April 07, 2009

Total Institution and Lifeworld

author_sally By Sally Raskoff

clip_image002An older member of my family recently spent a week in the hospital. Visiting him, I was reminded of a year-long hospital internship I once completed. The visit also brought to mind Erving Goffman's concept of the total institution in which people become immersed in an organization that consumes every aspect of their lives. Applying this concept to the realities of the hospital – especially from the viewpoint of a patient – is an easy task.

A total institution guides and monitors the inhabitant completely, taking over life’s daily habits with its routinized and highly structured bureaucratic patterns. In the hospital, the patient is usually confined to one’s bed if not one’s room, sometimes allowed to circle the hallway but usually only before “escaping” upon discharge. One is regularly interrupted or awakened by the staff members that come to take one’s vital signs, change an IV drip, or assess the overall condition or prognosis. The patient is not an individual but a product to be processed through the system.

Note the specialized language for the hospital as well; jargon that helps anesthetize and clean the setting to ensure an appropriately subdued and work focused environment.

The hospital is also a total institution for those who work there – long shifts and a plethora of patients due to the closing of other hospitals creates pressure for the staff to adhere to their tasks. The poor economic state of health care facilities, especially emergency rooms, accompanied by the for-profit nature of many of the hospitals brings with it an odd mixture of customer satisfaction campaigns and documents with exhausted and burned out workers who may or may not be enjoying their jobs.

There are other sociological concepts can help us better understand the hospital setting, such as the lifeworld concept.

Jürgen Habermas used the word to signify the personal sense of society that we each hold. To Habermas, the lifeworld encompasses societal values and common understandings that we learn through ongoing interaction with others in our social setting. These are the things we take for granted as given – things that, when we travel outside our own realities, we may be shocked to see that others may do them differently.

The lifeworld of the hospital may not correspond neatly with our own personal lifeworld in which our daily lives are the norm. However, we have certain understandings of what happens in a hospital thus the values and practices there are not a total surprise. People take on the various types of patient roles (compliant or resistant) and worker roles (conscientious or alienated) yet all have a sense that the building and jobs there exist for the purpose of healing people from their maladies.

(If you watch television hospital shows, your values and expectations may vary if your favorite show is Grey’s Anatomy, ER, or Nip/Tuck!)

The concept of lifeworld may help explain various events in the hospital differently than can the total institution concept does. For example, my relative, who is typically a calm and low-key, at one point yelled at a hospital worker to “get the @#! out of my room!”

Looking at this incident with the total institution in mind, one can see that some abnormal acting out might easily result from the loss of individuality and conformity to the hospital schedule (and the subsequent loss of sleep) .

While I wasn’t present when my relative yelled at the hospital worker, I learned later that there had been some interactions between the two of them that irked my relative greatly. His meal had been delayed, it was well into the week of his stay, and the worker had finally delivered some cold food but had left it on a tray far from the bed.

clip_image005Thinking in terms of the lifeworld concept, his already damaged sense of autonomy was violated when his food was left in the room in a place that was inaccessible to him (he was unable to get out of bed). That worker’s behavior violated his sense that a hospital was a place where everyone was there to treat him and make him feel better.

It seems that the worker’s lifeworld was imbued with expectations about doing their job but not necessarily with a desire to put up with demanding patients.

Perhaps the worker was exhibiting sings of alienation from their job and therefore felt perfectly fine with annoying a patient who annoyed him. It seems the two lifeworlds were colliding because their expectations and values were not coinciding.

Habermas was concerned about the power and capital infiltrating one’s lifeworld, resulting in less communicative action and more tension and destabilization.

The hospital incident was preceded by a lack of clear and consistent communication between patients. The bureaucratic demands on the staff and the patients’ isolation from social interactions fostered this lack of communication. Thus, each set of participants are not fully able to share their concerns, values, and opinions about anything much less the tasks at hand.

Considering hospital stays using the lifeworld concept can give us insight into the dynamics of what goes on in terms of structure and constraint, and also we might encourage more communicative action to allow for more worker empowerment and patient satisfaction.

What other sociological concepts and theories might be applied to this situation?


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Consider the people in hospital to play roles. One is the patient, others are hospital employees. Each sends and receives roles, actually or expectantly. The patient sends role expectations to the employees and vice versa, while simultaneously he receives role expectations from the employees and back. Different patients may send different roles to one employee. This is inter-sender role-conflict which might explain the employee's careless handling of the food platter for your relative. It may also have been intra-sender role-conflict when your relative has been moody during his stay. Or it may all be attributable to the employee, as a role-receiver: did he create an intra-receiver role conflict or may there have been an inter-receiver role conflict setting him apart from his colleagues? These same types of role-conflicts may be applicable to the patient(s). Source: C. Boekestijn, VU Amsterdam, 1980.

institutionalization, is evident in many areas of our society. The institution of being homeless, is a silent social disease no one want's to recognize except for a perfect defenseless minority to place societys ills on; for example crime.Talking about being restricted try being homeless, Americas boat people, cast them out to sea, no one will care or miss them.The problem is no other country will rush to their aid

This was a good article a can't think of how many people are instititionalized for many reason their are children that are in homes because no one wants them, so they stay there with no one it's really sad. When you are in a hospital because of any reason you their with others that have some of the same problems that you have, when you are in your room and want to be treated with respect you are expecting only that because they are employees it's their job to treat you with as much kindness as possible. It's really sad when people aren't even willing to go that extra mile for you instead they slack and leave you dinner on a table that you can't even reach. I hope that all you need to correct this problem is finding honest people to work for you to make that hospital feel more like home and the patients feel welcome.

It`s pretty common people that stayed for a long period of time in treatment in the hospital starts to be really stressful and tired of the hospital routine. So in my opinion it’s completely understandable when a patient starts to freak out in the hospital. However, this rule does not apply for the hospital`s employees, be in the hospital is their job, they must be trained to know how to deal with a stressful patient, and the employee on the post failed in that aspect. The patient is not there because he wants to; he is there to receive treatment because he got sick. At the same time, if we follow the logic, all the hospital`s employees choose their jobs as doctor, nurse or whatever, they choose to be there so it’s unacceptable a rude attitude of the employee toward a patient. Be in a total institution must be really hard; it changes your habits and routine completely in a very short period of time. So for the hospital`s employee presented in the post, I would suggest him to be more patient, and more kind, different from him people receiving treatment did not choose to be there.

This is a great article! I particularly enjoyed the first portion regarding Goffman's "Total Institution" theory and its practical applications. I had noticed some more blatant "total institutions" prior to reading this article (i.e. the military, reform schools, prisons, etc.) but had never thought of a hospital as being one. Now that I think about it hospital's are a prime example of an alienating experience run by a well-oiled bureaucratic machine.
It is a shame that a facility that is intended for the treatment and recovery of ailed persons would be so impersonal and alienating. However, hospitals in U.S. metropolises deal with such a high volume and are so understaffed that it seems its current system is the only viable way of dealing with all that volume.
Total institutions, and bureaucracies in general, however alienating they may be, in certain high traffic social services are the most sufficient way to operate social institutions dealing with the numbers that they do.

This is a very well thought out article. I agree that the concept of "lifeworld" plays a dramatic role in well functioning hospital. I also believe that these roles have to be established in any environment for it to run smoothly. We also have to take into account the stress being put on these people by having to play these roles, and how we can limit this stress by dividing up responsibilities and opening up communication. There's possibly a role strain going on because of the pressure and obligations on those involved, which can be limited by the limitation of the barriers in their communication.

Good job. I found your article very interesting. I never thought about a hospital as a total institution, but I now realize that it is. I used to think that the concepts of total institutions applied only to prisons, psychiatric institutions, and in the military. I now realize that their are many total institutions that I never thought of before.

I found this article to be very intresting. Since I am working my way towards the nursing program at East Carolina I feel as though my life will too be very time consuming and the concept of total institution may come into play for me some where down the road in my career. However, I've chosen this career because I love helping people and taking care of them in ways that other people cannot. Because of the Life World concept I believe that the hospital should have some sort of sterotype because it should be for the care of others. I'm fully prepared for patients that are having a hard time because I have empathy for those that are having a hard time.

Hospitals is a great example of total institution and life world. People need total institution in hospitals, it's a better and faster way to make the patient well again. All the hasels that patients and workers in hospitals deal with is just to make the patient safe and that is the job of a worker in a hospital. Nothing can be perfect but this idea is a way for peopke to strive to make our society better than it is now, only if we work as one. We should not take total institutions and the idea of life world for granted even when it can become annoying at times.

This article was very interesting. It showed there are so many roles being played in hospitals. There is the one of the doctor and patient. They both expect behaviors from each other and when there is more than one influence going to one party then their is a major role conflict. This was a great way to show how hospitals are running good due to the roles being played out.

I am puzzled that this is not discussed more - is debate institutionalised?

The list is huge, hostels, care homes, nursing homes. They cost a fortune and are serious infringements of human rights. Look up the UN Charter about disabled people.

The Cabinet Office is with its nudge unit increasing institutionalisation.

Where is the discussion about creating autonomous cooperative ways of being that enable independence?

Not sure if Mariella Frostrup the Young Ones is widely available.


I am a social psychologist interested in total institutions who spent three days in hospital and 30 days in a rehabilitation center. I have written a satire that I am ready to submit to an agent. It is called Thirty Days in a Home for the Dis jointed. I also found many points in my experience of 24/7 care that illustrate the very points theorized by Goffman who did not live in a total institution. As far as I know, I am the only patient in a hospital and rehab center to write about the underbelly of our alleged health system. Laugh and press for change. Only the rich can afford our health care. How come it is available in other countries to everyone? Read my book as soon as I find an agent or publisher. Gilda Haber PhD

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