GOFFMAN, E.: Asylum
str. 283-288,297-303,321-333
INeach societythere arefavouredways in which two individuaIs
canapproacb and have dealings with each other, for example, as
kindred to kindred, or high caste to low. Each of these frame
works for contact can be at once a sourceof identity, a guide for
ideal conduct, and a basis of both solidarity and divisiveness.
Each framework involves a set of interdependent assumptions
that fit together to form a kind of model. In every case we find
that characteristicpressures prevent persons from fully realizing
the ideal and that the resulting deviations have characteristic
reverberations. The student of society can therefore use for
his purposes the same models that members of society use for
theirs.
In our Western society, an important way in which two individuals
may deal with each other' is as server and served. By
exploring the assumptions and ideals behind this occupational
relationship, I think we can understand some of the problems of
mental hospitalization.
Specialized occupational tasks can be divided into two categories,
one where the practitioner 'meets the public' through his
work, a second where he does not, performing it only for the
establishedmembers of his work organization.I assume that the
problem of facing the public and of controlling it is sufficiently
central to merit treating together a11 who experience it. This
means that a hardware-storeclerk and a factorytool-bin man are
to be separated for purposes of study, in spite of similarities in
what they do.
Among tasks requiring the performer to meet the public, two
kinds may be distinguished, one where the public consists of a
sequence of individuals, and another where it consists of a sequence
of audiences. A dentist performs the first kind of task, a
comedian the second.
284 ASYLUMS
Tasks which require the practitioner to meet the public (in
either of its fonns)vary in the degreeto which they are presented
to this public as a personal service, that is, as an assistance desired
by the recipient. A personal-service occupation may be defined,
ideally, as one whose practitioner performs a specialized
personal servicefor asetof individualswhere theservicerequires
him to engage in direct personal communication with each of
them and where he is not otherwise bound to the persons he
serves.1By this definitionthe process of being served a summons,
for example, is not a personal service for the person served. A
psychologist who sells vocational testing to persons who want to
learn about their aptitudesis performinga personal service,butif
he tests the same persons for the empIoyrnent officeof an organization
they are merely the subjectsof hiswork and not hisclients.
So also, in spite of the languageof census takers, I exclude domestic
servants from the category of servers, since a maid has a
mistress, not a public, and I exclude charwomen, since they do
not routinely engage in direct communication with those who
walk on their clean floors.
In this paper I want to consider personal-serviceoccupations
as here defined, but I shall includesomepractitioners who do not
entirely fit my definition,sincetheideal onwhich it isbased draws
people who are not in a position to conform to it. Deviations
from an ideal imposed by self or others create problems of identity
that the student must understand in terms of the ideal -and
understand differentlydependingon the relation of the deviation
to the ideal: a high-pressure car salesman and an insurancecompanydoctor
both providesomethinglessthan a personalservice,
but for a different framework of reasons.
A traditional means of classifyingpersonal-serviceoccupations
isbythe honour accorded them, withtheliberal professionsfalling
at one extreme and the humble trades and crafts at the other.
This can be an obscuring distinction, separating by rank those
1. Sociological interest in service occupations stems largely from Everett
C. Hughes and is documented in the work of his students at the University
of Chicago, especially Oswald Hall and Howard S. Becker. See especially
the fatter's 'The ProfessionalDance Musicianand His Audience'. American
JOWMIof Sociology. LVII (1951). pp. 13644.
MEDICAL MODEL A N D MENTAL HOSPITALIZATION 285
who are similar in spirit. The divisionI want to employ places at
one extreme those, such as ticket-takers or telephone operators,
who perform a perfunctory technical service, and at the other
those with an expertness that involves a rational, demonstrable
competencethat can be exercised as an end in itself and cannot
reasonably be acquired by the person who is served. Perfunctory
servers tend to have customers, 'parties', or applicants; expert
servers tend to have clients. Both types of servers are likely to
have some independence from the persons they serve, but only
experts arein a positionto build that independenceinto a solemn
and dignified role. It is the social and moral assumptions underlying
the practice of expert, rather than perfunctory, servicing
that I want to consider in this paper.
I suggest that the ideals underlying expert servicing in our
society are rooted in the case where the server has a complex
physical system to repair, construct, or tinker with - the system
here being the client's personal object or possession. Hereafterin
this paper when I use the term service relation (or occupation)
this pure case will be implied unless the context necessitates a
more careful reference.
We deal with a triangle-practitioner, object, owner -and one
that has played an important historical role in Western society.
Every large society has expert servers, but no society has given
such servicemoreweight than has ours. Ours is a servicesociety,
so much so that even such institutions as stores come to follow
this style in word if not in fact, responding to the need of both
clerks and customersto feel that expert personal service is being
provided even while they despair of realizing it.
The type of social relationship I will consider in this paper is
one where some persons (clients) place themselves in the hands
of otherpersons(servers).Ideally,theclientbringstothisrelationship
respect for the server's technical competence and trust that
he will use it ethically; he also brings gratitude and a fee. On the
other side, the server brings: an esotericand empiricallyeffective
competence, and a willingness to place it at the client's disposal;
professional discretion; a voluntary circumspection, leading him
to exhibit a disciplined unconcern with the client's other affairs
or even (in the last analysis) with why the client should want the
286 ASYLUMS
service in the &st place; and, finally, an unservilecivility.2 This,
then, is the tinkering service.
We can begin to understand the servicerelation by examining
the concept of the fee. Thereis a doublesenseinwhich a feeisnot
a price.3 Traditionally a feeisanythingotherthan what theservice
is worth. When services are performed whose worth to the client
at the time is very great, the server is ideally supposed to restrict
himself to a fee determined by tradition -presumably what the
server needs to keep himself in decent circumstanceswhilehe d e
votes his life to his calling. On the other hand, when very minor
services are performed, the server feels obliged either to forgo
charging altogether or to charge a relatively large flat fee, thus
preventing his time from being trifled with or his contribution
(and ultimately himself) from being measured by a scalethat can
approach zero.4When he performs major services for very poor
clients, the server may feel that charging no fee is more dignified
(and safer) than a reduced fee.5 The server thus avoids dancingto
the client's tune, or even bargaining,and isable to showthat heis
motivated by a disinterested involvement in his work. And since
his work is the tinkering kind, which has to dowith nicely closed
and nicelyreal physical systems,it is precisely the kind of work in
which disinterested involvement is possible: a repair or construction
job that is good is also one that the server can identify with;
this adds a basis of autonomous interest to the job itself. Pre-
2. This description of the servicerelationshipdrawsheavily on Parson's
paper, 'The Professions and the Social Structure', which I feel is still
the leading statement in this area. See also Talcott Parsons and Neil
Smelser, Economy and Sociefy (Glencoe, Ill.: The Free Press, 1956), pp.
152-3.
3. See,for example, A. M. Carr-Saundersand P. A. Wilson, The Professions
(Oxford: The Clarendon Press, 1933). section 'Fees and Salaries'
pp. 451-60.
4. Themore lowly the tinkering trade,the more need the servermay have
to forgo charging for certain minor but skilled services. Among shoemakers
these acts of noblesse oblige canbecome lordly indeed,just at a time
in history when lords can no longer afford the original version.
5. Carr-Saundersand Wilson, op. cit., p. 452: 'In most other professions
[other than accountancy] the associations attempt to induce their members
not to undercut, though objection is never raised to the remission of fees
when the client is poor.'
MEDICAL MODEL AND MENTAL HOSPITALIZATION 287
sumably the server's remaining motivation is to help mankind as
such.
The server's attachment to his conception of himself as a disinterested
expert, and his readiness to relate to persons on the
basisof it, isa kind of secular vow of chastityand isat the root of
the wonderful use that clients make of him. In him they find
someone who does not have the usual personal, ideological, or
contractual reasons for helping them; yet he is someonewho will
take an intense temporary interest in them, from their own point
ofview, and in terms of their own best interests. As onestudent of
human affairs suggests:
As defined in this culture,theexpert is onewho deriveshis incomeand
status, one or both, from the use of unusually exact or adequate
information about his particular field, in the service of others. This
'use in theserviceof' is fixed in our industrialcommercial socialorder.
The expert does not trade in the implements or impedimenta of his
field; he is not a 'merchant,' a 'collector,' a 'connoisseur,' or a 'fancier,'
for these use their skill primarily in their own interest.6
It therefore pays the client to trust in those for whom he does not
have the usual guarantees of trust.
This trustworthiness available on request would of itself provide
a unique basis of relationship in oursociety, but thereisstill
another factor: the server's work has to do with a rational competence,
and behind this a belief in rationalism, empiricism, and
mechanism, in contrast to the more self-referential processes
that plague people.
The interaction that occurs when client and serverare together
ideally takes a relatively structured form. The server can engage
in mechanical, handwork operations on the client's possession,
especiallywork of a diagnostic kind; he can also engagein verbal
exchanges with the client. The verbal part itself contains three
components: a technical part, namely the giving and getting of
relevant repair (or construction) information; a contractualpart,
being a statement, often discreetly brief, regarding approximate
costs, approximate time for the job, and the like; and finally, a
.sociablepart, consisting of a few minor courtesies, civilities, and
6. Harry Stack Sullivan, 'The Psychiatric Interview', Psychiatry, XIV
(1951), p. 365.
288 ASYLUMS
signs of deference. It is important to seethat everythingthat goes
on between server and client can be assimilated to these components
of activity, and that any divergences can be understood in
terms of these normativeexpectations.Thefull assimilationof the
interaction between server and client to this framework is often
for the server one of the tests of a 'good' servicerelation.
The technically relevant information that the server needs, in
order to repair or construct effectively, comes to him from two
sources: from the client's verbal statements, and from the object
itself, through the direct impression it makes on the server. Following
the practice sometimesemployedin medicine, we can call
the client's reported difficulties symptoms, and the data directly
obtained by the server signs, although there is no particular warrant
for this usage in semiotics.The dignity of the servicerelation
is partly based on the capacity of the client to contribute usable
information, albeit filtered through lay language and lay sensibility.
The servicingcan then take on something of the spirit of a
joint undertaking, with the server showing some respect for the
client's unschooled appraisal of the trouble.
The server has contact with two basic entities: a client and the
client's malfunctioning object. Clients are presumably selfdetermining
beings, entities in the social world, that must be
treated with appropriateregard and ritual. Thepossessed object is
part of another world, to be construed within a technical, not a
ritual, perspective, The success of the servicing depends on the
serverkeepingthese two different kinds of entities separatewhile
giving each its due.
Let us now turn to the object that the serverrepairs or constructs.
I have describedthis object (or possession) as a physical systemiri .
need of expert attention, and I shall focus on repairs, as more
usual than construction. Linked with the notion of repairs is a
conception of the repair cycle, the phases of which I would like
to describe briefly.
We can begin by considering our everyday conception of
etiology. The common nail can serve us as a starting point, for it
is an object that commonly begins a repair cycle. A nail on the
MEDICAL M O D E L A N D MENTAL HOSPITALIZATION 297
server. We now have a triad - client, server, community - and
this can strike at the heart of serving even more than the triadic
feature that occurswhen the serverjoins anestablishment of some
kind and divides his loyalty between the firm's clients and the
firm's management.
We now turn to the medical version of the tinkering-services
model.12 Our giving our bodies up to the medical server, and his
rational-empirical treatment of them, is surely one of the high
points of the service complex. Interestingly enough, the gradual
establishment of the body as a serviceablepossession - a kind of
physicochemical machine - is often cited as a triumph of the
secularscientific spirit, when in fact this triumph seems in part to
have been both cause and effect of the rising regard for all types
of expert servicing.
The signs that medical men currently employ, especially signs
involving refined laboratory work, are increasingly sophisticated,
yet medical men still claim to rely on the patient for reporting
symptoms; the client is still a participant to be respected in the
service relationship. But, as with other competencies, there are
specialpoints of strain in fitting the treatment of the body into the
service framework. I would like to mention some of these, with
the understanding that the same problems also arise to some degree
in other kinds of servicing.
The first issue is that the body is, as psychoanalysts say, highly
cathected in our society; persons place great value on its appearance
and functioning and tend to identify themselves with it.
Individuals are uneasy about giving their bodies up to the
rational-empirical ministrations of others, and hence need their
'confidence' in the server continuously shored up by bedside
assurances. This problem must not be overstressed, however, not
because persons are ceasing to identify with their bodies but
because of what we are slowly learning about how much they
12. Compare T. S. Szasz, 'Scientific Method and Social Role in Medicine
and Psychiatry', A.M.A. Archives of Internal Medicine, CI (1958). pp. 232-
3, and his 'Men and Machines', British J O U ~ M ~for tire Philosophy of
Scienck, VIII (1958), pp. 310-17.
298 ASYLUMS
identify with quite non-curporal things, such as wrist watches
and cars, seeing in a threat to these 'good objects' a threat to
self.
The very willingness of clients to put their bodies' fate in the
hands of thcir physicians carries its own problem for medical
men: they may find that sympathy with the patient subjects them
to emotional stress when they are uncertain of what is wrong or
what can be done for the patient, or when they are certain that
little can be done and must impart this information to the person
(or his guardian) whose fate will be sealed by it.13 But fiere, perhaps,
we have a problem not for medical servicing as such but
for the individuals who perform it.
Another problem is that the body is one possessionthat cannot
be left under the care of the server while the client goes about his
other business. Admittedly physicians show a remarkable capacity
to carry on the verbal part of the server role while engaging
in the mechanical part, without this segregation breaking down,
but there are inevitable difficultieshere, since the client is very
interested in what is happening to his body and is in a good position
to see what is being done. (Barbers, hairdressers, and prostitutes
knowofthese troubles, too,of course,sincepoormechanical
activity on their part may be instantly perceived by the everpresent
client.) One solution is anaesthesia; another is the wonderful
brand of 'non-person treatment' found in the medical
world, whereby the patient is greeted with what passes as civility,
and said farewell to in the same fashion, with everything in between
going on as if the patient weren't there as a social person
at all, but only as a possession someone has left behind.14
13. An analysis of the pressures upon a physician to evade cornmunicat
~ n ga known bad prognosis and to offer an opinion when in fact he feels
unccrtain is provided in Fred Davis, 'Uncertainty in Medical Prognosis,
Clin~caland Functional ', American Jo~crnalof Sociology, LXVI (19601,
pp. 41-7.
14. The non-person solution seems especially effective when the examining
physician is acconlpanied by colleagues and subordinates, as when
making rounds, for then he will have participants available for a technical
conversation about the case. So effective is this way of suppressing the
social presence of the patient that his fate can be openly discussed around
his bed without the discussants having to feel undue concern; a technical
vocabulary presumably unknown t o the patient helps in this regard.
M E D I C A L MODEL A N D MENTAL HOSPITALIZATION 299
Another issue in medicine has to do with the appreciable margin
of merely palliative action, of 'elective procedures', and of
unsuccessful treatment. With many mechanical objects, every
possible disorder can be fixed, depending only on how much of
the original object is replaced with new parts, and this may require
no great skill. A radio mechanic of average ability can fix
absolutely any broken radio by the simple expedient of checking
out sections of the circuit and replacing the parts where the
trouble seems to lie. It is the realistic boast of a well-supplied
automotive-parts distributor that he can build a complete car in
his supply rooms from the parts on hand. Not so in medicine.
Some parts of the body cannot be replaced, and not all physical
disorders can be corrected. Further, due to medical ethics, a
physician cannot advise a patient to junk the badly damaged or
very worn object his body may have become (as can those who
serviceother types of objects), although the physician may tacitly
give such advice to other interested parties.
Although this lowered probability of repair is characteristic of
medicine, there are effective techniques for the management of
doubt. Even in the case of a brain surgeon, who may expect to
lose half his cases, clients can be made to see that this is merely a
chancy, last-resort department of medicine, made tolerable by
the probability of effectiveness achieved in many of the other departments.
Further, there are expert services, albeit of a nontinkering
kind, such as those a lawyer or broker provides, where
the probability of success may well be lower than in general
medicine and a sense of ethical professional service can still
survive. In all these cases the server can take the stand that,
whether he succeeds or fails this time, he is applying the best
techniques to the best of his abilities, and that in general it is
better to rely on these techniques and abilities than to rely on
pure chance. Respectful and continued relations between many
brokers and their clients attest to the fact that, once a service
definition of the situation is accepted, clients are willingto accept
a probability very little greater than chance as justification for
remaining within the relationship. The client finds that he must
consider not how well he has done with the server, but rather
how much worse he might have done without him, and with this
300 ASYLUMS
understanding he is led to accord the ultimate tribute to esoteric
skill: cheerful payment of the fee in spite of the loss of the object
that the server was hired to save.
Another interesting difficulty in applying the tinkeringservice
model to medical practice is that the injurious agent is
recognized in some cases to be not a randomly disposed improbable
event in the environment, but the environment itself.
Instead of there being one nail on the road, the road is covered
with them. Thus, for certain physical disorders, a given climate
or given type of work is exacerbating. If the patient can afford a
complete change of scenery, the pathogenic environment can be
looked upon as merely one of the many possible environments,
and hence the improbable member of a generally healthy class.
For many patients, however, change in life situation is not
practical, and the servicemodel cannot be satisfactorily applied.
Associated with the fact that the environment itself may be the
pathogenic agent is the possibility of pursuing medicine at the
community level, treating not a single individual but a large
social unit, and reducing the probability of a specific illness
within a whole set of persons rather than curinga specificpatient.
The whole emerging field of epidemiology is of this order, constituting
not so much a threat to medical practice on individuals
as a supplement to it.
Whilemany individualscan be relied upon to act asresponsible,
self-willingagents in regard to their bodies, it is apparent that the
very young, the very old, and the mentally ill may have to be
brought to medical attention 'for their own good' by someone
else, thus radically changing the usual relation between client,
possession,and server.Often anattemptismadetoassimilatesuch
situations to the free-agent model by having the patient brought
in by sonleone with whom he is socially identified, typically a
kinsman who can stand in forhim and as a guardian be trusted to
represent his ward's best interests. Perhaps a factor here is that
the seeking of medical service by free agents is often itself not so
free, but a product of consensus, if not pressure, on the part
of the patient's close kin group. It may be added that when dire
news must be given a patient he may suddenly find that his
capacities as object and as client are split apart. He retains his
MEDICAL MODEL A N D MENTAL HOSPITALIZATION 301
status as an object but his role as client is subtly transferred to
someone close to him. Sometimes the issue is not that he is no
longer competent as a social person but that the physician is
disinclined to become embroiled as a participant-witness of
someone's immediateresponsetoa destruction oflifechances.
The guardian problem can illustrate the conflict that may
arise between what a server and his discipline feel is in the best
interests of the client and what the client himself desires. This
potential conflict is sharpened by a further factor, the tension
between client interests and community interests. An obvious
exampleis the caseof communicablediseases,wherethephysician
has the legal obligation to protect the community as well as his
client. Other examples of this conflict are abortion and the
treatment of unreported gunshot wounds, although in both
casesthere is an out, an abortion often beingdefined as not in the
'best' interests of the person seeking it, and gunshot wounds being
treated, provided police authorities are informed at the same
time. A third instance is the early restriction on the use of plastic
surgery for purely cosmetic reasons, although what was at stake
here was not so much the welfareof the community asthe dignity
and disinterestedness of the medical profession itself. And of
course there are other instances, such as the Soviet physician's
interesting problem of whether to grant to a worker what will be
his only holiday although he doesn't have very much wrong
with him,*sor the American physician's problem of whether to
'write scrip' for drugsto confirmed addicts.
Another problem in managing medicine within the service
framework is that patients often feel they can seek advice from
their physician on non-medical matters, and the physician sometimes
feelshe has a specialcompetence thatjustifies his accepting
this diffusion of his role.16 More important, and increasingly
important, is another problem: in spite of the efforts of medical
professional associations, in somecountries medical practice as a
wholeis tending away from the ideal of the free practitioner with
an unorganized clientele to one where a bureaucratic agency of
15. M. G. Field, 'Structured Strainin the Role of the SovietPhysician',
American J o u r ~ Iof Sociology, LVIII (1953). pp. 493-502.
16. Szasz, 'Scientific Method ...'op. cit., p. 233 fn.
302 ASYLUMS
some kind provides service to clientswho have little choiceover
which of the availablephysiciansthey get to see. This is a serious
threat to the classic service relation, but I do not think we yet
know about its long-rangeconsequencefor theserviceideal.
From the point of view of this paper, the most relevant strain
in the application of the service model to medicine resides in the
workshop complex,in spiteof the fact that on someoccasions, as
in certain surgical undertakings, a roomful of people may be
intimately regulated by a multitude of detailed rules, almost all
of which are rationally grounded in technical considerations.
While typically presenting themselves as public service institutions
run for the benefit of mankind, some hospitals have frankly
operated for the profit of their owners, and all have shown concern
about the social characteristicsof their staff and patients. So,
too, many hospitals are involved in training programmes that
lead some treatment decisionsto be influenced not merely by the
needs of the patient in question but also by the techniques and
medications in which the hospital specializes. Similarly, many
hospitals are involved in research programmes that sometimes
lead to treatment dictated not so much by the needs of thepatient
as by the requirementsof theresearchdesign.
There are other difficulties, too. As already suggested, the
client will find it difFicult to treat his body, and have it treated,
impersonaliy, and to overlook thefact that he cannot use it in the
usual fashion while it is being repaired. Further, it is increasingly
appreciated that even a brief sojourn in the hospital can create
'separation anxiety' in the very young; the implicationis that the
workshop in such cases is not a benign neutral environment,
but a hurtful one. Furthermore, sincethe client must reside inthe
workshop during the active treatment phase of the repair cycle,
he is well situated to see the difficultiesof assimilating everything
that occurs around and to him to the servicemodel. The success
of the patient in making this assimilation necessarily resides in
his being deceived about certain procedures, becausealways some
of the hospital routine will be dictated not by medical considerations
but by other factors, notably rules for patient management
that have emerged in the institution for the convenience and
comfort of staff. (The same divergence from service-determined
MEDICAL MODEL A N D MENTAL HOSPITALIZATION 303
rulesistrue, ofcourse, ofeveryworkshop, but in theseotherworkshops
the client is not usually present to see what happens.) The
longertherequired stayin thehospital, and the more chronic and
lingering the disorder, the greater the difficultythe patient will
have in seeing the hospital as a thoroughly rational service
institution.
In spite of these and other difficulties in housing medical
services within a hospital establishment, there are factors which
are effective in allowing the patient to assimilate all his hospital
experience to the service model - providing his stay is not too
long. Obviously the hospital can provide the patient with the
benefit of heavy capital equipment and specialized instruments
that no doctor's officecould provide. Further, to rest immobilein
bed is, after all, defined as what one does in our societywhen one
is sick, and in some cases the patient may feel physically incapableof
doing anything else. Sometechnical aspects of medical
attention add additional support: bone fractures and many postoperative
states patently necessitate immobility, as do, occasionally,
such post-operative procedures as draining; some
therapies require a highly regulated diet; charting and lab work
often require constant availability of the patient. AII of this
provides rational justification for the posture the patient must
assumein thehospital.
An additional factor strengthens this assimilation of hospital
experienceto the servicemodel. Often during hospitalization and
post-hospital care there is a split introduced into the patient's
environment:within a bandage or cast or otherwise bounded part
of the body, a medically adjusted environment is intensively
maintained; the condition in which everythingoutside this boundary
is maintained can then be rationalized not on the direct
grounds of its salubriousness, but as a basis for ensuring the
maintenance of the inner environment. In this way the area over
which patently useful medical actions are maintained can be
greatly reduced without jeopardizing the possibility that the
patient will be able to assimilate everything that is occurring to
him to themedical model.
These bases of validity to the serviceclaims made by hospitals
make more secure the service stance assumed by the physician,
320 A S Y L U M S
line the patient must follow if the psychiatrist is to be a a m e d as
a medical server.
The likelihood of an unschooled patient following the psychiatric
line is not great. He may never in his life have had so
many reasons obvious to him for seeingthat he is not a voluntary
client and for being disgruntled at his condition. He sees the
psychiatrist as the person in power. In contact with the psychiatrist
the patient is likely to make those kinds of demands and
requests and take those stands that pull the relationship out of the
service schema to, for example, that of a charge pleading with
his master for more privileges, a prisoner remonstrating with an
unlawful jailer, or a prideful man declining to exchange communications
with someone who thinks he is crazy.
If the psychiatrist takes these complaints seriously, the relationship
ceasesto be the one for which he was trained. TOdefend
his own professional role and the institution that hires him, the
psychiatrist is under pressure to respond by treating these outpourings
not as directly usable statements of information but
rather as signs of the illness itself, to be discounted as direct information.32
But to treat the statements of the patient as signs, not
valid symptom reporting, is of course to deny that the patient is a
participant aswell as an object in a servicerelation.
The psychiatrist and patient tend to be doomed by the institutional
context to a false and difficult relationship and are
constantly funnelled into the contact that will express it: the
psychiatrist must extend service civility from the stance of a
server but can no more continue in that stance than the patient
ean accept it. Each party to the relationship is destined to seek
out the other to offerwhat the other cannot accept, and each is
destined to reject what the other offers. In many psychiatric
settings, one can witness what seems to be the same central encounter
between a patient and a psychiatrist: the psychiatrist
begins the exchangeby profferingthe patient the civil regard that
is owed a client, receives a response that cannot be integrated into
a continuation of the conventional service interaction, and then,
even while attempting to sustain some of the outward forms of
32. On the problem of discounted statements, see Stanton and Schwartz,
op. cit., p. 200 ff.
M E D I C A L M O D E L A N D M E N T A L H O S P I T A L I Z A T I O N 321
server-clientrelations, must twist and squirm his way out of the
predicament. All day long the psychiatric staff seems to be engaged
in withdrawing from its own implicit overtures.
In discussing the application of the expert service model to
various trades, I suggested some standard discrepancies or
strains and argued that institutional psychiatric servicing faced a
very extensive set of these problems. This situation is in itself
not very noteworthy; many 'expert' services are sold that satisfy
even less well than psychiatry the requirements of the model in
whose guise they are presented, albeit few involving so many
clients so sorely tried. What is analytically interesting about the
mental-hospital case is that doctors are involved, and so are
involuntary inmates. Medical doctors in our society areexemplars
of the rational, tinkering approach and ordinarily are allowed to
invest their performances with great dignity and weight. Having
committed much time and expenseto acquiring the medical role,
and expectingtheir daily activity to support them in the role their
training has vouchsafed them, they understandably feel compelled
to maintain a medical approach and the medical version
of the service model. Society at large seems to back them up in
this, for it is a satisfaction to us all to feel that those we exile to
madhouses are receiving treatment, not punishment, under a
doctor's care. At the same time, involuntary mental commitment
(and often even voluntary commitment) ordinarily entails for the
individual a condition of life that is impoverished and desoIate
indeed, often generating a sustained hostility to his captors. The
limited applicability of the medical model to mental hospitals
brings together a doctor who cannot easily afford to construe his
activity in other than medical terms and a patient who may well
feel he must fight and hate his keepers if any senseis to be made of
the hardship he is undergoing. Mental hospitals institutionalize a
kind of grotesque of theservicerelationship.
While both doctors and inmates find themselves in a difficult
institutional setting, the doctors, being in control s f the institution,
havethe greater opportunityto evolvesomemechanisms
322 A S Y L U M S
for coping with their problem. Their response to the situation
provides us not only with an important aspect of hospital life
but also with a case history of the interplay between social
models of being - in this case the expert server - and the social
establishments in which there is an attempt to institutionalize
these role identities.
There are some features of the hospital situation that help the
psychiatrist in the difficultiesof his role. The physician's legal
mandate over the fate of the patient and his institutional power
over some elements of staff automatically provide the authority
that other serversmust in part win through actualinteraction withthe
client. Further, while psychiatric knowledge often cannot
place the psychiatrist in a position to predict the patient's conduct
correctly, the same nescience provides the psychiatrist with
intemretive leeway: by addingpost hoc qualifications and adum-- - x
brations of his analyses, the psychiatrist can provide a picture of
what has been happening with the patient that can no more be
disproved than proved, as when an unanticipated psychotic break
gives rise to the interpretation that the patient now feels secure
enough or strong enough to express his psychosis. To this
authority that cannot be discredited, the psychiatrist can add a
force derived from medical tradition, 'clinical experience'.
Through this magical quality, the formally qualified person of
longest experience with the type of case in question is accorded
the final word when there is doubt or ambiguity, this person also
being apt to be the ranking practitioner present.
The psychiatrist, being medically trained, can provide minor
medical services to patients and can refer more difficult medical
cases to the hospital's hospital. This normative function (characteristic,
as suggested, of what must be done in the Army, on a
ship, in a factory, or wherever large numbers are gathered to
contribute to an administrative end), instead of being seen as an
ancillary housekeeping service, tends to be assimilated to the
centralfunctioningof theestablishment, thereby strengtheningthe
basis in reality of the notion that mental patients receive medicallike
treatment in mental hospitals. Interestingly enough, state
mental hospitals sometimes are so understaffed that medically
qualified personnel could spend all their time making minor
M E D I C A L M O D E L A N D M E N T A L H O S P I T A L I Z A T I O N
323
medical repairs on patients and must practise psychiatry - to the
extent they do -at the expenseof needed medical treatment.
An obvious way for the psychiatrist to solve his role problem
is to leave the state mental hospital as soon as he can'afford to,
often with the claim that he is leaving in order to go where
'it will really be possible to practise psychiatry'. He may go,
especially for the last year or two of his obligatory residency, to a
Iprivate hospital, perhaps of the psychoanalyticallyoriented kind,
where there is a patient load approaching that of private practice,
and where a higher ratio of patients are voluntary and 'suitable9
for psychotherapy. From such a hospital (or directly from the
state hospital), he may go into private practice, an arrangement
that may not bring his skill to many patients but will guarantee
that activity is conducted in accordance with the servicecomplex:
an oEce, a secretary, hour-long appointments, voluntary appearance
of the patient, sole control over diagnosis and treatment,
and so fopfh.33 For whatever reasons, this two- or three-stage
job cycle is sufficiently common to constitute a standard w e e r
pattern in psychiatry.
Where the psychiatrist cannot, or does not want, to leave the
state mental hospital, some other paths appear to have been
established for him. He may redefine his role from that of a
server to that of a wise governor, embrace the custodial aspects of
the institution, and devote himself to enlightened administration,
He can admit some of the weaknesses of individual therapy in the
situation and move in the direction of the newer social therapies,
33. It is remarkable that the self-disciplinerequired of the mental client
if he is to allow his psychiatrist to act like any other professional man
receives full and detailed justification in the psychoanalytical literature on
the basis of technical therapeutic considerations. A wonderful pre-arranged
harmony exists between what is good for the patient and what in fact the
psychiatrist requires if an office profession is to be maintained. To paraphrase
Mr Wilson, what is good for the profession is good for the patient.
I have foundespeciallyrefreshing the discussionof the psychologicalimportance
of the patient's appreciatingthat the therapisthas a life of his own and
that it would not be good for the patient if the therapistpostponed his vacation,
or saw the patient in response to midnight telephone calls, or allowed
himself to be physically endangered by the patient. See, for example, C. A.
Witaker and T. P. Malone, The Roots of Psychotherapy (New York: Blakiston
Co., 1953), pp. 201-202.
324 A S Y L U M S
attempting to involve the patient's kin in psychotherapy (on the
assumption that the disorder resides in a family system),34 or
attempting to locate therapy in the full round of daily contacts
that the patient has with all levels of staff.f.35He can turn to
psychiatric research. He can withdraw from patient contact as
much as possible, retreating into paper work, or into psychotherapy
with the lower levels of staff or with a small number of
'promising' patients. He can make a serious effort to warn the
patients whom he treats that his knowledge is small, but this kind
of candour seems destined to fail because the medical role is defined
otherwisein our society, and because the power the psychiatrist
has over the patient is not readily understood as something
that would be given to anyone who knew little.36 Occasionally
the psychiatrist becomes a 'patients' man', agreeing with their
claims as to what the institution is doing to them and voicing
open criticism of the establishment to them. If he takes none of
these tacks, the psychiatrist can at least become cynical about his
role inthehospital, thereby protectinghimself, if not his patients.37
In addition to these modes of adaptation involving career
alignments, we find adaptations of a more diffuse and more
ideological kind, in which staff levels participate. It is as if the
service dilemma constituted a sore spot in the hospital social
system,and that around this spot intellectual energies are expen-
34. Faced with the doctrinethat the patient may merely be the 'symptom
carrier' for his intimate circle, some research psychiatrists have made an
effortto import whole familieson to experimentalresidential wards. The side
problems consequent upon such novel living arrangements, especially as regards
the structure of family authority, are very great, and their masking
effect has perhaps been underestimated.
35. Here the psychiatrist may explicitly admit that he must be therapist
not to the individual but to the'hospital social system. Psychiatric and
medical training seem to equip doctors to accept the responsibility of
governing a ward or hospital,freeing them fromthe trepidationanindividual
might have who had relevant training or experience for the task.
36. For a comment on the fate of verbal modesty in the context of high
hospital office, see A. H. Stanton, 'Problems in Analysis of Therapeutic
Implications of the Institutional Milieu', in Symposium on Preventive and
Social Psychiatry, Walter Reed Army Institute of Research, Washington,
D.C. (15-17 April 1957), p. 499.
27 R-llrnnn nn. cit.. D. 200.
MEDICAL MODEL A N D MENTAL HOSPITALIZATION 325
ded to build up a protective skin of words, beliefs, and sentiments.
Whatever its source, the resulting system of belief semes
to bolster and stabilize the medical-service definition of the situation.
We arethus provided with an iLIustrationin miniature of the
relation between thought and social position.
Perhaps the most obvious instance of institutional ideology is
found in the public relations work that is currently fairly characteristic
of mental hospitals. Hallway displays, orientation booklets,
institutional magazines, displayable equipment, and newer
therapies - these sources of definitions of the situation await
patients, relatives, and visitors, establishing the obvious cIaims
of the medical-serviceline.
Further, we have in mental hospitals a collection of traditional
tales whose recounting illustrates the validity of the perspective
employed by staff. These stories tell of times a patient was given
privileges too early, or released against advice of physicians, and
went on to commit suicide or murder. Attendants have jokes
to tell illustrating the animal-like nature of patients. Those
staff members who attend diagnostic conferenceshave humorous
anecdotes about patients - for example, an inmate who made a
dignified claim to sanity but fkally allowed that he was an agent
of the FBI. There are stories of patients who begged to be kept
on a locked ward, or who engaged in obvious delinquencies in
order to prevent their own discharge. There are other tales of 'prepatients'
who displayed increasingly fiorid and dangerous psychotic
symptoms until others were finallyconvinced of the illness
and provided hospitalization, at which point the patients were
able to relax their symptomatology, having succeeded in communicating
their need for help. Finally, there are heart-warming
stories of impossible patients who finally came to form a good
relationship with an understanding doctor and thereafter dramatically
improved. As with the other of exemplary tales, these
relationship stories seem to centre on proof of the rightness of
the position taken by staff.38
The ideological or interpretative implications of management's
activity seem to focus on two issues, the nature of patients and
38. Patients, of course, have their own set of exemplary tales almost
equally discrediting of staff.
326 ASYLUMS I M E D I C A L M O D E L A N D M E N T A L H O S P I T A L I Z A T I O N 327
the nature of the hospital's activity, in both cases bolstering up
the medical-service definition of the situation.
The key view of the patient is: were he 'himself' he would
voluntarily seek psychiatric treatment and voluntarily submit to
it, and, when ready for discharge, he will avow that his real self
was all along being treated as it really wanted to be treated. A
variation of the guardian principle is involved. The interesting
notion that the psychotic patient has a sick self and, subordinated
to this, a relatively 'adult', 'intact', or 'unimpaired9 self carries
guardianship one step further, finding in the very structure of the
ego the split between object and client required to complete the
service triad.
The case record plays a role here. It provides a means of systematically
building up a picture of the patient's past that demonstrates
that a disease process had been slowly infiltrating his
conduct until this conduct, as a system, was entirely pathological.
Seemingly normal conduct is seen to be merely a mask or shield
for the essential sicknessbehind it. An over-all title is given to the
pathology, such,asschizophrenia, psychopathic personality, etc.,
and this provides a new view of the patient's 'essential9 character.39
When pressed, of course, some staff will allow that these
syndrometitles are vague and doubtful, employed only to comply
with hospital census regulations. But in practice these categories
become magical ways of making a single unity out of the nature
of the patient - an entity that is subject to psychiatric servicing.
Through all of this, of course, the areas of 'normal functioning'
in the patient can be discounted and disattended, except in so far
as they lead the patient willingly to accept his treatment.
The response of the patient to hospitalization can itself be
nicely handled by translating it into a technical frame of reference,
whereby the contribution of the hospital to the patient's trouble
becomes incidental, the important thing being the internally
generated mode of disturbance characteristic of the patient's
conduct. Interpersonal happenings are transferred .into the
patient, establishinghim as a relatively closed system that can be
39. The social psychology of perceived 'essential' character has recently
been developed by Harold Oarfinkel in a series of unpublished papers, to
which I am much indebted.
thought of as pathological and correctable. Thus an action that
the patient engages in with an officialof the institution that may,
to the official, have an aggressive cast is translated into a substantiveterm
like 'aggressivity' that can be located well within the
patient.40 Similarly, a ward situation in which nurses do not
bother to initiate contact with long-tern patients (who in fact ,.,
would respond to overtures) may be transferred into the patient
,by referring to him as 'mute'.41 As Szasz has suggested, this view
has similarities to the earlier view that the mental patient has a
devil or evil spirit within him that must be and need only be exor- . .
cized.42
This translation process can be clearly seen in the process of
group psychotherapy. In general this therapy -.the principal
verbal therapy patients in state hospitals receive - begins as a
gripe session during which patients express demands and complaints
in a relativelypermissiveatmosphere, with relativelydirect
access to a staff member. The only action on the part of the therapist
that seems consistent with his obligation to the institution
and his profession is to turn these demands aside by convincing
the patient that the problems he feels he is having with the institution
- or with kin, society, and so forth - are really his problems;
the therapist suggests that he attack these problems by
, '
rearranging his own internal worjd, not by attempting to alter
the action of these other agents. What we have here is a direct,
40. See John Money, 'Linguistic Resources and Psycho-dynamic Theory',
British Journal of Medical Psychology, XXVIII (1955), pp. 264-6. Useful examples
of'thistranslation process are found in Edwin Weinstein and Robert
Kahn, Dehial of lllness (Springfield, 111.:Charles Thomas, 1955). The authors
cite such terms as 'akinetic mutism', 'Anton's syndrome', 'reduplicative
paramnesia', 'anosognosia', which have been used traditionally to refer to a
patient's failure to admit his injured condition,; they then describe under
categories such as 'displacement', 'misnaming', 'paraphasia' the various
ways in which patients decline to respond to their situation in a civil and cooperative
way, the intransigence being described as a psycho-physiological
by-product of brain injury, not as a social response to involuntary threatening
treatment. See also Belknap, op. cit., p. 170.
41. Robert Sommer, 'Patients who grow old in a mental hospital'
Geriatrics, XIV (1959), p. 584.
42. T. S. Szasz, W. F. Knoff, and M. H. Hollender, 'The Doctor-Patient
Relationship and Its Historical Context', American Journal of Psychiatry,
CXV (1958), p. 526.
328 A S Y L U M S
although no doubt not intentional, effortto transform the patient
in his own eyes into a closed system in need of servicing. Thus, to
cite a relatively extreme example, I have seen a therapist deal
with a Negro patient's complaints about race relations in a partially
segregated hospital by telling the patient that he must ask
himself why he, among all the other Negroes present, chose this
particular moment to express this feeling, and what this expression
could mean about him as a person, apart from the state of
race relations in the hospital at the time-43
One of the most intimate service redefinitions of the patient's
nature is to be found in the idea of the 'danger mandate' characteristic
of many of the tinkering services. It has been said that a
medicalstudent becomes a doctor when he finds himself in a position
to make a crucial mistake.44 Underlying this attitude is a
belief that a serviceable system has organizational danger points
and can therefore be greatly damaged if unskilled action is taken
in these crucial, precarious matters. As already suggested, this
tends to provide rational grounds for a technical hierarchy of
skill and a social hierarchy of servers within any one servicing
establishment.
1
There is a version of the danger mandate in mental hospitals.
I
This is the view that a wrong action can greatly endanger the
patient, and that the psychiatrist is in a position, due to training
and skill,to take potentially dangerous actions regarding patients,
I
actions that lesser persons in the medical hierarchy ought not to
I
be allowed to take. Of course, in questions of prescribing drug
I
dosage and weighing possible contra-indicating side effects of
I
physical treatment, the model here holds well enough, but the
I 43. The techniques employed by group psychotherapists can be studied
as part of small-group indoctrination methods. For example, one commonly
I k d s that a few patients will be well versed in the psychiatric line and reli!
ably willing to take it. A gripe raised by a patient may then be picked up by
the therapist and referred back to these patients for their opinion. They
translate for the complainer, showing that his own fellows see his complaint
as part of his own personality, leaving the therapist to come in with the
authoritative translation, but now with some of the group polarized against
the complainer. A recent discussion of these issues may be found in Jerome
D. Frank, 'The Dynamics of the Psychotherapeutic Relationship'. Psychiatry,
XXIlI (1959), pp. 17-39.
44. Personal communication from Howard S. Becker.
M E D I C A L M O D E L A N D M E N T A L HOSPITALIZATION 329
cany-over into the psychotherapeutic realm is more precarious,
although often no less insisted on. It is sometimessLggested that
lesser personnel, such as social workers, nurses, and attendafits,
ought not to engage in 'amateur therapy', and certaidy not in
amateur 'psychoanalysis'. A staff psychiatrist who takes on an
JJ
inmate for special sessions of psychotherapy ought not to have hls
work tampered with by others, especiallylesser others. Thewrong
move during psychotherapy, it is said, can 'precipitate' a psychosis,
or cast the patient back into a regression from which he may
never return, and exemplary tales provide evidence for this. Now
while it is perfectly clear that this view fits in well with the traditional
notion of a danger mandate, and while it is clear that the
possession of this mandate confirms one's view of self as an expert
server,it is much less clear that a purely verbal act can in fact
have this effect. In any case, as previously suggested, any hospital
inmate in personal therapy is likely to be undergoing, during the
other twenty-three hours of each day, a barrage of potentially
traumatic experiences, relatively uncontrolled in barbarity, that
surely cloud any issue of a verbal probe going in the right or
wrong direction. Moreover, given the state of psychiatric knowledge
and skill, if a wrongly placed verbal shaft could cause this
kind of damage, patients would be in danger indeed during the
twenty-fourth hour.
Two further imputations about the patient's nature may be
described, both of which again function to support the service
model. When a patient is offereda discharge and declinesto take
it, sometimes engaging in activity calculated to assure his retention,
it is commonly said that this proves he is still ill, that he is,
in fact, too ill to leave. In this way a link is made between two
massive aspects of the situation: being defined as ill or well,
and being in or out of the hospital. There are of course many
good reasons unconnected with the service model for a patient's
diffidenceabout leaving. For example, he has already suffered the
stigma of being a mental patient and in this reduced status has
even poorer prospects on the outside than he did before he came
in; furthermore, by the time he is ready to be discharged he is
likely to have learned the ropes in the hospital and have worked
himself up to a desirable position in the 'ward system'.
330 A S Y L U M S
The other patient action that is rationalized in terms of the
medicalmodel isthat of sudden alterationinpropriety of conduct.
Since the current conduct of the patient is supposed to be a profound
reflection or sign of his personality organization - his
psychic system - any sudden, apparently unprovoked, alteration
in either a 'healthy' or a 'sick' direction must soinehow be accounted
for. Sudden changes for the worse are sometimes called
relapses or regressions. Sudden changes for the better are sometimes
called spontaneous remissions. Through the power of these
words the staffcan claim that, although they may not know what
caused the change, the change can be handled within the medical
perspective. Of course, this interpretation of the situation precludes
one's employing a social perspective. In what is called
sudden regression, the new conduct may involve no more or less
illness or health than any other alignment to life; and what is
accepted as spontaneousremission may be aresult of the patient's
not having been sick in the fist place.
I am suggestingthat the nature of the patient's nature is redefined
so that, in effectif not by intention, the patient becomes the
kind of object upon which a psychiatric servicecan be performed.
To be made a patient is to be remade into a serviceableobject, the
irony being that so little service is available once this is done.
And the great shortage of psychiatric staff can be seen as created
not by the number of illpersons but by the institutional machinery
that brings to this area the service definition of the situation.
I want now, finally, to consider the definitions that the stafF
maintain regarding the nature, not of the patient, but of the hospital's
action upon the patient. Since the staff possess the voice
of the institution, it is through these definitions that the administrative
and disciplinarymachinery of the hospital is presented to
the patient and to the public. In brief, we find that the facts of
ward management and the dynamics of the ward system are expressed
in the language of psychiatric medical service.
The patient's presence in the hospital is taken as prima facie
evidence that he is mentally ill, since the hospitalization of these
persons is what the institution is for. A very common answer to a
patient who claims he is sane is the statement: 'If you aren't sick,
you wouldn't be in the hospital.' The hospital itself, apart from
MEDICAL M O D E L A N D MENTAL HOSPITALIZATION 331
the therapeutic services administered by its trained staff9is said
to provide a sense of security for the patient (sometimes only to
be obtained by knowing that the door is locked)45 and a release
from daily responsibilities. Both of these provisions are said to be
therapeutic. (Whether therapeutic or not, it is difficult to find environments
which introduce more profound insecurities; and
what responsibilities are lifted are removed at a very considerably
and very permanent price.)
Other translations can be mentioned. Regimentation may be
definedas a framework of therapeutic regularity designed to allay
insecurity; forced social mixing with a multitude of heterogeneous,
displeased fellow inmates may be described as an opportunity
to learn that there are others who are worse off. Sleeping
dormitories are called wards, this being affirmed by some of the
physical equipment, notably the beds, which are purchased
through hospital suppliers. The punishment of being sent to a j
worse ward is described as transferring a patient to a ward whose I \
arrangements he can cope with, and the isolation cell or 'hole' is j
described as a place where the patient will be able to feel cornfort- ;I
able with his inability to handle his acting-out impulses.46 Making
a ward quiet at night through theforced taking of drugs,which per- '
mits reduced night staffing, is called medication or sedative treatment.
Women long sinceunable to perform such routine medical
tasks astaking bloods arecallednursesandwearnursing uniforms;
men trained as general practitioners are called psychiatrists.
Work assignments are defined as industrial therapy or as a means
through which the patient can express his reawakened capacity
for assuming civil duties. Reward for good behaviour by progressively
increasing rights to attend socials may be described as
psychiatric control over the dosage and timing of social exposure.
Patients housed where treatment is first given are said to be in the
'acute' service; those who fail to leave after the initial cycle of
medical action are moved to what is called the 'chronic service'
45. Of the more than hundred patients I knew in the hospital I studied,
one did allow that he felt too anxious to go more than a block or so from
his ward. I knew, or knew of, no patient who preferred a locked ward,
except patients described by staff.
46. See, for example, Belknap, op. cit., p. 191.
332 A S Y L U M S
or, more recently, 'continued-treatment wards'; those ready to
leave are housed in a 'convalescent ward'. Finally, discharge
itself,which at the end of a year tends to be granted to most fistadmission,averagely
cooperative patients or to any other patient
for whom kinfolk exert pressure, is often taken as evidence that
'improvement' has occurred, and this improvement is tacitly
imputed to the workings of the institution. (Among the reasons
for discharge of a particular patient m y be ward population
pressure, spontaneousremission, or the socialconformity instilled
in him by the disciplinary power of the ward system.) Even the
concise phrases, 'discharged as cured' or 'discharged as improved',
imply that the hospital had a hand in the curing or hproving.
(At the same time, failure to be discharged tends to be
attributed to the difiiculty of treating mental disorder and to the
stubbornness and profundity of this kind of illness, thus a B m
ing the medical model even in the face of not being able to do
anything for the patient.) In fact, of course, a high rate sf discharge
might just as well be taken as evidence of the improper
functioning of the hospital, for since little actual treatment is
available, the improvement of the patient occurs in spite of hospitalization,
and presumably might occur more frequently in circumstances
other than the deprived ones within the institution.
Some of the verbal translations found in mental hospitals represent
not-somuch medical terms for disciplinarypractices as a
disciplinary use of medical practices. Here the lore of state mental
hospitals contains some exemplary tales for sociologists. In
some mental hospitals, it has been said, one way of dealing with
female patients who became pregnant on the hospital grounds
was to perform hysterectomies. Less common, perhaps, was the
way of dealing with those patients, sometimes called 'biters',
who continued to bite persons around them: total extraction of
teeth. The first of these medical acts was sometimescalled 'treatment
for sexual promiscuity',the second, 'treatment for biting'.
Another example is the fashion, now sharply decliningin American
hospitals, of using lobotomy for a hospital's most incorrigible
and troublesome patients.47 The use of electro-shock, on the
47. I have been told of manic mental patients who were tubercular and
for whom lobotomy was prescribedlest their hyperactivitykill them. Thisis
MEDICAL M O D E L A N D M E N T A L HOSPITALIZATION 333
attendant's recommendation, as a means of threatening inmates
into discipline and quietening those that won't be tfireatened,
provides a somewhat milder but more widespread example of the
same process.48 In all of these cases, the medical action'is presented
to the patient and his relatives as an individual service,but
what is being serviced here is the institution, the specification of I
the action fitting in to what will reduce the administrator's
management problems. In brief, under the guise of the medicalservice
model the practice of maintenance medicine is sometimes
to be found.
CONCLUSION
In citing some senses in which mental hospitalization does not
fit the medical-service model, I have not mentioned the difficulties
in applying the model to outpatient private psychiatric prao
tice, although these of course exist (such as: the length of time
required for treatment, with consequent strain on the concept of
the fee; the low probability of effective treatment; and the very
great difficulty of knowing to what to attribute change in the
patient's condition).
Further, in focusing on the difficultiesof the application to the
mental hospital of the medical-service model, I do not mean to
imply that the application of the model has not sometimesproved
useful to those institutionalized as patients. The presence of
medical personnel in asylums has no doubt served to stay somewhat
the hand of the attendant. There seems little doubt that
doctors are willing to work in these unsalubrious, isolating environments
because the medical perspective provides a way of
looking atpeoplethatcuts across standard social perspectives and
thereforeprovidesa way of beingsomewhatblindto ordinarytastes
and distastes. The availability of the medical version of one's
situation has no doubt provided some patients with a claim on
a decision that does involve the personal service, not the maintenance,function
of medicine. It may be repeated that the act itself is not the determining
issue but rather the organizational context in which it is recommended.
48. See Belknap, op. cit., p. 192.