obtain immediate
cooperativeness from the inmate:
“Staff often feel that a recruit’s readiness to be appropriately deferential in his
initial face-to-face encounters with them is a sign that he will take the role of
the routinely pliant inmate… the initial moments of socialisation may involve an
‘obedience test’ and even a will-breaking contest: an inmate who shows
defiance receives immediate visible punishment, which increases until he
openly ‘cries uncle’ and humbles himself”
(Goffman, 1961)
This requirement of inmates of institutions to be submissive is reiterated by
Barham (1992) who quotes an informative account by Denis Martin – a
physician superintendent of a mental hospital in the early 1960’s:
“… in the traditional mental hospital the satisfactory running of the whole
hospital depended upon the submission of the patients to authority with a
minimum of resistance. Traditional ways developed of dealing with those who
were unable to submit adequately to the life of the institution… these consisted
mainly of locked doors, various forms of mechanical restraint and segregation
of the sexes. These were followed by the employment of heavy sedation and in
more recent years by the use of electrical cerebral treatment, prolonged sleep
by drugs and the operation of a prefrontal leucotomy”
(Martin, 1962, page 2 cited in Barham, 1992, Page 7)
The constant repression and browbeating of ‘inmates’ was compounded by
the environment in which they lived. Goffman identified 16 characteristics
which are found in the environments of total institutions:
1. all aspects of life are conducted in the same place, under the same
single authority
2. all activities are carried out in the company of others, treated alike and
required to do the same things together
3. the day’s activities are tightly scheduled with one activity leading to
another at a pre-arranged time
4. sequencing of activities is imposed by a system of explicit formal
rulings and a body of officials whose task is surveillance
5. various activities are brought together in a single rational plan designed
to fulfil the official aims of the institution
6. there is a basic split between a large managed group/the inmates, and
a small supervisory group
7. each group tends to conceive of the other in terms of narrow, hostile
types
8. staff tend to feel superior and righteous; inmates feel inferior,
blameworthy and guilty
9. social mobility between the two groups is severely restricted; social
distance is great and formally prescribed
10. the passage of information about staff plans for inmates is restricted
and inmates are excluded from decisions about their fate
11. incentives for work have little significance outside the institution
12. groups have only official points of contact
13. there is a barrier between the inmates and the outside world
14. inmates are de-possessed of their basic human rights
15. high-ranking inmates have more authority than low-ranking supervisors
16. inmates are expected to internalise the norms of staff
Institutional Neurosis
The term Institutional Neurosis was coined by Barton (1960) who defined it as
a disease characterised by:

apathy

lack of initiative

loss of interest in all but the mundane

submissiveness to authority and sometimes no expression of feelings
of resentment at harsh or unfair orders

lack of interest in the future and an apparent inability to make practical
plans for it

a deterioration in personal habits, toilet, and standards generally

a loss of individuality

resigned acceptance that things will go on as they are – unchangingly,
inevitably and indefinitely
Barton identified these symptoms as being a separate disorder from the one
which originally brought the individual into hospital and suggested that it was
produced by the contemporary methods of looking after people in mental
hospitals – i.e. custodial care (Swann, 1997). The signs, according to Barton
(1960) vary from the ‘patient’ who is mute and ‘stuporose’ to the ‘ward worker’
who has a role in the ward and who surrenders their whole life to the
institution without complaint.
Barton (1960) also identified an array of characteristics which are found in the
environments of institutions. These characteristics when compounded induce
the onset of institutional neurosis. The factors include:
1. loss of contact with the outside world
2. enforced idleness/loss of responsibility
3. Bossiness of medical and nursing staff
4. loss of personal friends, possessions and personal events
5. drugs
6. repressive atmosphere
7. loss of prospects outside the institution
The characteristics of people suffering from Institutional Neurosis are
described poignantly by Swann (1997) in a ‘pen-picture’ of a fictitious
character. As noted by Swann (1997), the terminology used in the pen-picture
was that which was used at the time depicted:
Pen Picture of Marjorie in 1970
In 1970 Marjorie was 56 years old and had lived most of her life in a
local mental handicap hospital. Marjorie did not know if her family were
still alive, as she had not had contact with them for the lat 30 years.
She was first admitted to the hospital nearly 40 years ago, when it was
clear that she would not be able to find employment. Her notes on
admission to the hospital described her as ‘feeble minded’ and in need
of a protective environment because of the risk of pregnancy following
a number of suspected incidents with local inhabitants. The cause of
Marjorie’s mental handicap was congenital syphilis, resulting from
maternal infection. She had a typical facial appearance which included
a saddleback nose, opacities of the cornea and nystagmus.
Marjorie lived on Primrose ward along with 45 other women with
varying degrees of mental and physical handicap. Primrose ward had
an unpleasant smell – a mixture of urine and faeces.
A typical day in Marjorie’s life would have started at around 7 am when
she would be wakened by the day staff starting their duty. She would
be told to go and wash and dress. Because she was more capable than
some of the others, Marjorie was able to jump the queue of naked
bodies waiting to be bathed or washed. Marjorie had no personal
belongings, and so washed with whatever toiletries were available. Noone seemed to bother much bout cleaning teeth. Sometimes it was
difficult for Marjorie to find a dress which would fit from the central
supply of clothes in a cupboard. Occasionally, particularly after the
weekend when the laundry staff had been away, it would be difficult, if
not impossible, to find any underwear at all. Marjorie’s help was often
enlisted by staff to look after some of the low-grade patients which who
she lived. She would help them to wash and dress in the morning, help
feed them at mealtimes and ’tuck them in’ at night. During the day,
having helped to get everyone bathed, dressed and fed, Marjorie stood
outside the front door to watch and chat with passers by. These usually
consisted of nurses and doctors going to meal breaks or starting and
finishing shifts at the hospital.
Referred to as ‘teabelly’ by staff and high-grade patients alike, it was
one of Marjorie’s jobs to make a drink of tea at meal times. This was
made exactly the same for all the patients: the tea was mixed with the
milk and sugar in a big teapot to save time. Meal times were particularly
noisy, with staff constantly shouting at patients to sit down and shut up.
Some of the patients used to take Marjorie’s food which made her very
agitated and upset. After Marjorie had helped to clear the pots away
she would wait by the door until the staff unlocked it, and then she
would quickly go back to her usual place outside. She only ventured
back indoors at mealtimes, cup of tea times and bed time. Bed time
was at 7pm and everyone was in just in time for the night staff to arrive
on duty. Marjorie slept in a large dormitory with the other 45 women.
Sometimes it was difficult to sleep because of the incessant screaming
and shouting of the patient who occupied the next bed, but for Marjorie,
as for many other patients during this time, this was a way of life”
(Swann, 1997 page 41)
ACTION LEARNING SET ACTIVITY
From your experience, consider some of the people who you have cared for
who have spent a long time living in an institution.
1. Provide a pen-picture of an individual who you feel shows/has shown
signs of institutional neurosis
2. Describe some of their characteristics and state why you feel these
characteristics have developed
3. Describe some of the characteristics of the environment in which they
lived
4. How many of Goffman’s characteristics of a total environment were
evident?
5. How many of Barton’s characteristics of institutional neurosis were
evidence?
6. What are the implications for practice?
References and Recommended Reading
ALLOT, M. & ROBB, M (1998) Understanding Health and Social Care: an
introductory reader London, Sage Publications
BARHAM, P. (1992) Closing the Asylum: The Mental Patient in Modern Society
London, Penguin
BARTON, R. (1960) Institutional Neurosis Stonebridge Press, Bristol
BARTON, R. (1998) Family Involvement in the Pre-discharge Assessment of long
stay patients with learning disabilities: a qualitative study Journal of Lerning
Disabilities for Nursing, Health and Social Care Vol 2, No 2, Pages 79 – 88
CLARK, D.H. (1996) The story of a Mental Hospital: Fulbourn 1858 – 1983
London, Process Press
FAULKS, S. (2006) Human Traces London, Vintage Books
GATES. B (2007) [Ed] Learning Disabilities Toward Inclusion [5th Edition] London,
Churchill Livingstone
GOFFMAN, E. (1961) Asylums: Essays on the social situation of mental
patients and other inmates London, Penguin
MALIN (1995) Services for people with learning disabilities London, Routledge
PILLING, S. (1991) Rehabilitation and Community Care London, Routledge
SKULL (1996) Asylums, Utopias and Realities, Ch 1 TOMLINSON, D. & CARRIER,
J. [Eds] (1996) Asylum in the Community London, Routledge
SWANN (1997) Development of Services, Ch 3 GATES, B. [Ed] (1997) Learning
Disabilities [3rd Edition] London, Churchill Livingstone
TOMLINSON, D. & CARRIER, J. [Eds] (1996) Asylum in the Community London,
Routledge