In 1959 Erving Goffman wrote a journal article called “The Moral Career of a Mental Patient.” Career means those experiences that a mental patient can expect to have and Moral means the effect those experiences will have on him. Mental Patient refers to those who experience hospitalization (not those who may be mentally ill but are outside of a hospital situation). Thus, the title could mean, The Expected Effects of Experiences of a Person in a Mental Hospital.
In a mental hospital the patients or inmates may be there for a variety of different illnesses and for a variety of different reasons. Though the patients are fundamentally different, “they are,” Goffman writes, “confronted by some importantly similar circumstances and respond to these in some importantly similar ways…. The student of mental hospitals can discover that the craziness or ‘sick behavior’ claimed for the mental patient is by and large a product of the claimant’s social distance from the situation that the patient is in, and is not primarily a product of mental illness” (125).
Goffman divides the “career”, or hospital experience, into three phases: pre-patient phase, in-patient phase and ex-patient phase. Starting with the pre-patient phase Goffman quotes Harry Stack Sullivan as saying, “What we discover in the self system of a person undergoing schizophrenic changes or schizophrenic processes, is then, in its simplest form, an extremely fear-marked puzzlement, consisting of the use of rather [general]… referential processes in an attempt to cope with what is essentially a failure at being human – a failure at being anything that one could respect as worth being” (Harry Stack Sullivan, Clinical Studies in Psychiatry, New York, Norton, 1956; pp. 184-185).
The pre-patient is started on his road to confinement by the “complainant” who may not be the first to encounter problems with the pre-patient but is the first to make an effective move against the pre-patient. Some pre-patients may have a “long series of ineffectual actions taken against them” before confinement (126).
Contingencies play a role in whether the patient enters the hospital and can include: socio-economic status, visibility of the offense, proximity to a mental hospital, … community regard for the type of treatment given in available hospitals , and so on.” (126).
Goffman writes, “The pre-patient’s career may be seen in terms of an extrusory model; he starts out with relationships and rights, and ends up, at the beginning of his hospital stay, with hardly of either. The moral aspects of this career, then, typically begin with the experience of abandonment, disloyalty, and embitterment” (126).
A Circuit of agents and agencies are used to put the pre-patient in the hospital. First is the next-of-relation, usually the person the pre-patient trusts the most. Second is the complainant, the person who apparently started the process. And third the mediators that include: police, clergy, general medical practitioners, office psychiatrists,… social service workers, and so on. Once these are done and the person is a patient the hospital administrator is the significant agent (127).
The pre-patient often starts out thinking the next-of-relation is taking him to see a professional as an equal. But many times the next-of-relation has made prior arrangements with the professional and the pre-patient feels betrayed by who he thought was someone he could trust above anyone. The “next-of-relation” may have to testify against the pre-patient in front of a mental health commission and this “betrayal can verge on a ‘degradation ceremony’” (128). Mediators can cause a sense of betrayal. They may actually believe the mental hospitals are short term places of rest “and not as places of coerced exile” (129). Pre-patients are given euphemisms like “rest in a hospital” and then feel “conned” when they find themselves in what essentially is a prison. The agents make it sound “nice” so they won’t have to deal with the raw emotion the pre-patient is feeling at the realization he is losing his freedom and rights.
Once the pre-patient becomes a patient and is admitted the hospitals use the next-of-relation as a “guardian”, as someone who is “on their team.” They do this because, “if the guardian is satisfied with what is happening to the new inpatient, the world (or rather their critics) ought to be [also]” (129).
Now the hospital goes to work building a case history against the new inpatient. He whole past is scrutinized for negative behavior that might have “symptomatic” significance. They want to show that “all along he had been becoming sick, that he finally became very sick, and that if he had not been hospitalized much worse things would have happened to him – all which, of course, may be true” (131).
Goffman writes, “I think that most of the information gathered in case records is quite true, although it might seem also to be true that almost anyone’s life course could yield up enough denigrating facts to provide grounds for the record’s justification of commitment” (137).
In the beginning of his hospital stay the patient may feel strongly not to be known as anyone “who could possibly be reduced to these present circumstances…” (131). “Consequently, he may avoid talking to anyone, [and] may stay by himself when possible” (131). The patient may next, after a period of time, begin to socialize with others. This has been called “settling down” or “coming out” and signals an acceptance of his new situation.
The patient’s conception of self will next be attacked. By the institution’s restriction of free movement and total control of the patient’s life the patient begins to learn about the limited extent to which a conception of oneself can be sustained when the usual setting of supports for it are suddenly removed” (132). The bad conditions of the psychiatric hospital are not blamed on economics but rather the patient’s self. He is told this is “all you can handle.” He may next be confronted by staff stating his past has been a failure, the fault is his attitude to life is wrong and if he wants to be a person he will have to change his way of dealing with people and conceptions of himself” (133).
If the patient is released the next-of-relation “receives” the discharged ex-patient. The patient may be bitter towards them for helping put him in the mental hospital. He plays that this arrangement is ok in order to get out. However, the relationship is strained because the next-of-relation has such inordinate power over the ex-patient (139).
Goffman writes, “In the usual cycle of adult socialization one expects to find alienation and mortification followed by a new set of beliefs about the world and a new way of conceiving of selves” (141).
The mental patient’s rebirth takes the form of strong belief in the psychiatric perspective, or, briefly at least, a devotion to the social cause of better treatment for mental patients” (141).
Erving Goffman wrote this journal article from the point of view of the mental patient in 1959. Almost twenty years later, in the late seventies, everything he wrote about still held true. I know because I was in Kalamazoo Regional Psychiatric Hospital at that time for about seven months. I had also been in Pine Rest Christian Mental Hospital for a month on two separate occasions and in Kent Oaks Community Mental Hospital on two separate occasions.
Next I would like to talk about my experience with mental illness, and then I would like to answer any questions you might want to ask.
After graduation from high school in the spring of 1976 I went to Western Michigan University in the fall of that same year. I got all A’s but my incessant studying, lack of friendships, and moral confusion left me desperate at the end of the semester. I called my mom and she took me home. I studied at the local junior college in the Winter of 1977. Many of my high school friends were there and I was ashamed to be there having “failed” to complete Western and come home. Failure to be what I thought I should be at college had initiated a slow spiral of depression (undiagnosed) in me. I felt “guilty of sin” for the first time in my life. I couldn’t shake it. I felt like I should talk to God. I asked God to speak to me the way He did with Moses. To my shock my spirit was impressed by His Spirit and He said, “You’re a sinner.” Now He didn’t mean the regular-church-going-sinner that everyone was, He meant like a street walking prostitute. (That was the worst I could think of at that time. Now I do not look down on anyone, as I am the worst sinner I know. I also have great compassion for prostitutes now, as many are victims of childhood sexual abuse). After God told me I was a sinner, I said, “No, I’m not.” He said it again, “You’re a sinner.” I said again, “No, I’m not.” He became righteously indignant. He said, “I’m going to humble you for five years.” I disrespectfully yelled, “FIVE YEARS?” He said, “Alright, ten.” (That was my first lesson). I sat down on my bed. My mom came through the door of our house and instantly I became paranoid of people finding out my mental condition. I was afraid every moment of every day, asleep or awake, and I was especially afraid of getting locked up.
My condition worsened and eventually I was locked up. For the next few years I was in and out of mental hospitals and half-way houses. I obtained and quickly lost many jobs. I got a job at a local newspaper in 1985 and one lady working there, Bonnie, felt prompted by God to tell me about how much Jesus loves me. I wasn’t interested. She then sadly said that if I reject Jesus’ love the only alternative was going to hell. That got my attention. After thinking it over I thought I had absolutely nothing left to lose so I surrendered to Jesus. God asked me to ask Him for anything. Omar Khadafy was wrecking havoc with the world so I asked that he not be in the public eye again. Shortly thereafter, President Reagan bombed Khadafy’s home and though Khadafy was not there he quickly left the world spotlight. A family member was addicted to alcohol. I couldn’t ask God to force him to get saved because God respects us too much to force us to love Him. Instead I asked God to help him find whatever he was looking for in the bottle. Shortly thereafter he gave up alcohol for a season. God convinced me that He cared about us and that he could do anything. It was not exactly ten years that God humbled me, it was only about nine, but I’m not complaining. He’s the best thing that has ever happened to me. I have had the right drugs for Paranoid Schizophrenia, Major Depression, Bipolar, and Anxiety for the last 25 years. I am graduating May 1, 2010 and I plan to go to grad school to get a M.S. and possibly a Ph.D. in counseling. I want to help people to be able to make better choices than I did. And I want them to know that Jesus is there to help them.
The first lesson in being a Mental Patient
Psych wards were invented because their originators thought watching grass grow would be too exciting :-). It is mind numbing boredom. The TV blared WGN from the corner of the room by the ceiling constantly. We played the card game spades so many times that I could tell the outcome of playing that hand by what the cards I was dealt. I played pool (pocket billiards) so much that I could roll a ball down the middle of the table and shoot it and the cue ball in the far corner pockets while the first ball was still rolling. I used to wonder why I never had gone white water rafting or hang gliding because I would have loved to have had those memories to relive in the locked ward. (When I got out I did learn to scuba dive).
The schizophrenia affected my vision sensory system. In a large grocery store, when I looked down an aisle, what greatly stood out was all at once was the lines made by the tile floor and shelving and the boxes on the shelving. Then when I walked down the aisle and looked at the boxes on the shelves I saw all the boxes at once and could not concentrate on just one box to read what it was.
Major depression and emotions
When you are driving and the light ahead turns red there is an emotional response. My foot lifts off the gas almost involuntarily and I step on the brake almost automatically. None of these responses occurs with major depression. When I saw the light turn red it meant nothing at first. I had to consciously think, “Okay, the light’s turned red I need to lift my foot off the gas and press the brake.” I was continuously forcing my body to move, nothing was automatic like it was before.
My perception as a patient of hospital priorities in treating the person’s mental illness was that they were first and foremost, above all things, wanting to establish their dominance over you. As long as you continued to believe you were a person with dignity and rights they sought to persuade you through their treatment of you that you had no rights, no dignity and you weren’t a person. They sought for you to believe they had absolute control over you. And the mental hospital was set up so they could do just that.
I developed a great respect for people treating other people with kindness and respect. Doctors could walk right past you, right next to you, with eyes straight ahead, never acknowledging that you existed. Nurses and attendants did this to a lesser extent, but always with the attitude that they were higher than you, better than you.
One attendant and one doctor, out of the dozens I interacted with, treated me like I was a normal, respectable human being. I have a great deal of respect for those two. They didn’t have to treat me as a normal person and their work culture certainly didn’t support or reward decent behavior. They did it because they remained human in a situation that almost always distorted the humanness of both patient and care giver.
Who is afraid of whom?
The first time I was in Kent Oaks I didn’t associate with the patients. I was reasonably guarded and nervous and so they told me that I could relax and just be myself. Well, I believed them and so since I had joked around a lot before when I was “normal” I decided to tell a joke and the punch line was a slow “chip off the block” routine to the female attendant’s shoulder. The male nurse said, “Okay Jim let’s go,” and they put me in solitary aka the quiet room. Later I was asked why I had tried to hit the lady and that it had scared her to death. That’s when I realized everything I said or did was not going to be interpreted by who I was but rather by where I was and the label they were determining for me. I couldn’t “act natural” in a mental hospital (which was what I was told was needed to get out). The chip off the old block routine was endearing on the outside, it was a scary threat on the inside. I needed to be my old self to get out. When I was my old self they locked me up.
What I never really understood at the time I was in the mental hospitals was how afraid some of the staff was of us patient/inmates. We were the ones with our minds not thinking effectively, we were the ones that were afraid of everything, including them.
In Kalamazoo we had a male nurse that acted like he was Patton or something. He was dictatorial and gruff. I had been on thorazine for months and I believed I was not getting any dream sleep because of it. I felt this was causing me to operate half in a dream world that was worse than the thorazine. I decided to not swallow my liquid thorazine when given to me and spit it out later. When I tried this the male nurse ordered me to swallow and when I didn’t he became very agitated and I ran away (I immediately realized that I had nowhere to run in a locked ward). He kept telling me to swallow and when I got to the end of the locked hall I swallowed. He was enraged when I stopped running and he caught up to me. He held on to my head by a fistful of my hair and held my left arm with his other fist. He breathed threats of giving me a double shot of thorazine. He put me in solitary and came in later with two other men, gave me a shot and left me there until the next morning.
The logic of illogic
Schizophrenia made logical thinking seem illogical and illogical thinking seem logical. For example, I felt the less meds I took the less crazy I was. This went on for almost ten years. Then, God gave me a gift. I had the thought: what would happen if I took the meds the way they were supposed to be taken? Maybe they would help. This thought had never occurred to me as logical before for nearly the last ten years. I had always previously associated taking meds with shame and admitting I had a defective brain (which I saw as equivalent to saying I personally was defective).
One time a group of us from the ward were taken to the “ice cream shop” on the grounds. I was in the ice cream shop and I saw a drinking fountain across the street. I asked the attendant that had been nice to me if I could go get a drink. He said yes, and I walked over to the drinking fountain and I felt a rush of adrenalin as I kept going right past it.
I walked down the street towards the edge of the grounds and my mind was flooded with anxious thoughts. I walked into a neighborhood and told a lady my car had broken down and could I use her phone? I asked for a yellow pages and called a cab company. She questioned me as to where my car was. I told her the name of the only street I knew in Kalamazoo. She said with a tone that that was quite a ways away to have walked over here. I was getting nervous. She was suspecting me of something so I thanked her for letting me use her phone and walked to the end of her driveway to wait for the cab. She was calling out to me from her house asking questions when the cab showed up. I got in happy to leave that problem behind and asked the driver if he could take me to Grand Rapids? He said yes and that I would also need to pay him for half the way back to Kalamazoo. When I got to my mom and dad’s mobile home I got all of my money and paid the driver for the way there but I didn’t have the money for the way back. I told him I would pay him later. He smiled and left. I promptly forgot about paying him what I owed and went inside the mobile home, got the keys to my mom and dad’s car and drove it an hour north to their lakefront home. I parked the car and climbed the long stairs to the house while my mother and aunt asked me what I was doing. I didn’t say anything but went straight for my motorcycle keys. My mom grabbed the keys too and held on because she knew I wouldn’t hit her. She played my integrity against me. They called my dad in and he wrestled me to the ground. I swore at them and I knew it was over. The sheriff’s department came and got me and transported me back to Kalamazoo. I found out years later from my mom that the hospital officials were impressed I had made it over one hundred miles in my quest for freedom and so they speeded up my release.
Mental Illness is real. Just like other organs of the body it can become chemically, or electrically unbalanced and intervention may be necessary. Please remember that even the most “spaced out” person has feelings and is listening intently to you though they might not be able to express that to you. Any kindness you show them will not be wasted. They will remember. And God will remember too.