Table of Contents ||| Chirobase Home Page

An Ethnography
of a Chiropractic Clinic

Chapter 3: The Behavior Setting

© 1975
James B. Cowie, PhD
Julian B. Roebuck, PhD

A behavior setting has been defined above as consisting of: (1) nonbehavioral elements of milieu and time which includes bounded space, objects, areas (subsettings), and time limits; (2) standing behavior patterns; and (3 the relationship between the behavioral and nonbehavioral factors. (It should be reemphasized that this distinction is a heuristic one, similar, say, to the distinction normally made between status and role, and is used solely for purposes of analytical description.) Any behavior setting consists of these more or less stable elements, which actors use as the basis of their actions. Moreover, these elements are unique to each setting.

In order to ultimately discover those practices exhibited by actors in the Clinic whereby they present to themselves and to one another the setting as they respond to it situationally, each of the above features must be examined in detail. This is the purpose of the present chapter.

An effort has been made to show how the practitioner and his staff utilize presentational devices (stage props) within the setting to give to his patients, and especially his new patients, a feeling of confidence in what has been demonstrated to be a deviant setting (see Chapter 1).

As one critic has observed [1:15-16], a possible weakness in Ball's study [2].of an abortionist's attempt to accomplish this same end -- relieving patient anxiety -- is that it is dangerous to infer intentionality or meaning to the behavior of actors. Like Roebuck and Frese [3], I am not concerned with actors' consciousness but with how directly observable impressions are created and sustained. Whereas in their study of an after-hours club, they mention that the staff "appear to be . . . only dimly 'conscious'" of impression management, the practitioner in the present study was quite conscious of this activity. Much backstage conversation testifies to this fact and, as such, is empirically admissible data.

EXTERIOR CHARACTERISTICS

The chiropractic office was located in the central part of a small town in a Southern state. Directly across from the Clinic was the city police department. The building immediately adjacent to the Clinic was the largest and most respectable church in town. The Clinic itself was located in a two-story, renovated structure which housed a bank, and on the other side, a flower shop.

The residents of this mixed commercial/residential neighborhood were established, white, and middle class; many were retired. The town population as a whole, however, was heterogeneous in that both black and white neighborhoods were interspersed.

A large white sign, prominent against the dark wood exterior of the building, advertised the Clinic's presence. A heavy glass door, upon which were posted office hours, marked the only entrance. Patients entered directly from the sidewalk, ascending two concrete steps.

THE WAITING ROOM

The waiting room (approximately 10 x 15 feet) was directly visible from the street. Uncarpeted, it was furnished by a central table surrounded by several chairs placed against the walls. Directly opposite the entrance was a wall behind which was located the private office of the practitioner. A shoulder-level sign-in counter was located in the center of this wall, affording the chiropractor and his assistants a panoramic view of the room and the sidewalk outside. Usually an FM radio, tuned to relaxing music, conveyed the impression of serious quietude.

The waiting-room walls, made of inexpensive, unpretentious wood paneling, were heavily decorated with pictures, signs, and posters -- all of which communicate the chiropractic message with an air of professionalism. The largest and most impressive of these was entitled "Chiropractic Defined." (The ICA definition.) Also included as part of the wall decorations was it prominent picture of the practitioner's graduating class, which closely resembles that of any large establishment university.

While all of the above are intended to impress upon the patient an atmosphere of competent professionalism, there were also found on the walls a number of handwritten signs expressing a form of homespun philosophy or message for everyday living and/or health care: "An ounce of prevention is worth a pound of cure"; "Many automobiles get better care than most human bodies"; "A stitch in time not only saves nine, but often a human life"; "The graveyards are filled with those who neglected regular care of their health." Although these messages seemed unprofessional, it will later be seen that they played an important part in conveying the message of chiropractic philosophy. As the practitioner expressed it:

It affects everything you do, say, feel ,and think. Chiropractic is an art. . . . You must reexamine your whole life and the way you live it. These little signs get people to thinking.

The signs, which were changed frequently, were the topic of conversations between the staff and patients and were used expressly for that purpose. "It's a natural. Everybody is interested in living and life. When I talk about the meaning of life and death, people got to listen." These handwritten messages were found throughout the Clinic, and they were placed purposefully in strategic locations.

Admission to the Clinic

Admission was similar to the routines found in many establishment medical settings: the prospective patient went to the admissions window, was greeted by the chiropractic assistant and signed in. No attempt to secure any information other than name and address was made at this time. The patient was always asked to sit down and make himself comfortable. Attention was directed to the magazines and pamphlets, which had been placed on the central table and on several chairs. All of the reading, materials pertained directly to the nature and purpose of chiropractic and/or natural health care. Magazines (Today's Chiropractic, Health, Prevention), booklets (Chiropractic Could Save Your Life), newspapers (Spinal Column), and pamphlets ("Chiropractic: An Explanation"; "Why Chiropractic?") engaged the patient's attention." Many chiropractors often leave a copy of the Bible, opened to an appropriate passage, in a conspicuous place. As Goffman has noted, newspapers and other reading material in public places serve to offer to actors a "minimal involvement" whenever the individual "feels he ought to have an involvement but does not." [4:51-52]

It should be noted that the assistant, like the practitioner himself, wears no special clothing other than ordinary street apparel. The practitioner, in trying to convey the image of chiropractic as "simple and natural ' felt that to wear a white jacket of the establishment physician was inconsistent to this end. However, it should be added that some chiropractors, especially mixers, choose to wear white jackets in order to promote their professional image.

During the waiting period in which the practitioner may or may not have been busy ("The patient expects to wait. . ."), the assistant attempted to engage the patient in casual conversation. Topics such as the weather were discussed. If the patient asked a question concerning chiropractic or related topics, the subject was actively pursued. The assistant saw this as an opportunity to "dip," or convert, the patient into the general philosophy and orientation of chiropractic. The dipping procedure was an integral part of the overall rhetoric and was pursued whenever the opportunity afforded itself. Although the assistant attempted to stimulate interest and curiosity, a line was drawn whenever specific questions concerning the philosophy or adjustment technique arose. One patient was heard to ask the assistant:

If what it says here [referring to an article in one of the chiropractic magazines] Is true, then I Should be feeling better in a couple of weeks. Right?

The assistant replied:

That's a good question. A lot of people ask the same thing. There's really no easy answer, but the Doctor is a lot better at explaining it than I am. Be sure to ask him when you go in.

Often the assistant would brief the practitioner concerning the nature of the question or concern, thus allowing for preparation of an answer.

Many times regular patients were allowed to enter immediately into the adjustment area without going through the process of signing in). For these patients the atmosphere was much less formal, and they were made to feel at home by being welcomed on a first-name basis. In numerous instances the assistants and the practitioner were addressed informally, This was encouraged in patients defined as having been thoroughly dipped into the philosophy of chiropractic.

Immediate entry was also given to those patients, either new or regular, who state any need to see the practitioner. This was clone sometimes at the expense of making other patients extend their wait. When asked about the fairness of this practice, the practitioner replied:

Oh come on! I'm running a business here. I'm not going to let five bucks walk out the door. I've got kids to feed. Most people don't know the difference anyway. They think he's got an appointment. if I don't get my hands on him the first time, I'm sure as hell not going to get him again.

The decor of the waiting room entrance presented to the patient what appeared to be a respectable and, for the most part, conventional front. Many prospective patients, upon entering the Clinic for the first time, were apprehensive and expressed an inadequate definition of the situation. By giving the patient time to become adjusted to the surroundings; and some indication as to the ground rules, the aura of mystery associated with chiropractic was to some extent alleviated. As one regular patient confided to a new patient:

I didn't know what to expect. I'd heard a lot of goofy things and I didn't even want to come the first time, but my boss told me it would get me back to work fast if I did, so f came. After you find out what it's all about is when it begins to do you some good. They're pretty good people here.

Various attempts were made by the Clinic's personnel to relate to the patients by structuring personal encounters. Often, when a known patient was observed approaching the front door, his card was quickly pulled from the file and all pertinent personal information was reviewed. Questions concerning the well-being of the patient's family, his state of health, or any other personal matter served to draw the individual into the immediate behavior setting. Patients, particularly regulars, responded favorably to this tactic. Some patients were observed reciprocating this personal attention by bringing gifts of flowers, cookies, etc., to the staff.

Like Ball [2] and Roebuck and Frese [3], I have extended Goffman's definition of "front," which included setting, appearance, and manner as a framework for the analysis of self presentation to the overall establishment and the actors within it [5:22-30].

Not all patients responded positively to this "just-plain-folks" treatment, however. One patient was heard commenting to a friend outside the Clinic, "I come in here 'cause I got bad trouble in my back, and she [the assistant] wants to talk about my family. Hell, that's none of her business!" These varying patient responses were important for the practitioner in that they served as the basis for his classification of patients into one of a series of types and consequently structured both the form and the content Of future interaction with them.

THE ADJUSTMENT AREA SUBSETTING

After a waiting period, which was situationally judged appropriate, the patient was told, "The doctor will see you now. Will you come through the door on your right?" The door was opened by the assistant and the patient was led down a narrow hallway, past the practitioner's private office, toward the adjustment area, which constituted the primary behavior subsetting in the total configuration of the Clinic.

The hallway, through which the patient passed, was unadorned except for a large bulletin board on the right directly across from the entryway to the private office. This board posted information of a seemingly more transitory nature than other forms of written rhetoric found elsewhere in the Clinic. They included newspaper clippings and articles (all undated) which denounced various kinds of drugs; e.g., aspirin, vaccines, etc.). Other similar newsworthy items relative to chiropractic were seen, conveying the impression of an immediate awareness and concern for current health care issues. Most of these clippings had been reproduced, thus concealing the fact that some were as much as thirty years old. Also affixed to the board were photographs of the practitioner, garbed in the traditional graduation gown and holding his diploma, as well as several pictures of his children. Three of the handwritten messages were also interspersed.

If the patient had been accompanied to the Clinic by one or more supportive others, the assistant or the practitioner would encourage, and in many cases recommend, that these persons accompany the patient to the adjustment area. This was an important procedure and will be discussed at some length in a following chapter.

The Scene

The adjustment area was the largest room in the Clinic (15 x 25 feet) and served as the center of all patient-oriented interaction, Descending one step from the end of the hallway, the room was seen to be fully enclosed, windowless, and without outside exit. Wall-to-wall carpeting and soft fluorescent lights set into a soundproof ceiling lent an atmosphere of quiet seclusion and privacy. The walls, like those of the waiting room, were of dark, conservative paneling. A door on the left opened upon a small bathroom, and on the right another door, left ajar, exposed an impressive array of X-ray equipment.

Central to the adjustment area itself, however, was the adjustment table, which was located in "upper stage right" (on the left as one enters the room from the hall). Technically known as the Zenith-Thompson Pneumatic Terminal Point Chiropractic Adjustment Table, it presented a formidable appearance to the new patient. Standing upright, it was seen to be constructed of four vinyl-covered sections: (1) the FM (forward motion) head piece, composed of two spaced sections covered with a wide strip of replaceable tissue paper for the patient's face; (2) the dorsal-lumbar section, also constructed of two parallel pieces; (3) the pelvic section, which supported the pelvis and the legs; and (4) a small ankle support section. Each section could be adjusted to conform to the height and proportions of each individual patient. Additionally, the pelvic section was equipped with a mechanical device triggered with a remote control foot pedal, which allowed this section to suddenly drop a short distance and return to its original position automatically. While the device was in an upright position, the patient stepped upon a small platform resting on the floor. The entire table was then mechanically lowered to the floor with an electrical humming sound. The underside of the table, now beneath the upholstered cushions, revealed the impressively complex mechanics of the machine: chrome-plated gears, the motor, as well as various tubes and wires. Thus, an advertisement directed to perspective buyers read: "No table today has so many advantages for doctor and patient."

The table was placed approximately 3 feet from the wall, thus allowing the practitioner to move freely around the prone patient. When the adjustment was completed, the table was returned to an upright position, permitting the patient to easily step backward and away.

Directly opposite the adjustment table, close to the facing wall, several straight-backed chairs surrounded a small card table upon which were placed a note pad, pens, pencils, blank patient information cards, blood pressure gauge, and an assortment of brochures and pamphlets.

Attached to the rear wall were two large charts -- one depicting the nervous system, and the other a rear view of the skeletal structure of the human body. Both focused upon the spinal column. The charts had been commercially printed with details of precise anatomical terms. Also, in the center of the same wall, hung a replica of the human skeleton, minus appendages. The skeleton faced the wall, exposing the spine. Pieces of thin multicolored cord had been interwoven between the vertebra, demonstrating, the major and minor nerves as they led to various parts of the body.

In addition to these prominent and professionally appearing demonstration devices, affixed to the walls of the adjustment area were more handwritten signs. The content of these messages, however, varied somewhat from those found in the waiting room and elsewhere in the Clinic. In the words of the practitioner, they were designed to

make people think about chiropractic and what it's all about. I mean, when you get people to really wonder about what makes your heart beat ("WHAT MAKES YOUR HEART KEEP BEATING? THINK ABOUT IT!"), they're getting dipped, whether they know it or not. DE [Dynamic Essential] is what this thing is all about. You've got to have faith in it. You can't come right out and tell them, they'll laugh at you.

A frequently used aid in promoting and selling the idea of the Life Force, which was so central to the orientation and philosophy of the ICA chiropractor, was a large handwritten poster that had been placed adjacent to the table and chairs. It read:
For those patients who had complained of a specific ailment or discomfort, a pamphlet rack, constructed of perforated board and wire hangers, was used to dispense information. These small, one-page "fact sheets" were free, and the patients could take as many as they wished for their own use or to "give to friends or relatives who may need some good, sound, practical advice." The rack itself hung within easy reach of the practitioner while seated with patients around the table.

Completing the wall rhetoric in the adjustment area was a Chiropractic Prayer. It had been commercially reproduced as the standard prayer for all ICA chiropractors and it was endorsed by that organization. Essentially it was an appeal to a higher power, without reference to any specific religious denomination, including Christianity, for help in the effective use of the hands in order to ameliorate "the pain in this troubled world." This higher power, which was never explicitly defined, was referred to variously by the practitioner as Innate Intelligence, the Wisdom of the Body, Dynamic Essential, or Life Force.

Some patients openly discussed this topic and expressed their understanding of it in purely objective, biological terms: nerve energy did not seem to pose much of a problem to the practical patient. Others, however, responded quite differently. An elderly female patient, who had been seeing the practitioner for some months on a regular basis, confided to the researcher:

I surely do like that man. I do believe what he says. He's got a lot of schooling . . . [but] he talks to me like a friend. I ain't never had a real doctor talk to me about the Spirit like he does.

The adjustment area subsetting was characterized by a facade of respectable professionalism carefully combined with a "down to earth" hominess. The practitioner, in a purposeful way, used the setting and its components in a highly efficient presentation of a non-threatening, yet professionally powerful, self-image.

THE X-RAY SUBSETTING

Patients entering the X-ray room with the practitioner observed it to be fairly small (8 x 10 feet) and filled with standard, yet complex equipment: the X-ray machine itself; a lead backdrop shield; racks of exposed negatives, many of' which were hanging on the walls and always one on the lighted viewer; several wall charts covered with complicated mathematical figures, diagrams, and procedural instructions. The room was designed for efficiency and was the only one in the Clinic devoid of extraneous trappings or decorations. The absence of carpet contributed to the tone of clinical austerity. The only adornment was the wooden wall paneling found in all other rooms.

The technique utilized by the chiropractor was referred to as spinography or spinal radiography. The practitioner took pictures according to standard procedure, producing a classical spinography of the entire spinal column, and smaller pictures, usually a detail of the neck and pelvic areas from both back and side views.

The X-ray room was the only subsetting area in use denied access to the author, for reasons of protection. It can be assumed, however, that little interaction took place during this period of isolation for the following reasons: (1) the practitioner was indeed concerned with producing pictures of clarity and precision and must therefore be conscientious of technique; (2) relatively little time was spent in the area other than the time normally required for taking the pictures; and, (3) the practitioner stated that the setting was not truly conducive to conversation with the patient. The latter usually was asked to return to the adjustment area and wait while last-minute details of the X-ray procedure were completed.

It should not be concluded that the time spent in the X-ray setting was unimportant from a behavioral point of view. The procedure and the photographs served to promote interest, confidence, and commitment in the patient. When the pictures were placed in the patient's file, it produced a sense of belonging and self-identification with the Clinic and with chiropractic in general.

The practitioner, returning to the adjustment room and the waiting patient, seated himself at the interview table to review the patient's problem. Literature was dispensed along with advice concerning "the home care of the spine." Such advice may include rest periods to allow the body to respond "naturally" to the adjustment, proper sleeping positions, and possibly some appropriate series of exercises.

It is not uncommon for chiropractors, when learning that a patient is going out of town for several days or weeks, to give him his X-rays and a list of chiropractors (in this case, ICA members) located en route. This practice serves two functions: reciprocal agreement between chiropractors assures a higher volume of business for each, and an emphasis on the importance of returning the pictures assures the return of the patient also.

THE HALLWAY SUBSETTING AS TERMINATION POINT

In most cases the practitioner made the decision of when the adjustment area interview was concluded, unless the patient took it upon himself to leave. Normally the patient followed the practitioner back through the hall, at the end of which was the door to his private office on the right. Opening the door as they entered, the practitioner seated himself at his desk next to the file cabinet, leaving the patient standing in the doorway. Posted conspicuously on the door was a neatly lettered poster designating fees:
At this point the practitioner briefly reviewed the patient's case and recommended an appropriate time for the next appointment. This appointment was based on the "physical needs" of the patient. After this had been established, the fee was discussed, pointing out the advantages of the prepay plan. Patients were usually encouraged to tell family members of the beneficial treatment they had received with the hope they would bring others with them at the next visit. When the matters of appointment and fees had been settled, the conversation terminated on a friendly and encouraging note.

As will be seen in the following chapter, hallway interaction is of major concern when attempting to understand other aspects of the behavior setting. The patient was free to raise questions, and often was encouraged to do so, concerning any aspect of chiropractic. Often the bulletin board -- easily seen by the patient -- was made the focus of attention. The practitioner could direct the patient's attention to an article or item of interest that had been posted there specifically for this purpose, whereas in the waiting room, the adjustment area, or the X-ray area, the form and content of the interaction had been guided, for the most part, by the practitioner or an assistant, the "burden of proof" in the hallway setting was now purposefully accorded the patient. Depending upon the practitioner's reading of the patient's definition of the situation, including the practitioner's projection of self-image, he typed the patient in terms of future behavioral expectations.

BACKSTAGE SUBSETTING

The practitioner's private office, while open to view for the patient during the course of his visit, was nonetheless actually closed to him in that he was denied access to much of the interaction which took place there at other times. The wood-paneled room itself (12 x 15 feet) was sparsely furnished, the most prominent feature was the wall-to-wall bookshelf directly facing the hall entry. The practitioner's desk and an upright file cabinet were directly opposite the sign-in window. The telephone was within easy reach of the desk. Three straight-backed chairs completed the floor furnishings. The walls displayed a variety of items, the most prominent of these being the practitioner's framed diplomas from the Palmer College of Chiropractic. They were arranged in a way as to be easily seen from the waiting room through the sign-in window. They included the diploma of Doctor of Chiropractic, a Certificate of Proficiency-X-ray, and a Certificate of Merit." The significance of the latter is somewhat questionable in that the practitioner admitted to me that it was awarded as the consequence of "grading some exam papers one semester for an instructor at the college. Everyone gets it." Also given a position of central prominence was a sign printed in boldface script, "signed" by Thomas Edison, and available from Palmer College for $3.50 without frame:

The doctor of the future will give no medicine but will interest his patients in the care of the human frame and in the cause and prevention of dis-ease.

Several of the handwritten signs were also evident: "Children Learn What They Live"; "It Takes 65 Muscles To Frown and Only 13 To Make a Smile -- Why Not Smile?"; "It Is Easier To Stay Well than To Get Well." A lighted candle placed upon the sign-in shelf ("A candle loses nothing by lighting mother candle. We're here to help you.") added to the decor.

The background music from the radio assured a certain degree of privacy in this backstage area when there were patients in the waiting room, as did the level of the sign-in window which was located above eye level when patients were seated. It was possible to converse in low tones in the office and be assured of not being overheard.

The professional performance team (defined by Goffman [5]) as "any set of individuals who cooperate in the staging of a single routine" [5]) consisting of the practitioner and his assistants, utilized this backstage area as their central meeting place. During those periods when there were not any patients in the Clinic, the practitioner and his staff would spend their free time in this subsetting.

Occasionally during these interim periods the practitioner would suggest to his staff members moving to the adjustment area for conversation and/or adjustments. The practitioner, as a "true believer" in chiropractic, encouraged those backstage others -- assistants, family, friends and professional allies -- -to undergo adjustment routinely. The author, during the course of his employment. underwent an average of live adjustments a week, despite the fact that the average patient is told for what are apparently purely economic reasons that adjustments are not normally needed on a daily basis.

This chapter has focused upon the physical and temporal essentials of' the total configuration of the behavior setting, of the Clinic. Furthermore, standing patterns of behavior for the new patient have been outlined. In the following chapter both onstage and backstage interaction as it occurs against this dramaturgcal backdrop will be discussed.

REFERENCES

1. Douglas JD. Observations of Deviance. New York: Random House, 1970.
2. Ball DW. An abortion clinic ethnography. Social Problems 14::293-30, 1967.
3. Roebuck, Julian B. and Wolf Frese. The After-Hours Club: Ethnography of an Unserious Behavior Setting (forthcoming).
4. Goffman I. 1963. Behavior in Public Places. New York: Free Press, 1963.
5. Goffman I. The Presentation of Self in Everyday Life. New York: Doubleday, 1959.

Next Chapter ||| Table of Contents
Chirobase Home Page